Emergency department utilization and outpatient follow-up after traumatic injury

Background: Trauma patients continue to experience increased risk of re-injury and adverse health events after hospital discharge. This retrospective analysis of outcomes among trauma patients advances understanding of risks for fragmented care after discharge. Methods: We conducted a retrospective analysis of all Level 1 and 2 trauma patients evaluated at an urban Level I trauma center between April 1, 2005 and April 1, 2010. We collected patient demographic information, clinical data including admission toxicology and discharge functional status, healthcare utilization after trauma, and mortality data. Our primary outcome of interest was outpatient provider contact within 2 months of discharge. The secondary outcomes of interest were 2-month and 1-year Emergency Department (ED) use, 1-year inpatient rehospitalization at the study hospital, and 3-year mortality. Multivariate logistic regression was used to determine the association between patient characteristics, subsequent ED, hospital and clinic use, and mortality. Results: In a multivariate model including patient demographics, severity of injury, use of hospital consultation services, and discharge functional status, failure to receive outpatient physician follow up within 2 months of discharge was significantly associated with increased age (adjusted odds ratio (AOR) per year [95%CI, 1.01 [1.00-1.02]), male sex (AOR [95% CI], 1.24 [1.02-1.51]), Medicaid insurance compared to private insurance (AOR [95% CI], 1.56 [1.21-2.01]), no insurance compared to private insurance (AOR [95% CI], 3.79 [3.04-4.72]), and higher discharge expressive function and locomotion. Patients with Medicaid or self-pay insurance status were significantly less likely to see an outpatient physician within 12 months (AOR [95% CI], 0.26 [0.21-0.33] for uninsured patients, 0.56 [0.46-0.78] for Medicaid patients) and were more likely to return for ED evaluation at 2 months (AOR [95% CI], 1.45 [0.99-2.12] for uninsured patients, 1.97 [1.36-2.9] for Medicaid patients) and 12 months (AOR [95% CI], 1.9 [1.35-2.68] for uninsured patients, 2.29 [1.64-3.21] for Medicaid patients) compared to privately insured patients. At two months after discharge, both uninsured patients and Medicaid patients were more than twice as likely as privately insured patients to have required ED care but not have seen an outpatient physician (AOR [95% CI], 2.10 [1.31-3.36] for uninsured patients, 2.61 [1.50-4.53] for Medicaid patients). These patients did not have increased risk of requiring inpatient hospitalization in this same period. Conclusions: Similar rates of failure to follow up and short-term ED use between uninsured patients and Medicaid patients suggest that Medicaid coverage may not have adequately reduced barriers to outpatient healthcare utilization after traumatic injury.