Specialty: General Surgery

Keywords: Healthcare costs; Medicaid; Financial toxicity

Background:
Pediatric traumatic injury is associated with long-term morbidity as well as substantial economic burden. Prior work has labeled the catastrophic out-of-pocket medical expenses borne by patients as financial toxicity. We hypothesized uninsured rural patients to be vulnerable to exorbitant costs and thus at greatest risk of financial toxicity (ROFT).

Methods:
Pediatric patients (<18 years) experiencing traumatic injury were identified in the 2016- 2019 National Inpatient Sample (NIS). Patients were considered to be at ROFT if their hospitalization cost exceeded 40% of post-subsistence income. Individual family income was computed using a gamma distribution probability density function with parameters derived from publicly available US Census Bureau data, in accordance with prior work. A multivariable logistic regression was developed to assess factors associated with ROFT.

Results:
Of an estimated 225,265 children identified for study, 34,395 (15.3%) were Rural. Rural patients were more likely to experience ROFT (29.1 vs 22.2%, p<0.001), compared to Urban patients. After adjustment, rurality (reference: urban status; Adjusted Odds Ratio [AOR] 1.45, 95% Confidence Interval [CI] 1.36 – 1.55) and uninsured status (reference: private; AOR 1.85, 95% CI 1.67 – 2.05) remained linked to increased odds of ROFT. Specifically among patients with private insurance, Rural patients experienced markedly higher predicted ROFT, relative to Urban.

Conclusions:
Our findings suggest a complex interplay between rural status and insurance type in the prediction of ROFT after pediatric trauma. With recent budget cuts to Medicaid and the Children's Health Insurance Program (CHIP), and the continued exclusion of undocumented children from eligibility, such findings represent the need for improved trauma infrastructure for pediatric care. Future studies should identify feasible cost-mitigation strategies to target policy interventions and ensure equitable access to trauma care for vulnerable pediatric victims.