A report published Online First by Archives of Surgery, one of the JAMA/Archives journals, revealed that the odds of dying appear to increase for patients treated at hospitals with higher proportions of minority trauma patients, however, racial disparities may offer some explanation for differences in outcomes between trauma hospitals.
Previous research has shown that injuries are the third largest contributor to racial disparities in U.S. mortality, with variations in quality care and outcomes probably significantly contributing to this problem according to background information in the article. Even when socioeconomic status and insurance coverage are controlled for, some studies still indicated that health care is less complex and of lesser quality for minorities. The authors comment that treatment preferences, implicit biases as well as institutional and health system related factors might also play a role in race-based differences in outcomes.
They write:
“The objective of our study is to use the largest available national trauma registry to determine whether patients treated at hospitals primarily serving minority patients with trauma have higher rates of in-hospital mortality. If this were found to be true, then these hospitals could be targeted for performance improvement initiatives that could help reduce disparities experienced by racial and ethnic minorities.”
Adil H. Haider, M.D., M.P.H., from the Johns Hopkins School of Medicine, Baltimore, and his team evaluated 311,568 patients records aged 18 to 64 years who were white, black or Hispanic and had an Injury Severity Score of nine or greater. The patients were treated at 434 hospitals between 2007 and 2008 with patient records supplied by the National Trauma Data Bank.
The team divided hospitals into categories depending on the percentage of minority patients admitted with trauma with the reference group including hospitals with less than 25 % of minority patients. The reference group was compared with hospitals that had between 25% to 50 % of minority patients and those with over 50% of minority patients.
Hospitals classed as principally minority (i.e. over 50 % of minority patients) were likely to have younger patients, fewer female patients, more patients with penetrating trauma, and with 5% showed the highest rate of crude mortality (death from all causes).
After adjusting the data for potential confounders, researchers noted that compared with the reference group, the odds of death seemed to increase 16 % in hospitals with 25 to 50% minority patients and 37 % in hospitals with over 50 % minority patients. Hospitals with at least 25% of minority patients tended to be level 1 trauma centers and teaching hospitals.
When data of patients who suffered a blunt injury was analyzed, the odds of death increased to 18% in hospitals with 25 to 50 % minority patients and to 45 % in those with over 50 % minority patients. Hospitals with increased percentages of minority patients tended to have more patients without health insurance in comparison with the reference group, but the odds of mortality increased in all three hospital groups for these patients.
The authors conclude:
“The exact mechanisms that lead to the higher mortality rates observed at hospitals with a disproportionately high percentage of minority patients need to be investigated further.”
This research could investigate potential aspects that affects patients’ survival rates, for example pre-hospital transport variations, pre-existing conditions and other disparities as well as hospitals’ adherence to trauma protocols and other process measures.
The researchers recommend that hospitals that predominantly cater for minority patients and large numbers of uninsured patients should be the focus of initiatives to financially strengthen them. They conclude stating:
“Augmenting the assets of resource-poor institutions and implementing culturally competent quality-of-care improvement programs at hospitals that primarily serve minority populations may be an excellent first step toward reducing racial disparities in trauma outcomes and improving care for all patients.”
Invited Critique: Ethnicity, Insurance Status, and Hospitals Serving Predominantly Minorities
Ali Salim, M.D., from Cedars-Sinai Medical Center in Los Angeles commented on Haider and his team’s study in an invited critique. He argues that the researchers conclude that it is irrelevant what type of facility patients get transported to after a trauma injury but Salim states that the majority of minority hospitals have worse outcomes, regardless of the designation of their trauma centers (level 1, 2, or 3) or their teaching status. He writes, “This provocative study raises more questions than it answers.”
Salim highlights that health care reform will further complicate the situation, writing:
“These low-performing hospitals are lacking in resources, which leads to low performance. This low performance will negatively effect reimbursement. How do we stop this vicious cycle from perpetuating these outcomes that seem to disproportionately affect minority patients? Perhaps just having this discussion is a good first step.”
Written by Petra Rattue