Impact of Race, Ethnicity, and Insurance Type on In-hospital Mortality in Children with Traumatic Injury

OBJECTIVE: To evaluate the association of insurance status and race/ethnicity with in-hospital mortality among pediatric trauma patients. METHODS: We conducted a retrospective cohort study using the National Trauma Data Bank (2007-2019, excluding 2018). Patients younger than 17 years with an Injury Severity Score > 9 were included. Multivariable logistic regression was used to assess the independent and combined associations of race/ethnicity and insurance status with in-hospital mortality, adjusting for age, sex, injury severity, Glasgow Coma Scale, and mechanism of injury. RESULTS: A total of 148,019 pediatric patients were included (66% male; median age 11 years [IQR 5-15]). Non-Hispanic White children comprised 60% of the cohort, followed by Hispanic (15%) and Non-Hispanic Black (15%). Private (38%) and Medicaid (32%) were the most common insurance types; 7.6% were self-pay. Overall mortality was 4.4%, highest among Non-Hispanic Black children (6.6%) and self-pay patients (7.5%). In adjusted analyses, self-pay status was associated with increased mortality compared with Medicaid (OR 1.23, 95% CI 1.12--0.36), as was Non-Hispanic Black race (OR 1.15, 95% CI 1.06-1.24). Firearm-related injury was strongly associated with mortality (OR 4.18, 95% CI 3.59-4.86). No significant interaction was observed between race/ethnicity and insurance status. CONCLUSIONS: Insurance status is an independent predictor of mortality in pediatric trauma, with self-pay patients at highest risk. Racial disparities were attenuated after adjustment, and the effect of insurance was consistent across racial and ethnic groups.