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Trauma care does not discriminate: The association of race and health insurance with mortality following traumatic injury.

ABSTRACT: Previous studies have reported that black race and lack of health insurance coverage are associated with increased mortality following traumatic injury. However, the association of race and insurance status with trauma outcomes has not been examined using contemporary, national, population-based data.We used data from the National Inpatient Sample on 215,615 patients admitted to 1 of 836 hospitals following traumatic injury in 2010. We examined the effects of race and insurance coverage on mortality using two logistic regression models, one for patients younger than 65 years and the other for older patients.Unadjusted mortality was low for white (2.71%), black (2.54%), and Hispanic (2.03%) patients. We found no difference in adjusted survival for nonelderly black patients compared with white patients (adjusted odds ratio [AOR], 1.04; 95% confidence interval [CI], 0.90-1.19; p = 0.550). Elderly black patients had a 25% lower odds of mortality compared with elderly white patients (AOR, 0.75; 95% CI, 0.63-0.90; p = 0.002). After accounting for survivor bias, insurance coverage was not associated with improved survival in younger patients (AOR, 0.91; 95% CI, 0.77-1.07; p = 0.233).Black race is not associated with higher mortality following injury. Health insurance coverage is associated with lower mortality, but this may be the result of hospitals' inability to quickly obtain insurance coverage for uninsured patients who die early in their hospital stay. Increasing insurance coverage may not improve survival for patients hospitalized following injury.Epidemiologic and prognostic study, level III.

SUBMITTER: Osler T

PROVIDER: S-EPMC4410431 | biostudies-literature | 2015 May

REPOSITORIES: biostudies-literature

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Trauma care does not discriminate: The association of race and health insurance with mortality following traumatic injury.

Osler Turner T Glance Laurent G LG Li Wenjun W Buzas Jeffery S JS Wetzel Megan L ML Hosmer David W DW

The journal of trauma and acute care surgery 20150501 5

<h4>Background</h4>Previous studies have reported that black race and lack of health insurance coverage are associated with increased mortality following traumatic injury. However, the association of race and insurance status with trauma outcomes has not been examined using contemporary, national, population-based data.<h4>Methods</h4>We used data from the National Inpatient Sample on 215,615 patients admitted to 1 of 836 hospitals following traumatic injury in 2010. We examined the effects of r ...[more]

PMID: 25909426

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Project description:OBJECTIVES:To examine the impact of early myocardial workload on in-hospital mortality following isolated severe traumatic brain injury. DESIGN:Retrospective cohort study. SETTING:Data from the National Trauma Databank, a multicenter trauma registry operated by the American College of Surgeons, from 2007 to 2014. PATIENTS:Adult patients with isolated severe traumatic brain injury (defined as admission Glasgow Coma Scale < 8 and head Abbreviated Injury Score ? 4). INTERVENTIONS:Admission rate-pressure product, categorized into five levels based on published low, normal, and submaximal human thresholds: less than 5,000; 5,000-9,999; 10,000-14,999; 15,000-19,999; and greater than 20,000. MEASUREMENTS AND MAIN RESULTS:Data from 26,412 patients were analyzed. Most patients had a normal rate-pressure product (43%), 35% had elevated rate-pressure product, and 22% had depressed rate-pressure product at hospital admission. Compared with the normal rate-pressure product group, in-hospital mortality was 22 percentage points higher in the lowest rate-pressure product group (cumulative mortality, 50.2%; 95% CI, 43.6-56.9%) and 11 percentage points higher in the highest rate-pressure product group (cumulative mortality, 39.2%; 95% CI, 37.4-40.9%). The lowest rate-pressure product group was associated with a 50% increased risk of mortality, compared with the normal rate-pressure product group (adjusted relative risk, 1.50; 95% CI, 1.31-1.76%; p < 0.0001), and the highest rate-pressure product group was associated with a 25% increased risk of mortality, compared with the normal rate-pressure product group (adjusted relative risk, 1.25; 95% CI, 1.18-1.92%; p < 0.0001). This relationship was blunted with increasing age. Among patients with normotension, those with depressed and elevated rate-pressure products experienced increased mortality. CONCLUSIONS:Adults with severe traumatic brain injury experience heterogeneous myocardial workload profiles that have a "U-shaped" relationship with mortality, even in the presence of a normal blood pressure. Our findings are novel and suggest that cardiac performance is important following severe traumatic brain injury.

Project description:Importance:Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival. Objective:To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants:The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ?3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions:Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures:Primary: survival to hospital discharge; secondary: survival to hospital admission. Results:Of the included patients, the median age was 45 years, 14?666 (67.1%) were men, 7181 (32.9%) were women; 16?408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21?852 met inclusion criteria for analysis (preimplementation phase [P1]: 15?228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P?=?.40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P?<?.001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P?<?.001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P?=?.02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P?<?.001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P?=?.02). Conclusions and Relevance:Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines. Trial Registration:ClinicalTrials.gov identifier: NCT01339702.

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Trauma care does not discriminate: The association of race and health insurance with mortality following traumatic injury.

Publications

Trauma care does not discriminate: The association of race and health insurance with mortality following traumatic injury.

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