Abstract
BackgroundIn the United States social disparities in health outcomes are found wherever they are sought, and they have been documented extensively in trauma care. Because social factors cannot cause a trauma outcome directly, there must exist mediating causal factors related to the nature and severity of the injury, the robustness of the victim, access to care, or processes of care. An understanding these mediators is the point of departure for addressing inequities in outcomes.FindingsData were extracted from the registry of the Trauma Quality Improvement Program of the American College of Surgeons for 2007 through 2010. Inclusion criteria were age less than 19 years and head Abbreviated Injury Scale score of 4, 5, or 6. An Oaxaca-Blinder decomposition was undertaken to analyze the relative contributions of a large set of covariates to the difference in mortality rates between Black and White children. Covariates were aggregated into the following categories: “Severity,” “Structure and Process,” “Mechanism,” “Demographics,” and “Insurance.” Eligible for analysis were 7273 White children and 2320 Black children. There were 1661 deaths (17.3%) The raw mortality rates were 15.6 and 22.8% for White and Black children, respectively. Factors categorized as “Severity” accounted for 95% of the mortality difference, “Mechanism” accounted for 13%, “Insurance” accounted for 5%, and “Demographics” accounted for 2%. The contribution of “Structure and Process” did not attain statistical significance.ConclusionsSeverity of injury accounts for most of the disparity between Black and White children in traumatic brain injury mortality rates. Mechanism, insurance status, and gender make a small contributions. Because insurance status like other social factors cannot directly affect trauma survival, what mediates its contribution requires further study.
Highlights
In the United States social disparities in health outcomes are found wherever they are sought, and they have been documented extensively in trauma care
A recent analysis of data from the Trauma Quality Improvement Program (TQIP) of the American College of Surgeons (ACS) has confirmed many previous observations of racial disparities in Traumatic brain injury (TBI) mortality and presented evidence that factors captured in the TQIP dataset accounted for those disparities (Piatt 2020)
Oaxaca-Blinder decomposition (OBD) begins with a statistical model of the outcome of interest, in this case mortality after childhood TBI, and asks the counterfactual question, “How much disparity would remain if the disadvantaged group had the same values for the model covariates as the advantaged group?” The mathematics of the OBD is readily understood in the case of a linear model such as least-squares regression
Summary
In the United States social disparities in health outcomes are found wherever they are sought, and they have been documented extensively in trauma care. Because social factors cannot cause a trauma outcome directly, there must exist mediating causal factors related to the nature and severity of the injury, the robustness of the victim, access to care, or processes of care. After statistical adjustments for many covariates reflecting severity of injury, mechanisms of injury, insurance status, demographic factors, and processes of care, Black children experienced a risk of mortality no greater than White children. This conclusion raises 2 immediate questions: Which factors account for the disparities? This conclusion raises 2 immediate questions: Which factors account for the disparities? And can they be modified to promote health equity?
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