Social determinants of health and patient-level mortality prediction after trauma

Abstract

BACKGROUND:Social determinants of health (SDOH) impact patient outcomes in trauma. Census data are often used to account for SDOH; however, there is no consensus on which variables are most important. Social vulnerability indices offer the advantage of combining multiple constructs into a single variable. Our objective was to determine if incorporation of SDOH in patient-level risk-adjusted outcome modeling improved predictive performance. METHODS:We evaluated two social vulnerability indices at the zip code level: Distressed Community Index (DCI) and National Risk Index (NRI). Individual variable combinations from Agency for Healthcare Research and Quality's SDOH data set were used for comparison. Patients were obtained from the Pennsylvania Trauma Outcomes Study 2000 to 2020. These measures were added to a validated base mortality prediction model with comparison of area under the curve and Bayesian information criterion. We performed center benchmarking using risk-standardized mortality ratios to evaluate change in rank and outlier status based on SDOH. Geospatial analysis identified geographic variation and autocorrelation. RESULTS:There were 449,541 patients included. The DCI and NRI were associated with an increase in mortality (adjusted odds ratio, 1.02; 95% confidence interval, 1.01-1.03 per 10% percentile rank increase; p < 0.01, respectively). The DCI, NRI, and seven Agency for Healthcare Research and Quality variables also improved base model fit but discrimination was similar. Two thirds of centers changed mortality ranking when accounting for SDOH compared with the base model alone. Outlier status changed in 7% of centers, most representing an improvement from worse-than-expected to nonoutlier or nonoutlier to better-than-expected. There was significant geographic variation and autocorrelation of the DCI and NRI (DCI; Moran's I 0.62, p = 0.01; NRI; Moran's I 0.34, p = 0.01). CONCLUSION:Social determinants of health are associated with an individual patient's risk of mortality after injury. Accounting for SDOH may be important in risk adjustment for trauma center benchmarking.

Cues to care: Chronic disease diagnosis in young adult trauma patients

“…Although there are regional differences in disease prevalence between our population and nationally, these high rates of undiagnosed chronic disease are likely a reflection of the sociodemographic risk factors inherent in a trauma population and with less access to care, as reflected by high percentages of uninsured patients and low rates of documented PCPs. 7 Surprisingly, markers traditionally considered proxies for access to care did not always translate to improved diagnosis rates, health care touchpoints, or effective utilization of these services. Although urbanicity and reporting a PCP differed significantly between the cohort with and without UD, neither effectively contributed to the predictive ability of our model when other demographic characteristics were included.…”

“…2 The trauma population has additional risk factors, including sociodemographic risk factors, high uninsurance rates, and decreased access to routine care, which are associated with chronic disease, both diagnosed and undiagnosed. 5,7 However, limited studies quantify the burden of chronic disease among young adults, with the Centers for Disease Control and Prevention report being one of the first to focus explicitly on the young adult population. There are no studies that quantify chronic disease burden for young adults that experience trauma.…”

Recent Developments in Mouse Trauma Research Models: A Mini-Review

“…However, the downsides of using murine models in such a complex field of research, as represented within this review, should always be borne in mind. Apart from focusing on clinical relevance and clinical translatability, further improvement of existing models should also consider the importance of social determinants of health as they are relevant for the outcome and mortality after trauma (Phelos et al, 2022), but are often overlooked within current studies.…”

Association of race and socioeconomic status with time to pain control among pediatric trauma patients managed nonoperatively

“…Injury is a leading cause of morbidity and mortality in children, 1 with notable inequities in the rates, types, and outcomes of injuries depending on a child's social determinants of health (SDH) 2–5 . The World Health Organization defines the SDH as “the conditions in which people are born, grow, work, live, and age.” 6 There are also notable inequities in pain management based on a child's SDH in all phases of care.…”