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Explaining the Paradoxical Age-based Racial Disparities in Survival After Trauma: The Role of the Treating Facility

Hicks, Caitlin W. MD, MS*; Hashmi, Zain G. MBBS*; Hui, Xuan MD*; Velopulos, Catherine MD*; Efron, David T. MD*; Schneider, Eric B. PhD*; Cooper, Lisa MD, MPH; Haut, Elliott R. MD*; Cornwell, Edward E. III MD; Haider, Adil H. MD, MPH, FACS*,‡

doi: 10.1097/SLA.0000000000000809
Original Articles

Objective: The objective of our study was to determine if differences in outcomes at treating facilities can help explain these age-based racial disparities in survival after trauma.

Background: It has been previously demonstrated that racial disparities in survival after trauma are dependent on age. For patients younger than 65 years, blacks had an increased odds of mortality compared with whites, but among patients 65 years or older the opposite association was found.

Methods: Data on white and black trauma patients were extracted from the Nationwide Inpatient Sample (2003–2009) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Standardized observed-to-expected mortality ratios were calculated for individual treating facilities, adjusting for age, sex, insurance status, mechanism of injury, overall injury severity, head injury severity, and comorbid conditions. Observed-to-expected ratios were used to benchmark facilities as high-, average-, or low-performing facilities. Proportions and survival outcomes of younger (range, 16–64 years) and older (≥65 years) patients admitted within each performance stratum were compared.

Results: A total of 934,476 patients from 1137 facilities (8.3% high-performing, 85% average-performing, and 6.7% low-performing) were analyzed. Younger black patients had a higher adjusted odds of mortality compared with younger white patients [odds ratio, 1.19; 95% confidence interval, 1.11–1.27], whereas older black patients had a lower odds of mortality compared with older white patients [odds ratio, 0.81; 95% confidence interval, 0.74–88]. A significantly greater proportion of younger black patients were treated at low-performing facilities compared with both younger white patients and older black patients (49.6% vs 42.2% and 38.7%, respectively; P < 0.05).

Conclusions: Nearly half of all young black trauma patients are treated at low-performing facilities. However, facility-based differences do not seem to explain the paradoxical age-based racial disparities after trauma observed in the older population.

It has been previously demonstrated that racial disparities in trauma survival are dependent on age. Here, we demonstrate that significantly more young black patients were treated at low-performing facilities compared with young white and older black patients. However, facility-based differences do not explain the age-based racial disparities observed in the older population.

*Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD

Department of Surgery, Outcomes Research Center, Howard University College of Medicine, Washington, DC

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Reprints: Adil H. Haider, MD, MPH, FACS, Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, 1800 Orleans St, Zayed 6107, Baltimore, MD 21287. E-mail: ahaider1@jhmi.edu.

Disclosure: Supported by National Institutes of Health/NIGMS K23GM093112-01 and American College of Surgeons C. James Carrico Fellowship for the study of Trauma and Critical Care (A.H.H.). Dr Haut is the primary investigator of the National Institutes of Health Mentored Clinician Scientist Development Award K08 1K08HS017952-01 from the Agency for Healthcare Research and Quality entitled “Does Screening Variability Make DVT an Unreliable Quality Measure of Trauma Care?” Dr Haut receives royalties from Lippincott, Williams, & Wilkins for a book he coauthored (Avoiding Common ICU Errors). He has received honoraria for various speaking engagements regarding clinical and quality and safety topics and has given expert witness testimony in various medical malpractice cases.

The data herein was presented as an Oral Presentation at the American College of Surgeons 2013 Clinical Congress in Washington, DC 10/2013 (reference no. SF2013-38680).

The remaining authors have no conflicts of interest to disclose.

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