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Most hospitals in the United States are required to provide emergency care to all patients, regardless of insurance status. However, uninsured patients might be unable to access non-acute services, such as post-discharge inpatient care (PDIC). This could result in prolonged acute hospitalization. We tested the hypothesis that insurance status would be independently associated with both PDIC and length of stay (LOS).An observational study was undertaken using the California State Inpatient Database (2007-2011), which captures 98% of patients admitted to hospital in California. All patients with a diagnosis of orthopedic lower limb trauma were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes 820-828. Multivariable logistic and generalized linear regression models were used to adjust odds of PDIC and LOS for patient and hospital characteristics.There were 278,573 patients with orthopedic lower limb injuries, 160,828 (57.7%) of which received PDIC. Uninsured patients had lower odds of PDIC (adjusted odds ratio 0.20, 95% confidence interval 0.17-0.24) and significantly longer hospital LOS (predicted mean difference 1.06 [95% confidence interval 0.78-1.34] d) than those with private insurance.Lack of health insurance is associated with reduced access to PDIC and prolonged hospital LOS. This potential barrier to hospital discharge could reduce the number of trauma beds available for acutely injured patients.

Original publication




Journal article


The Journal of surgical research

Publication Date





140 - 144


Center for Surgery and Public Health, Harvard Medical School, One Brigham Circle, Boston, Massachusetts; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.


Humans, Hip Fractures, Leg Injuries, Hospitalization, Length of Stay, Patient Discharge, Linear Models, Logistic Models, Databases, Factual, Adult, Aged, Aged, 80 and over, Middle Aged, Medically Uninsured, Health Services Accessibility, California, Female, Male, Healthcare Disparities