A Retrospective Cohort Study on Health Insurance: Related Disparities in Trauma Patients After Penetrating Injuries: 2000-2014.

OBJECTIVE: Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS: A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS: Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION: Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status.

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013-2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88-6.69) (OR: 11.24; 95% CI: 8.53-13.95), more time spent in ICU (2.73; 1.70-3.76) (7.98; 6.10-9.87), and increased risk for surgical site infection (1.32; 1.03-1.68) (2.54; 1.71-3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Racial disparities after vascular trauma are age-dependent.

OBJECTIVE: Different racial disparities exist between white and black all-cause trauma patients depending on their age group; however, the effects of race and age on outcomes after vascular trauma are unknown. We assessed whether the previously described age-dependent racial disparities after all-cause trauma persist in the vascular trauma population. METHODS: Vascular trauma patients were identified from the Nationwide Inpatient Sample (January 2005 to December 2012) using International Classification of Diseases-Ninth Edition codes. Univariable and multivariable analyses were used to compare in-hospital mortality and amputation for blacks vs whites for younger (16-64 years) and older (≥65 years) age groups. RESULTS: Black patients (n = 937) were younger, more frequently male, without insurance, and suffered from more penetrating and nonaccidental injuries than white patients (n = 1486; P < .001). On univariable analysis, blacks had a significantly higher risk of death (odds ratio, [OR], 1.78; 95% confidence interval [CI], 1.16-2.74) and a significantly lower risk of amputation (OR, 0.54; 95% CI, 0.38-0.77), but these differences were not sustained after adjusting for baseline differences between groups. When stratified by age, there were significant racial disparities in mortality and amputation on univariable analysis. After risk adjustment, these differences persisted in the older group (mortality: OR, 5.95; 95% CI, 1.42-25.0; amputation: OR, 4.21; 95% CI, 1.28-13.6; P < .001) but not the younger group (mortality: OR, 1.31; 95% CI, 0.71-2.42; amputation: OR, 0.92; 95% CI, 0.58-1.46; P = not significant). Differences in survival and amputation after vascular trauma appear to be related to a higher prevalence of nonaccidental penetrating injuries in the younger black population. Race was the single greatest predictor of poor outcomes in the older population (P ≤ .008). CONCLUSIONS: Older black patients are nearly five-times more likely to experience death or amputation after vascular trauma than their white counterparts. Contrary to reports suggesting that younger white patients have better outcomes after all-cause trauma than younger black patients, racial disparities among patients with traumatic vascular injuries appear to be confined to the older age group after risk adjustment.

Minority trauma patients tend to cluster at trauma centers with worse-than-expected mortality: can this phenomenon help explain racial disparities in trauma outcomes?

OBJECTIVES: To determine whether minority trauma patients are more commonly treated at trauma centers (TCs) with worse observed-to-expected (O/E) survival. BACKGROUND: Racial disparities in survival after traumatic injury have been described. However, the mechanisms that lead to these inequities are not well understood. METHODS: Analysis of level I/II TCs included in the National Trauma Data Bank 2007-2010. White, Black, and Hispanic patients 16 years or older sustaining blunt/penetrating injuries with an Injury Severity Score of 9 or more were included. TCs with 50% or more Hispanic or Black patients were classified as predominantly minority TCs. Multivariate logistic regression adjusting for several patient/injury characteristics was used to predict the expected number of deaths for each TC. O/E mortality ratios were then generated and used to rank individual TCs as low (O/E <1), intermediate, or high mortality (O/E >1). RESULTS: A total of 556,720 patients from 181 TCs were analyzed; 86 TCs (48%) were classified as low mortality, 6 (3%) intermediate, and 89 (49%) as high mortality. More of the predominantly minority TCs [(82% (22/27) vs 44% (67/154)] were classified as high mortality (P < 0.001). Approximately 64% of Black patients (55,673/87,575) were treated at high-mortality TCs compared with 54% Hispanics (32,677/60,761) and 41% Whites (165,494/408,384) (P < 0.001). CONCLUSIONS: Minority trauma patients are clustered at hospitals with significantly higher-than-expected mortality. Black and Hispanic patients treated at low-mortality hospitals have a significantly lower odds of death than similar patients treated at high-mortality hospitals. Differences in TC outcomes and quality of care may partially explain trauma outcomes disparities.

Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma.

BACKGROUND: Patients with penetrating injuries are known to have worse outcomes than those with blunt trauma. We hypothesize that within each injury mechanism there should be no outcome difference between insured and uninsured patients. METHODS: The National Trauma Data Bank version 7 was analyzed. Patients aged 65 years and older and burn patients were excluded. The insurance status was categorized as insured (private, government/military, or Medicaid) and uninsured. Multivariate analysis adjusted for insurance status, mechanism of injury, age, race, sex, injury severity score, shock, head injury, extremity injury, teaching hospital status, and year. RESULTS: A total of 1,203,243 patients were analyzed, with a mortality rate of 3.7%. The death rate was significantly higher in penetrating trauma patients versus blunt trauma patients (7.9% vs 3.0%; P < .001), and higher in the uninsured (5.3% vs 3.2%; P < .001). On multivariate analysis, uninsured patients had an increased odds of death than insured patients, in both penetrating and blunt trauma patients. Penetrating trauma patients with insurance still had a greater risk of death than blunt trauma patients without insurance. CONCLUSIONS: Insurance status is a potent predictor of outcome in both penetrating and blunt trauma.