A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care

Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study

Background

Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA.

Methods

The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury.

Results

14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%.

Conclusion

The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage.

Level of evidence

2.

Societal Burden of Trauma and Disparities in Trauma Care

Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.

National analysis of over and under-triage rates in relation to trauma population risk factors and associated outcomes across various levels trauma centers

INTRODUCTION

Over and under-triage represent a misallocation of resources that can affect patient outcomes. The purpose of this study is to evaluate over and under-triage rates in relation to risk factors and associated outcomes of trauma patients nationwide.

METHODS

A retrospective cohort study using the Trauma Quality Improvement Program from 2017 to 2020. Multivariable regression models were used to assess predictors of over-triage (activation when unnecessary) and under-triage (limited activation when full activation was necessary).

RESULTS

22.2 % (32,782) of the study population were over-triaged and 20.3 % (29,996) were under-triaged. Most over-triaged patients were Black, with Medicaid, or had a penetrating injury, whereas most under-triaged patients were White, with private/commercial insurance, or had a blunt injury. With covariates adjusted for, Pacific Islander (p = 0.024) and American Indian patients (p = 0.015) were associated with higher odds of over-triage, and Hispanic patients had higher odds of under-triage (p<0.001). Patients with Medicare (p<0.001) had higher odds of over-triage, and patients with private/commercial insurance (p<0.001) had higher odds of under-triage compared to Medicaid patients. Patients in level II (p<0.001) and level III (p<0.001) trauma hospitals were associated with higher odds of over-triage.

CONCLUSION

Pacific Islander and American Indian patients, Medicare, and level II and III trauma centers are at increased risk of over-triage rates, while Hispanic and privately insured trauma patients had a higher risk for under-triage. Future studies should further investigate factors contributing to poor outcomes linked to under-triage practices and methods to improve consistency and standardization of triage tools across various levels of trauma centers.

Race and Ethnicity Influences Outcomes of Adult Burn Patients

Outcomes of burn survivors is a growing field of interest; however, there is little data comparing the outcomes of burn survivors by ethnicity. This study seeks to identify any inequities in burn outcomes by racial and ethnic groups. A retrospective chart review of an ABA Certified burn center at a large urban safety net hospital identified adult inpatient admissions from 2015 to 2019. A total of 1142 patients were categorized by primary ethnicity: 142 black or African American, 72 Asian, 479 Hispanic or Latino, 90 white, 215 other, and 144 patients whose race or ethnicity was unrecorded. Multivariable analyses evaluated the relationship between race and ethnicity and outcomes. Covariate confounders were controlled by adjustment of demographic, social, and prehospital clinical factors to isolate differences that might not be explained by other factors. After controlling for covariates, black patients had 29% longer hospital stays (P = .043). Hispanic patients were more likely to be discharged to home or to hospice care (P = .005). Hispanic ethnicity was associated with a 44% decrease in the odds of discharge to acute care, inpatient rehabilitation, or a ward outside the burn unit (P = .022). Black and Hispanic patients had a higher relative chance of having publicly assisted insurance, versus private insurance, than their white counterparts (P = .041, P = .011 respectively). The causes of these inequities are indeterminate. They may stem from socioeconomic status not entirely accounted for, ethnic differences in comorbidity related to stressors, or inequity in health care delivery.

Comparing Pediatric Physical Trauma Outcomes by Special Health Care Needs Status

BACKGROUND AND OBJECTIVES

Children and Youth with Special Health Care Needs (CYSHCN) have differing risk factors and injury characteristics compared with peers without special health care needs (SHCN). We examined the association between SHCN status and complications, mortality, and length of stay (LOS) after trauma hospitalization.

METHODS

We conducted a cross-sectional study using 2018 data from the National Trauma Data Bank for patients aged 1 to 18 years (n = 108 062). We examined the following hospital outcomes: any complication reported, unplanned admission to the ICU, in-hospital mortality, and hospital and ICU LOS. Multivariate regression models estimated the effect of SHCN status on hospital outcomes after controlling for patient demographics, injury severity score, and Glasgow Coma Score. Subanalyses examined outcomes by age, SHCN, and injury severity score.

RESULTS

CYSHCN encounters had a greater adjusted relative risk (ARR) of any hospital complications (ARR = 2.980) and unplanned admission to the ICU (ARR = 1.996) than encounters that did not report a SHCN (P < .001). CYSHCN had longer hospital (incidence rate ratio = 1.119) and ICU LOS (incidence rate ratio = 1.319, both P < .001). There were no statistically significant in-hospital mortality differences between CYSHCN and those without. Lower severity trauma was associated with a greater ARR of hospital complications for CYSHCN encounters versus non-CYSHCN encounters.

CONCLUSIONS

CYSHCN, particularly those with lower-acuity injuries, are at greater risk for developing complications and requiring more care after trauma hospitalization. Future studies may examine mechanisms of hospital complications for traumatic injuries among CYSHCN to develop prevention and risk-minimization strategies.

Impact of the Social Determinants of Health on Adult Trauma Outcomes

Social determinants of health (SDOHs) have been well studied within the literature in the United States but the effects of these determinants of health on patients with trauma have garnered less attention. The interaction between patients with SDOHs and patients with trauma requires clinicians caring for this population to view patients with trauma through a multifaceted lens. The purpose of this article will be to illuminate the drivers of trauma in the adult population and how the SDOHs and the health-care system come together to contribute to disparities in trauma outcomes.

Differences in mental health engagement and follow-up among Black and White patients after traumatic injury

BACKGROUND

Severe injury necessitating hospitalization is experienced by nearly three million US adults annually. Posttraumatic stress disorder and depression are prevalent clinical outcomes. The mechanisms by which programs equitably promote mental health recovery among trauma-exposed patients are understudied. We evaluated clinical outcomes and engagement among a cohort of Black and White patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate mental health recovery after traumatic injury.

METHODS

Trauma Resilience and Recovery Program is a four-step model that includes (1) bedside psychoeducation about mental health recovery following traumatic injury, (2) a text-messaging symptom tracking system, (3) a 30-day postinjury mental health screen, and (4) referrals to mental health services. Data describe 1,550 patients enrolled in TRRP within a Level I trauma center ( Mage = 40.86; SD, 17.32), 611 of whom identified as Black (74.5% male) and 939 of whom identified as White (67.7% male).

RESULTS

Enrollment in TRRP was nearly universal (97.9%) regardless of race or injury mechanism. Enrollment and usage of the text-message system were statistically similar between Black (35.7%) and White patients (39.5%). Trauma Resilience and Recovery Program reengaged Black and White patients at a similar rate at the 30-day postinjury follow-up. However, Black patients were more likely to report peritraumatic distress at the bedside and clinical elevations in posttraumatic stress disorder and depression on the 30-day screen. Referrals were more likely to be accepted by Black patients relative to White patients with clinically elevated symptoms.

CONCLUSION

Enrollment and engagement were comparable among Black and White patients served by TRRP. Data provide preliminary evidence to suggest that TRRP is feasible and acceptable and engages patients in mental health follow-up equitably. However, research that includes careful measurement of social determinants of health and long-term follow-up examining initiation, completion, and benefit from treatment is needed.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

History of Equity, Diversity, and Inclusion in Trauma Surgery: for Our Patients, for Our Profession, and for Ourselves

Purpose of Review

Disparities exist in outcome after injury, particularly related to race, ethnicity, socioeconomics, geography, and age. The mechanisms for this outcome disparity continue to be investigated. As trauma care providers, we are challenged to be mindful of and mitigate the impact of these disparities so that all patients realize the same opportunities for recovery. As surgeons, we also have varied professional experiences and opportunities for achievement and advancement depending upon our gender, ethnicity, race, religion, and sexual orientation. Even within a profession associated with relative affluence, socioeconomic status conveys different professional opportunities for surgeons.

Recent Findings

Fortunately, the profession of trauma surgery has undergone significant progress in raising awareness of patient and professional inequity among trauma patients and surgeons and has implemented systematic changes to diminish these inequities. Herein we will discuss the history of equity and inclusion in trauma surgery as it has affected our patients, our profession, and our individual selves.

Summary

Our goal is to provide a historical context, a status report, and a list of key initiatives or objectives on which all of us must focus. In doing so, the best possible clinical outcomes can be achieved for patients and the best professional and personal “outcomes” can be achieved for practicing and future trauma surgeons.

Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality

BACKGROUND

Racial disparities in trauma care have been reported for a range of outcomes, but the extent to which these remain after accounting for socioeconomic and environmental factors remains unclear. The objective of this study was to evaluate the unique contributions of race, health insurance, community distress, and rurality/urbanicity on trauma outcomes after carefully controlling for specific injury-related risk factors.

METHODS

All adult (age, ≥18 years) trauma patients admitted to a single Level I trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed. Primary outcomes were mortality, rehabilitation referral, and receipt of opioids in the emergency department. Demographic, socioeconomic, and injury characteristics as well as indicators of community distress and rurality based on home address were abstracted from a trauma registry database.

RESULTS

Analyses revealed that Black patients (n = 13,073) were younger, more likely to be male, more likely to suffer penetrating injuries, and more likely to suffer assault-based injuries compared with White patients (n = 10,946; all p < 0.001). In adjusted analysis, insured patients had a 28% lower risk of mortality (odds ratio, 0.72; p = 0.005) and were 92% more likely to be referred for postdischarge rehabilitation than uninsured patients (odds ratio, 1.92; p = 0.005). Neither race- nor place-based factors were associated with mortality. However, post hoc analyses revealed a significant race by age interaction, with Black patients exhibiting more pronounced increases in mortality risk with increasing age.

CONCLUSION

The present findings help disentangle the social determinants of trauma disparities by adjusting for place and person characteristics. Uninsured patients were more likely to die and those who survived were less likely to receive referrals for rehabilitation services. The expected racial disparity in mortality risk favoring White patients emerged in middle age and was more pronounced for older patients.

LEVEL OF EVIDENCE

Prognostic and epidemiological, Level III.

Healthcare disparities in trauma: why they exist and what we can do

PURPOSE OF REVIEW

This review will explore the underlying causes of healthcare disparities among trauma patients and offer considerations for reducing inequities to improve trauma care.

RECENT FINDINGS

Newly recognized racial disparities exist with respect to triaging trauma patients and in acute pain management. Social Determinants of Health offers a model to understand disparity in trauma care.

SUMMARY

Race, ethnicity, socioeconomic status, and access to healthcare drive outcome disparity among trauma patients. These disparities include reduced healthcare services, inadequate pain management, reduced postdischarge care, and increased mortality. Increasing workforce diversity may mitigate implicit bias and improve cultural competency. Social determinants of health impact the disparities in trauma care and offer a framework to address care through creative solutions.

Gunshot wounds sustained during legal intervention versus those inflicted by civilians: A comparative analysis

BACKGROUND

Existing data demonstrate that injuries sustained during legal intervention (LI) differ from those incurred during civilian interpersonal violence (CIV), but gunshot wounds (GSWs) have not yet been specifically examined. This study was undertaken to provide an in-depth analysis of patients shot during LI versus CIV.

METHODS

Patients injured by GSW and captured by the National Trauma Data Bank (2007-2017) were included. Exclusions were transfer from outside hospital or self-inflicted, accidental, or undetermined injury intent GSWs. Study groups were defined by injury circumstances: GSWs sustained during LI versus CIV. Univariable analysis compared demographics, clinical/injury data, and outcomes.

RESULTS

In total, 248,726 patients met inclusion/exclusion criteria: 98% (n = 243,150) CIV versus 2% (n = 5,576) LI. Race varied significantly between study groups (p < 0.001). White patients were the most commonly injured race after LI (n = 2,176, 39%). Black patients were the most commonly injured race after CIV (n = 139,067, 57%). Psychiatric disease (9% vs. 2%, p < 0.001) was more common among LI GSWs. The LI patients were more frequently tachycardic (18% vs. 13%, p < 0.001), hypotensive (26% vs. 14%, p < 0.001), and comatose (34% vs. 15%, p < 0.001). The LI patients had higher Injury Severity Scores (13 vs. 9, p < 0.001), required emergent surgical intervention (39% vs. 28%, p < 0.001) and intensive care unit admission (47% vs. 32%, p < 0.001) more often, and had longer hospital stay (4 vs. 3 days, p < 0.001). Mortality was higher after LI (27% vs. 14%, p < 0.001).

CONCLUSION

Significant racial and injury severity differences exist between patients shot during LI and CIV. White patients were the most commonly injured race after LI, while Black patients were the most commonly injured race during CIV. In addition, Black patients were overrepresented in both groups when compared with their proportion in the US population. LI patients were more significantly injured, as quantified by clinical, injury, and outcomes variables including increased mortality. Further study of patients shot during LI is needed to better understand this increased burden of injury.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level IV.

High Social Vulnerability and "Textbook Outcomes" after Cancer Operation

BACKGROUND

The effect of community-level factors on surgical outcomes has not been well examined. We sought to characterize differences in "textbook outcomes" (TO) relative to social vulnerability among Medicare beneficiaries who underwent operations for cancer.

METHODS

Individuals who underwent operations for lung, esophageal, colon, or rectal cancer between 2013 and 2017 were identified using the Medicare database, which was merged with the CDC's Social Vulnerability Index (SVI). TO was defined as surgical episodes with the absence of complications, extended length of stay, readmission, and mortality. The association of SVI and TO was assessed using mixed-effects logistic regression.

RESULTS

Among 203,800 patients (colon, n = 113,929; lung, n = 70,642; rectal, n = 14,849; and esophageal, n = 4,380), median age was 75 years (interquartile range 70 to 80 years) and the overwhelming majority of patients was White (n = 184,989 [90.8%]). The overall incidence of TO was 56.1% (n = 114,393). The incidence of complications (low SVI: 21.5% vs high SVI: 24.0%) and 90-day mortality (low SVI: 7.0% vs high SVI: 8.4%) were higher among patients from highly vulnerable neighborhoods (both, p < 0.05). In turn, there were lower odds of achieving TO among high-vs low-SVI patients (odds ratio 0.83; 95% CI, 0.78 to 0.87). Although high-SVI White patients had 10% lower odds (95% CI, 0.87 to 0.93) of achieving TO, high-SVI non-White patients were at 22% lower odds (95% CI, 0.71 to 0.85) of postoperative TO. Compared with low-SVI White patients, high-SVI minority patients had 47% increased odds of an extended length of stay, 40% increased odds of a complication, and 23% increased odds of 90-day mortality (all, p < 0.05).

CONCLUSIONS

Only roughly one-half of Medicare beneficiaries achieved the composite optimal TO quality metric. Social vulnerability was associated with lower attainment of TO and an increased risk of adverse postoperative surgical outcomes after several common oncologic procedures. The effect of high SVI was most pronounced among minority patients.