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

Abstract

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.

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

“…Of these publications, 4,104 were excluded and 74 articles were included (Supplemental Digital Content, Supplementary Figure 1, http://links.lww.com/TA/D174). 2–76 A bimodal distribution shows that location and access disparities represented the majority of articles, followed by age and race (Fig. 1).…”

“…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. 2 Additional studies have demonstrated how disparities in sex/gender, access to care, age, and health literacy interact to cause similar discrepancies in outcomes.…”

“…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 2 .…”

What medical–legal partnerships can do for trauma patients and trauma care

“…S ocial and structural determinants of health have a major impact on outcomes after traumatic injury, 1 often outstripping the role of acute medical care. 2 Clinicians and health systems are striving to address these societal inequities to improve outcomes for trauma patients. 3,4 Some of these health-harming social factors have legal remedies, and attorneys or other trained legal advocates could support patient health by applying existing legal protections and resources.…”

“…Trauma patients are also frequently negatively influenced by legal structures like policing, firearm violence, and involvement with the legal system. 2 In addition, trauma patients may benefit from legal access to state compensation policies that provide funds for victims of violence or crime. Trauma patients and trauma systems of care therefore stand to benefit from addressing health-harming legal needs.…”