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Previous studies have shown an association between insurance status and use of resources for inpatient care. We sought to assess whether insurance status influences decisions regarding the evaluation and treatment of head injured patients in the emergency department (ED). Head injured patients were identified from ED data from 4 hospitals reporting to the Kentucky Emergency Medical Services Information System. Multiple regression analysis using admission, ED length of stay, and ED charges as outcome variables was then performed. From 216,137 ED visits there were 8,591 (4%) head injured patients identified from the database. Eliminating those with revisits, transfers to another hospital in the database, and isolated facial lacerations, there were 3,821 cases. Controlling for age, hospital, race, primary diagnosis, and indicators of severity of the injury, insurance status was significantly associated with hospital admission. Those uninsured were the least likely to be admitted (OR 0.41; 95% CI (0.31, 0.50), whereas those with public insurance had an intermediate probability (OR 0.50 95% CI (0.37, 0.68) as compared with those with private insurance. Similarly, ED charges were lower for Medicaid patients than insured patients ($880) and tended to be slightly lower for uninsured patients ($1,043) than insured patients ($1,141) (P =.001). Length of stay in the ED was shorter for publicly insured patients (179 minutes) than uninsured (186 minutes) and privately insured patients (192 minutes) (P =.001). The extent of evaluation and admission for head injured patients is associated with insurance status. This creates a dual standard of care for patients. Practitioners should work to standardize the evaluation of patients independent of paying status.

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OBJECTIVES: To analyze data from motor vehicle crashes (MVCs) involving teenaged drivers in Kentucky for 1994, and derive cost estimates of these crashes. METHODS: Crash data were obtained from the Kentucky Traffic Accident Facts 1994 Report and the Kentucky Accident Reporting System. The National Highway Traffic Safety Administration's Crash-Cost program was used to generate cost estimates for Kentucky data. RESULTS: Teenaged drivers had significantly higher MVC fatal and non-fatal injury rates than did adult drivers. The deaths rates were 43.6 and 19.0 per 100,000 for teens and adult drivers, respectively. Odds ratios (ORs) were calculated to estimate the relative risk for (1) involvement in an MVC, (2) fatal or incapacitating injury, and (3) fatal injury for teenaged compared with adult drivers. The crude ORs were statistically significant at each age. Cost estimates were calculated on a per person/vehicle basis. A single fatal injury was $642,700. A critical injury was $563,000. In general, unit costs rose with increasing levels of injury severity. For the total number of fatal injuries, costs exceeded $91 million. For non-fatal injuries and property damage only crashes, total costs were $318 million. Overall, the total cost estimate for MVCs involving teenaged drivers was nearly $410 million. CONCLUSIONS: Strategies aimed to reduce the number of MVCs attributed to teenaged drivers should reduce both the number and costs of crash related deaths and injuries. Graduated driver licensing (GDL) systems are one plausible approach toward achieving this goal. By recently enacting a GDL system in Kentucky, it is anticipated that many lives and dollars will be saved.

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The Kentucky Emergency Medical Services Information System was formed in 1993 to establish a centralized registry of prehospital and emergency department data. These data can aid individual providers in planning and providing patient services and state planners in systems development and disease surveillance. This article seeks to provide an overview of the system for providers of acute care services in Kentucky, its current capabilities and future goals.

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Our objective was to analyze differences in postneonatal mortality rates between the southeastern (Appalachian) region of Kentucky and the remainder of the state to identify factors associated with increased mortality in the Appalachian (AP) region. The relative risk of postneonatal deaths in the AP region when compared with the remainder of Kentucky (KY) was 1.38 (95% confidence interval = 1.15-1.65). Adjustment for birth weight, maternal age, and marital status of the parents had no appreciable effect on the risk ratio; however, adjustment for maternal education negated the increased risk of postneonatal death among the AP region births. When causes of postneonatal death were compared, three specific disease groupings were disproportionately represented among AP infants: Sudden Infant Death Syndrome (SIDS); congenital malformations; and infections. Most striking was the excess risk of infection-related death because it represents a preventable component in the postneonatal mortality excess of the AP region; and, because of the apparent association with maternal "under education." These findings are discussed within a public health intervention context.

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The mortality rates of infants born in Kentucky during 1982 and 1983 were analyzed to determine whether there were differences between poor and nonpoor infants. We used computer matching with the Social Insurance Food Stamp files and with the Aid for Families With Dependent Children files to define poor and nonpoor Kentucky resident families. The crude death rate for poor infants was 13.7/1,000 births, and the nonpoor death rate was 10.8/1,000 births. After adjusting for several important variables, we found that the poor infant was at a significantly greater risk for death than the nonpoor infant but only during the postneonatal period (relative risk 2.04, P = .0003). Some differences by sex and race were noted. Sudden infant death syndrome and infections were largely responsible for the poor infants' higher postneonatal mortality risk.

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Results are presented of a study of the medical care-seeking behavior of black adult residents of lower and middle socioeconomic status in two predominantly black, yet geographically and socioeconomically distinct communities within the District of Columbia. Against a varied distribution of primary medical care opportunities within the District, substantial differences are demonstrated in their use by lower- and middle-status residents of a lower-class community. These differences are not, however, manifested among lower- and middle-status residents of an essentially middle-class neighborhood. The patterns of medical care-seeking behavior are observed within a framework of an almost total avoidance of the available medical care personnel and facilities in the proximate suburbs.

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