Race and trauma mortality: The effect of hospital-level Black–White patient race distribution

Abstract

BACKGROUNDRace-related health disparities have been well documented in the United States. In some settings, Black patients have better outcomes in hospitals that serve high proportions of Black patients. We hypothesized that Black trauma patients would have lower mortality in high Black-serving (H-BS) hospitals.METHODSWe identified all adult patients with Black or White race and with an Injury Severity Score of ≥4 from the 2017 National Inpatient Sample. We collected hospital identifier, mechanism, age, sex, comorbidities, urban-rural location, insurance, zip code income quartile, and injury severity calculated from International Classification of Diseases, Tenth Revision, codes. We used a previously published method to group hospitals by proportion of Black patients served: HB-S (top 5%), medium Black serving (5–25%), and low Black serving (L-BS; bottom 75%). Adjusted logistic regression using an interaction variable between race and hospital service rank (reference: White patients in H-BS) was used to identify factors associated with mortality.RESULTSWe analyzed 184,080 trauma patients (median age, 72 years [interquartile range, 55–84 years]; Injury Severity Score, 9 [4–10]), of whom 11.7% were Black. Overall mortality was 4%. Of 2,376 hospitals, 126 (5.3%) were H-BS and 469 (19.7%) were medium Black serving. Furthermore, 29.8% of Black and 3.6% of White patients were treated at H-BS hospitals, while 71.7% of White and 23.6% of Black patients were treated at L-BS hospitals (p < 0.001). Black patients had the lowest mortality at H-BS hospitals (odds ratio [OR], 0.76 [0.64–0.92]) and the highest mortality (OR, 1.43 [1.13–1.80]) at L-BS hospitals. White patients had the lowest mortality at L-BS hospitals (OR, 0.76 [0.64–0.92]).CONCLUSIONAfter adjusting for patient and hospital factors, disparities exist such that Black and White patients have the best outcomes in hospitals that treat those patients most frequently, suggesting potential for racial bias at the institutional level. Further efforts must be made to promote equitable treatment at all hospitals and reduce these disparities.LEVEL OF EVIDENCEPrognostic and Epidemiologic; Level IV.

Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery

“…Although findings on mortality varied in studies regarding race/ethnicity, we identified that Black patients had improved mortality rates in hospitals that served primarily Black patients. 5 These differences highlight bias in trauma treatment based on race/ethnicity. While studies on health literacy were less common, they identified that low health literacy led to poor understanding of injuries and treatment plans, decreased compliance with discharge instructions, and worse long-term functional outcomes.…”

“…22,23 Compared with their White peers, Black patients with hip fractures were more likely to experience delayed time to procedures (15.5% vs. 10.6%; p < 0.001), increased complication rates, and a longer hospital stay duration (7.4 days vs. 6.4 days), however one study found that Black trauma patients had lower mortality rates in hospitals with a higher proportion of Black patients (mortality at high black-serving hospitals: OR, 0.76; 95% CI, 0.64-0.92; p = 0.004; mortality at low black-serving hospitals: OR, 1.43; 95% CI, 1.13-1.80; p = 0.003). 5…”

“…[2][3][4] Evaluating the cause and effect of these disparities is necessary to improve patient outcomes of those from disadvantaged backgrounds. 5 Over the past decade, trauma and ACS literature has exhibited an increased focus on the link between health care disparities and patient outcomes. 2 The effects of social determinants of health (SDOH) on the delivery of care are often multifactorial and complex, requiring an understanding of health care systems, medical education, local economic factors, and patient demographics.…”

“…6 Recent studies have demonstrated a greater understanding of how race and ethnicity affect trauma and ACS outcomes such as mortality. 5 One study reveals trauma-related deaths could be linked to racial disparities in the care of Black patients. 7 Similarly, studies have shown that a lack of insurance, especially in under-represented pediatric patients, is linked to higher mortality after trauma, and can also be predictive of outcomes in adults such as post-hospitalization care and disposition.…”

“…Health care disparities, defined as differences in measurable outcomes related to social, economic, and environmental disadvantage, are linked to many trauma and ACS patient outcomes including mortality and complications 2–4 . Evaluating the cause and effect of these disparities is necessary to improve patient outcomes of those from disadvantaged backgrounds 5 …”