Disparities In Trauma Outcomes Research Articles

Morbidity and Length of Stay After Injury Among People Experiencing Homelessness in North America

Traumatic injury is a leading cause of hospitalization among people experiencing homelessness. However, hospital course among this population is unknown. To evaluate whether homelessness was associated with increased morbidity and length of stay (LOS) after hospitalization for traumatic injury and whether associations between homelessness and LOS were moderated by age and/or Injury Severity Score (ISS). This retrospective cohort study of the American College of Surgeons Trauma Quality Programs (TQP) included patients 18 years or older who were hospitalized after an injury and discharged alive from 787 hospitals in North America from January 1, 2017, to December 31, 2018. People experiencing homelessness were propensity matched to housed patients for hospital, sex, insurance type, comorbidity, injury mechanism type, injury body region, and Glasgow Coma Scale score. Data were analyzed from February 1, 2022, to May 31, 2023. People experiencing homelessness were identified using the TQP's alternate home residence variable. Morbidity, hemorrhage control surgery, and intensive care unit (ICU) admission were assessed. Associations between homelessness and LOS (in days) were tested with hierarchical multivariable negative bionomial regression. Moderation effects of age and ISS on the association between homelessness and LOS were evaluated with interaction terms. Of 1 441 982 patients (mean [SD] age, 55.1 [21.1] years; (822 491 [57.0%] men, 619 337 [43.0%] women, and 154 [0.01%] missing), 9065 (0.6%) were people experiencing homelessness. Unmatched people experiencing homelessness demonstrated higher rates of morbidity (221 [2.4%] vs 25 134 [1.8%]; P < .001), hemorrhage control surgery (289 [3.2%] vs 20 331 [1.4%]; P < .001), and ICU admission (2353 [26.0%] vs 307 714 [21.5%]; P < .001) compared with housed patients. The matched cohort comprised 8665 pairs at 378 hospitals. Differences in rates of morbidity, hemorrhage control surgery, and ICU admission between people experiencing homelessness and matched housed patients were not statistically significant. The median unadjusted LOS was 5 (IQR, 3-10) days among people experiencing homelessness and 4 (IQR, 2-8) days among matched housed patients (P < .001). People experiencing homelessness experienced a 22.1% longer adjusted LOS (incident rate ratio [IRR], 1.22 [95% CI, 1.19-1.25]). The greatest increase in adjusted LOS was observed among people experiencing homelessness who were 65 years or older (IRR, 1.42 [95% CI, 1.32-1.54]). People experiencing homelessness with minor injury (ISS, 1-8) had the greatest relative increase in adjusted LOS (IRR, 1.30 [95% CI, 1.25-1.35]) compared with people experiencing homelessness with severe injury (ISS ≥16; IRR, 1.14 [95% CI, 1.09-1.20]). The findings of this cohort study suggest that challenges in providing safe discharge to people experiencing homelessness after injury may lead to prolonged LOS. These findings underscore the need to reduce disparities in trauma outcomes and improve hospital resource use among people experiencing homelessness.

Racial, Gender, and Neighborhood-Level Disparities in Pediatric Trauma Care.

Disparities in trauma outcomes and care are well established for adults, but the extent to which similar disparities are observed in pediatric trauma patients requires further investigation. The objective of this study was to evaluate the unique contributions of social determinants (race, gender, insurance status, community distress, rurality/urbanicity) on trauma outcomes after controlling for specific injury-related risk factors. All pediatric (age < 18) trauma patients admitted to a single level 1 trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed (n = 14,398). Primary outcomes were receipt of opioids in the emergency department, post-discharge rehabilitation referrals, and mortality. Multivariate logistic regressions evaluated demographic, socioeconomic, and injury characteristics. Multilevel logistic regressions evaluated area-level indicators, which were derived from abstracted home addresses. Analyses adjusting for demographic and injury characteristics revealed that Black children (n = 6255) had significantly lower odds (OR = 0.87) of being prescribed opioid medications in the emergency department compared to White children (n = 5883). Children living in more distressed and rural communities had greater odds of receiving opioid medications. Girls had significantly lower odds (OR = 0.61) of being referred for rehabilitation services than boys. Post hoc analyses revealed that Black girls had the lowest odds of receiving rehabilitation referrals compared to Black boys and White children. Results highlight the need to examine both main and interactive effects of social determinants on trauma care and outcomes. Findings reinforce and expand into the pediatric population the growing notion that traumatic injury care is not immune to disparities.

Rural and urban patterns of severe injuries and hospital mortality in Australia: An analysis of the Australia New Zealand Trauma Registry: 2015–2019

IntroductionIn Australia, people living in rural areas, compared to major cities are at greater risk of poor health. There is much evidence of preventable disparities in trauma outcomes, however research quantifying geographic variations in injuries, pathways to specialised care and patient outcomes is scarce. Aims(i) To analyse the Australia New Zealand Trauma Registry (ATR) data and report patterns of serious injuries according to rurality of the injury location ii) to examine the relationship between rurality and hospital mortality and iii) to compare ATR death rates with all deaths from similar causes, Australia-wide. MethodA retrospective cohort study of patients in the ATR from 1st July 2015 to 30th June 2019 was conducted. Descriptive analyses of trauma variables according to rurality was performed. Logistic regression quantified the moderating effect of rurality on trauma variables and hospital mortality. Australian death data on similar injuries were sourced to quantify the additional mortality attributable to severe injury occurring outside Major Trauma Centres (MTCs). ResultsCompared to major cities, rural patients were younger, more likely to have spinal cord injuries, and sustain traffic-related injuries that are ‘off road’. Injuries occurring outside people's homes are more likely. Mortality risk was greater for patients sustaining severe traumatic brain injury (TBI) spinal cord injury (SCI) and head trauma in addition to intentional injuries. Compared to the ATR data, Australian population-wide trauma mortality rates showed diverging trends according to rurality. The ATR only captures 14.1% of all injury deaths occurring in major cities and, respectively, 6.3% and 3.2% of deaths in regional and remote areas. ConclusionCompared to major cities, injuries occurring in rural areas of Australia often involve different mechanisms and result in different types of severe injuries. Patients with neurotrauma and intentional injuries who survived to receive definitive care at a MTC were at higher risk of hospital death. To inform prevention strategies and reduce morbidity and mortality associated with rural trauma, improvements to data systems are required that involve data linkage and include information about patient care from pre-hospital providers, regional hospitals and major trauma centres.

Racial and Sex Disparities in Trauma Outcomes Based on Geographical Region.

Disparities in outcomes among trauma patients have been shown to be associated with race and sex. The purpose of this study was to analyze racial and sex mortality disparities in different regions of the United States, hypothesizing that the risk of mortality among black and Asian trauma patients, compared to white trauma patients, will be similar within all regions in the United States. The Trauma Quality Improvement Program (2010-2016) was queried for adult trauma patients, separating by U.S. Census regions. Multivariable logistic regression analyses were performed for each region, controlling for known predictors of morbidity and mortality in trauma. Most trauma patients were treated in the South (n = 522388, 40.7%). After risk adjustment, black trauma patients had a higher associated risk of death in all regions, except the Northeast, compared to white trauma patients. The highest associated risk of death for blacks (vs. whites) was in the Midwest (odds ratio [OR] 1.30, P < .001). Asian trauma patients only had a higher associated risk of death in the West (OR 1.39, P < .001). Male trauma patients, compared to women, had an increased associated risk of mortality in all four regions. This study found major differences in outcomes among different races within different regions of the United States. There was also both an increased rate and associated risk of mortality for male patients in all regions. Future prospective studies are needed to identify what regional differences in trauma systems including population density, transport times, hospital access, and other trauma resources explain these findings.

Racial disparities in post-discharge healthcare utilization after trauma

BackgroundRacial disparities in trauma outcomes have been documented, but little is known about racial differences in post-discharge healthcare utilization. This study compares the utilization of post-discharge healthcare services by African-American and Caucasian trauma patients. MethodsTrauma patients with an Injury Severity Score (ISS)≥9 from three Level-I trauma centers were contacted between 6 and 12 months post-injury. Utilization of trauma-related healthcare services was asked. Coarsened exact matching (CEM) was used to match African-American and Caucasian patients. Conditional logistic regression then compared matched patients in terms of post-discharge healthcare utilization. Results182 African-American and 1,117 Caucasian patients were followed. Of these, 141 African-Americans were matched to 628 Caucasians. After CEM, we found that African-American patients were less likely to use rehabilitation services [OR:0.64 (95% CI:0.43–0.95)] and had fewer injury-related outpatient visits [OR:0.59 (95% CI:0.40–0.86)] after discharge. ConclusionsThis study shows the existence of racial disparities in post-discharge healthcare utilization after trauma for otherwise similarly injured, matched patients.

The Social Determinants of Trauma: A Trauma Disparities Scoping Review and Framework.

The drivers of trauma disparities are multiple and complex; yet, understanding the causes will direct needed interventions. The aims of this article are to (1) explore how the injured patient, his or her social environment, and the health care system interact to contribute to trauma disparities and examine the evidence in support of interventions and (2) develop a conceptual framework that captures the socioecological context of trauma disparities. Using a scoping review methodology, articles were identified through PubMed and CINAHL between 2000 and 2015. Data were extracted on the patient population, social determinants of health, and interventions targeting trauma disparities and violence. Based on the scoping review of 663 relevant articles, we inductively developed a conceptual model, The Social Determinants of Trauma: A Trauma Disparities Framework, based on the categorization of articles by: institutional power (n = 9), social context-place (n = 117), discrimination experiences (n = 59), behaviors and comorbidities (n = 57), disparities research (n = 18), and trauma outcomes (n = 85). Intervention groupings included social services investment (n = 54), patient factors (n = 88), hospital factors (n = 27), workforce factors (n = 31), and performance improvement (n = 118). This scoping review produced a needed taxonomy scheme of the drivers of trauma disparities and known interventions that in turn informed the development of The Social Determinants of Trauma: A Trauma Disparities Framework. This study adds to the trauma disparities literature by establishing social context as a key contributor to disparities in trauma outcomes and provides a road map for future trauma disparities research.

The Impact of Payer Source on Trauma Outcomes in a Pediatric Population.

Determine if there were differences in conclusions drawn regarding disparities in trauma outcomes based on literature-derived payer source definitions in a pediatric population. Retrospective registry review of admitted pediatric trauma patients (≤17 years of age) at a level II pediatric trauma facility. Eligible patients were categorized into 3 payer source definitions: definition 1: commercially insured, Medicaid, uninsured; definition 2: insured, uninsured; definition 3: commercially insured, underinsured. Logistic regression was used to determine the influence of payer source on outcomes. Payer source was not significant in definition 1, 2, or 3 for intensive care unit length of stay (LOS), hospital LOS, medical consults, or mortality. For hospital disposition, payer source was significant in definition 1, the uninsured were 90% less likely than commercially insured to be discharged to continued care. In definition 2, the uninsured were 88% less likely than insured to be discharged to continued care. In definition 3, the underinsured were 57% less likely than commercially insured to be discharged to continued care. Differences between the literature-derived definitions were not observed and therefore conclusions drawn did not differ across definitions. The investigation demonstrated payer source was not associated with in-hospital outcomes (intensive care unit LOS, hospital LOS, medical consults, and mortality), but was with posthospital outcomes. Findings warrant future examinations on the categorization of payer source in pediatric patients and hospital disposition to gain a greater understanding of disparities related to payer source in pediatric trauma, specifically in terms of posthospital care.

Outcomes of trauma admission for falls: influence of race and age on inhospital and post-discharge mortality

BackgroundRacial disparities in trauma outcomes occur, but disparities in fall mortality are unknown. The objective of this study was to determine inhospital and 1-year fall mortality among patients discharged from an urban trauma center. MethodsWe conducted a retrospective analysis of fall patients in our trauma registry (1997 to 2008) linked to the National Death Index to determine postdischarge mortality. Statistical analysis included chi-square tests, multivariable logistic regression, and Cox proportional hazards models. ResultsThere were 7,541 fall admissions. There was no clinically significant difference in inhospital mortality between blacks and whites with age stratification. One year after discharge, blacks younger than 65 years were more likely to die of disease (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.62). ConclusionsAlthough rates of inhospital mortality are similar, blacks younger than 65 years have a higher risk of dying after discharge due to disease when stratified by age highlighting the need for continued medical follow-up and prevention efforts.

The Hispanic paradox: does it exist in the injured?

BackgroundHispanics have similar or lower all-cause mortality rates in the general population than non-Hispanic whites (NHWs), despite higher risks associated with lower socioeconomic status, hence termed the “Hispanic Paradox.” It is unknown if this paradox exists in the injured. We hypothesized that Hispanic trauma patients have equivalent or lower risk-adjusted mortality and observed-to-expected mortality ratios than other racial/ethnic groups. MethodsRetrospective analysis of adult patients from the 2010 National Trauma Data Bank was performed. Hispanic patients were compared with NHWs and African Americans (AAs) to assess in-hospital mortality risk in each group. ResultsCompared with NHWs, Hispanic patients had lower unadjusted risk of mortality. After adjusting for potential confounders, the difference was no longer statistically significant. Mortality risk was significantly lower for Hispanic patients compared with AAs in both crude and adjusted models. Hispanic patients had significantly lower observed-to-expected mortality ratios than NHWs and AAs. ConclusionDespite reports of racial/ethnic disparities in trauma outcomes, Hispanic patients are not at greater risk of death than NHW patients in a nationwide representative sample of trauma patients.

Racial and Regional Disparities in the Effect of the Affordable Care Act's Dependent Coverage Provision on Young Adult Trauma Patients

Disparities in trauma outcomes based on insurance and race are especially pronounced among young adults who have relatively high uninsured rates and incur a disproportionate share of trauma in the population. The 2010 Dependent Coverage Provision (DCP) of the Affordable Care Act (ACA) allowed young adults to remain on their parent's health insurance plans until age 26 years, leading to >3 million young adults gaining insurance. We investigated the impact of the DCP on racial disparities in coverage expansion among trauma patients. Using the 2007-2012 National Trauma Data Bank, we compared changes in coverage among 529,844 19- to 25-year-olds with 484,974 controls aged 27 to 34 years not affected by the DCP. Subgroup analyses were conducted by race and ethnicity and by census region. The pre-DCP uninsured rates among young adults were highest among black patients (48.1%) and Hispanic patients (44.3%), and significantly lower among non-Hispanic white patients (28.9%). However, non-Hispanic white young adults experienced a significantly greater absolute reduction in the uninsured rate (-4.9 percentage points) than black (-2.9; p = 0.01) and Hispanic (-1.7; p < 0.001) young adults. These absolute reductions correspond to a 17.0% relative reduction in the uninsured rate for white patients, 6.1% for black patients, and 3.7% for Hispanic patients. Racial disparities in the provision's impact on coverage among trauma patients were largest in the South and West census regions (p < 0.01). Although the DCP increased insurance coverage for young adult trauma patients of all races, both absolute and relative racial disparities in insurance coverage widened. The extent of these racial disparities also differed by geographic region. Although this policy produced overall progress toward greater coverage among young adults, its heterogeneous impact by race has important implications for future disparities research in trauma.

Significant Sex-Based Outcome Differences in Severely Injured Chinese Trauma Patients

A body of experimental evidence suggests that the female sex is associated with a lower risk of mortality after trauma-hemorrhage. However, controversy remains regarding the mechanism responsible for these differences and if basic science findings correspond to clinical differences. Racial disparities in trauma outcomes have also been increasingly described. Until now, research on the association between sex and trauma patient outcomes mainly focused on patients in Europe and the United States. Our research attempted to determine whether the female sex is associated with a survival advantage among severely injured Chinese trauma patients. A retrospective analysis of data derived from the Emergency Intensive Care Unit of the Shanghai Sixth People';s Hospital Acute Trauma Center during 2010 to 2013 was performed to characterize differences in sex-based outcomes after severe blunt trauma. The patient study cohort (858 Asian subjects) was then stratified by age and injury severity (using the Injury Severity Score [ISS]). Crude and adjusted odds ratios (ORs) were calculated to evaluate the association between sex and nosocomial infection rate and hospitalized mortality, both overall and by age and ISS category subgroups. Among all trauma patients, females had a significantly lower risk of in-hospital mortality compared with males (OR, 0.41; 95% confidence interval [95% CI], 0.20 - 0.85). This difference was most apparent for patients younger than 50 years (OR, 0.31; 95% CI, 0.12 - 0.82) and the group with ISS scores of 25 or higher (OR, 0.39; 95% CI, 0.17 - 0.91). No differences in the development of nosocomial infections between sexes were seen among the overall patient group and subgroups. This study revealed a statistically significant association between sex and mortality among severe blunt trauma patients, particularly those patients younger than 50 years and with ISSs of 25 or higher. Women had significantly lower mortality than men after severe blunt trauma. These results highlight the important role of sex hormones and sex-based outcome differences after severe traumatic injury in the Chinese population.

Association between race and age in survival after trauma.

Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information. To determine whether racial disparities in trauma survival persist in patients 65 years or older. Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index. In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index. A total of 1,073,195 patients were included (502,167 patients 16-64 years of age and 571,028 patients ≥65 years of age). Most older patients were white (547,325 [95.8%]), female (406 158 [71.1%]), and insured (567,361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323,741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods. Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes.

Counting the lives lost: how many black trauma deaths are attributable to disparities?

BackgroundThe number of black trauma deaths attributable to racial disparities is unknown. The objective of this study was to quantify the excess mortality experienced by black patients given disparities in the risk of mortality. Materials and methodsWe performed a retrospective analysis of patients aged 16–65 y with blunt and penetrating injuries, who were included in the National Trauma Data Bank from 2007–2010. Generalized linear modeling estimated the relative risk of death for black patients versus white patients, adjusting for known confounders. This analysis determined the difference in the observed number of black trauma deaths at Level I and II centers and the expected number of deaths if the risk of mortality for black patients had been equivalent to that of white patients. ResultsA total of 1.06 million patients were included. Among patients with blunt and penetrating injuries at Level I trauma centers, white males and females had a relative risk of death of 0.82 (95% confidence interval [CI], 0.80–0.85) and 0.78 (95% CI, 0.74–0.83), respectively, compared with black patients. Similarly, at Level II trauma centers, white males and females had a relative risk of death of 0.84 (95% CI, 0.80–0.88) and 0.82 (95% CI, 0.73–0.91). Overall, of the estimated 41,613 deaths that occurred at Level I and II centers, 2206 (5.3%) were excess deaths among black patients. ConclusionsOver a 4-y period, approximately 5% of trauma center deaths could be attributed to racial disparities in trauma outcomes. These data underscore the need to better understand and intervene against the mechanisms that lead to trauma outcomes disparities.

Disparities in Trauma Outcomes Between Patients With Different Types of Insurance: Analysis and Implications for Healthcare Reform Policy

Disparities in Trauma Outcomes Between Patients With Different Types of Insurance: Analysis and Implications for Healthcare Reform Policy

Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: The case for inner-city pedestrian injury prevention programs

Pedestrian trauma is the most lethal blunt trauma mechanism, and the rate of mortality in African Americans and Hispanics is twice that compared with whites. Whether insurance status and differential survival contribute to this disparity is unknown. This study is a review of vehicle-struck pedestrians in the National Trauma Data Bank, v7.0. Patients <16 years and > or =65 years, as well as patients with Injury Severity Score (ISS) <9, were excluded. Patients were categorized as white, African American, or Hispanic, and as privately insured, government insured, or uninsured. With white and privately insured patients as reference, logistic regression was used to evaluate mortality by race and insurance status after adjusting for patient and injury characteristics. In all, 26,404 patients met inclusion criteria. On logistic regression, African Americans had 22% greater odds of mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.06-1.41) and Hispanics had 33% greater odds of mortality (OR, 1.33; 95% CI, 1.14-1.54) compared with whites. Uninsured patients had 77% greater odds of mortality (OR, 1.77; 95% CI, 1.52-2.06) compared with privately insured patients. African American and Hispanic race, as well as uninsured status, increase the risk of mortality after pedestrian crashes. Given the greater incidence of pedestrian crashes in minorities, this compounded burden of injury mandates pedestrian trauma prevention efforts in inner cities to decrease health disparities.

Perioperative Medicine

Perioperative Medicine

Pedestrians Struck by Motor Vehicles Contribute to Disparities in Trauma Outcomes: The Case for Inner City Pedestrian Injury Prevention Programs

Background: Pedestrians struck by motor vehicles are known to have the highest mortality rates of any blunt trauma mechanism. Centers for Disease Control (CDC) data demonstrate that Black and Hispanic patients suffer nearly twice the rate of death from this mechanism of trauma than do Whites. Whether this is due solely to a higher incidence of pedestrian injuries, or is also due to race-based differences in survival after pedestrian injury, is unknown. Similarly, the contribution of insurance status to the risk of mortality from pedestrian trauma is also unknown.