Disparities in Adult and Pediatric Trauma Outcomes: a Systematic Review and Meta‐Analysis

Abstract

Background Although safeguards requiring emergency care are provided regardless of a patient's payor status, disparate outcomes have been reported in trauma populations. The purpose of this systematic review and meta‐analysis was to determine whether race/ethnicity or insurance status had an effect on mortality and to systematically present the literature in the adult and pediatric trauma populations during the last decade. Methods An online search of PubMed, Cochrane Library, Google Scholar, and SAGE Journals was performed for publications from January 2009 to March 2019. The Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines were used. The GRADE Working Group criteria were utilized to assess the evidence quality. A meta‐analysis was conducted to compare mortality between insured/uninsured and Caucasian/non‐Caucasian patients. Results Our search revealed 680 publications that qualified for evaluation. Of these, 41 were included in the final analysis. Twenty‐six studies included adults only, nine studies included pediatric patients only, and six studies evaluated both. Twelve studies evaluated the effects of race/ethnicity, 18 examined insurance status, and 11 investigated both. Uninsured patients had 22% greater odds of death than insured patients (OR 1.22; CI 1.21–1.24). Non‐Caucasian patients had 18% greater risk of death than Caucasian patients (OR 1.18; CI 1.17–1.20). Conclusion Both the adult and pediatric trauma populations suffer outcome disparities based on race/ethnicity and insurance status. Overall, patients without insurance coverage and minority groups (i.e., non‐Caucasians) had worse outcomes, as measured by odds of death and all‐cause mortality.

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

“…This finding adds to prior research documenting higher mortality rates for adult and pediatric trauma patients lacking health insurance, adjusting for race, injury type, and injury severity 11,34,38,39 . The effect size reported in the present study (28% greater odds of death for uninsured) is comparable to the aggregate effect size reported for studies published between 2009 and 2019 (22% greater odds of death for uninsured) 34 but lower than the aggregate effect size reported for studies published between 1990 and 2011 (117% greater odds of death for uninsured) 11 . Research further suggests that insurance type impacts mortality, with uninsured and publicly insured trauma patients being more likely to die than those with private insurance 40 .…”

“…Trauma patients with insurance were less likely to die than uninsured patients, controlling for established mortality risk factors such as race, age, community distress, and injury characteristics (i.e., type, severity). This finding adds to prior research documenting higher mortality rates for adult and pediatric trauma patients lacking health insurance, adjusting for race, injury type, and injury severity 11,34,38,39 . The effect size reported in the present study (28% greater odds of death for uninsured) is comparable to the aggregate effect size reported for studies published between 2009 and 2019 (22% greater odds of death for uninsured) 34 but lower than the aggregate effect size reported for studies published between 1990 and 2011 (117% greater odds of death for uninsured) 11 .…”

“…11 A recent systematic review found that racial minority and uninsured patients were 18% and 22% more likely to die from a traumatic injury than their White/Caucasian and insured counterparts, respectively. 34 One critical challenge for research on trauma disparities is to account for the overlapping and potentially confounding effects of race, SES, and insurance status on outcomes, while adjusting for patient-level (e.g., demographic) and often-overlooked geographic (e.g., neighborhood deprivation) factors that may differentially impact patient population subgroups. 26 Despite evidence that apparent racial disparities in trauma mortality are eliminated after controlling for neighborhood poverty levels and insurance status, 29 a review of National Trauma Data Bank studies found that almost half did not adequately control for disparity-relevant factors.…”

“…Disparities based on race, SES, and insurance status, have been documented for a range of health outcomes across the continuum of trauma care 11 . A recent systematic review found that racial minority and uninsured patients were 18% and 22% more likely to die from a traumatic injury than their White/Caucasian and insured counterparts, respectively 34 . One critical challenge for research on trauma disparities is to account for the overlapping and potentially confounding effects of race, SES, and insurance status on outcomes, while adjusting for patient-level (e.g., demographic) and often-overlooked geographic (e.g., neighborhood deprivation) factors that may differentially impact patient population subgroups 26 .…”

The Shortage of Trauma Surgeons in the US

“…Insurance prevalence also has major impacts on TC distribution and total inpatient care financial cost. 38,39 One potential explanation for these findings could be closure of TCs disproportionately affecting certain populations. 39,40 Lastly, the financial consequences of decreased TSs must be considered as economic burden of inpatient trauma patient care has been calculated to surpass $37 billion.…”