Insurance status and pediatric mortality in nonaccidental trauma

Nonaccidental trauma (NAT) is a leading cause of injury and death in early childhood. We sought to understand the association between insurance status and mortality in a national sample of pediatric NAT patients.We performed a retrospective cohort study using the 2012-2014 National Trauma Databank. We included children ≤18 y hospitalized with NAT (The International Classification of Diseases, Ninth Revision codes: E967-968). The primary exposure was insurance status (categorized as public, private, and uninsured). The primary outcome was emergency department or inpatient mortality from NAT.We identified 6389 children with NAT. Mean age was 1.6 y (standard deviation 3.7), with 41% female and 42% of an ethnic or racial minority. Most were publicly insured (77%), with 17% privately insured and 6% uninsured. Mean injury severity score (ISS) was 13.9 (standard deviation 10.3). Overall, 516 (8%) patients died following NAT. Compared to patients who survived, those who died were more likely to be younger (mean age 1.0 y versus 1.6 y; P 0.001), uninsured (13% versus 6%; P 0.001), transferred to a higher-care facility (57% versus 49%; P 0.001), and more severely injured (mean ISS 25.9 versus 12.8; P 0.001). After adjusting for age, race, transfer status, and ISS, uninsured patients had 3.3-fold (95% CI = 2.4-4.6) greater odds of death compared to those with public insurance. For every 1 point increase in ISS, children had 12% (95% CI = 11%-13%) increased adjusted odds of death.Pediatric patients without insurance had significantly greater odds of death following NAT, compared to children with public insurance. Knowledge that uninsured children comprise an especially vulnerable population is important for targeting potential interventions.