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The Influence of Race and Insurance in Trauma Transfers from Adult to Pediatric Centers: A Statewide Cohort Analysis
Afif N. Kulaylat, MD MSc, Division of Pediatric Surgery, Penn State Hershey Children's Hospital Christopher S. Hollenbeak, PhD, Division of Outcomes Research and Quality, Penn State College of Medicine Scott B. Armen, MD, Division of Trauma, Acute Care, and Critical Care Surgery, Penn State Hershey Medical Center Robert E. Cilley, MD, Division of Pediatric Surgery, Penn State Hershey Children's Hospital Brett W. Engbrecht, MD MPH, Division of Pediatric Surgery, Penn State Hershey Children's Hospital

Background: While recent literature has described disparate outcomes on the basis of race and socioeconomic differences in both adult and pediatric trauma patients, it is unknown whether these factors also influence the likelihood of subsequent interhospital transfer between adult and pediatric trauma centers (PTC).

Methods: Data on trauma patients ≤ 14 years initially evaluated at level I and II adult trauma centers (ATC) were obtained from the Pennsylvania Trauma Outcome Study (2008-2012). Demographic data, race, insurance status, mechanism of injury and injury severity score (ISS) were compared. Multivariate logistic regressions were performed to evaluate predictors of subsequent transfer. Due to interactions between race and insurance status, stratified analyses were performed.

Results: There were 3,377 children identified, 2,560 (75.8%) of whom were transferred. At ATC-I and ATC-II, transfer rates to PTC-I were 65.7% and 67.0%, respectively. For all insurance types, non-white race was associated with increased odds of transfer (Medicaid Odds Ratio (OR) 2.0, commercial OR 1.9, self-pay OR 3.9, all p<0.01). When stratified by race, non-whites with self-pay insurance (OR 2.5, p<0.05) were more likely to be transferred compared to those with commercial insurance. ATC-I were more likely to transfer non-white (OR 6.0), Medicaid (OR 1.8), and self-pay patients (OR 3.1), while factors associated with transfer at ATC-II were missing race (OR 4.6) and Medicaid (OR 0.6) (all p<0.01).

Conclusions: Race and insurance are associated with interhospital transfer in pediatric trauma in Pennsylvania. It is unclear to what extent these disparities represent unconscious biases or unmeasured differences in access or nature of traumatic injury.

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