Racial, ethnic and insurance disparities revealed in post-hospital care after trauma
According to the results of a new study published in the Journal of the American College of Surgeons, African-Americans, Hispanics and uninsured patients use fewer post-hospitalization services after traumatic injury, including home health care, skilled nursing care, and rehabilitation.
Notably, the authors found African-American patients fell short of post-hospital care in only a few categories, while disparities were highest among the Hispanic population. The study found Hispanic patients were far less likely to utilize post-hospitalization facilities and services regardless of insurance status, and therefore could have more severe long-term health consequences compared with other populations. This disparity could be due to a number of factors, including language barriers, provider or institutional bias, fear of the medical system, or fear of legal repercussions due to immigration status.
"Population disparities in health care have long been recognized, but this study is aimed at helping us comprehend the underlying mechanisms that lead to unequal outcomes among injured patients and demonstrates that race, ethnicity, and insurance status do indeed have important associations with post-hospital care after traumatic injury," said Adil Haider, MD, MPH, FACS, senior author of the study and associate professor of surgery, anesthesiology and critical care medicine, and co-director, Center for Surgery Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore.
The study examined 2007 data in the National Trauma Data Bank (NTDB) for trauma patients between the ages of 18 and 64. Of the 136,239 patients who met inclusion criteria, more African-American patients (80.5 percent) and Hispanics (86.2 percent) were discharged to home than white patients (76.8 percent). Fewer African-American patients (3.2 percent) and Hispanic patients (3.1 percent) were discharged to rehabilitation facilities than white patients (6.0 percent), and Hispanics were less likely to be discharged to home health care and nursing facilities than whites (African-American patients and white patients had similar rates for these services).
Researchers also found notable disparities in care based on insurance status. Hispanic patients were discharged at lower rates to all post-hospital care facilities regardless of whether they had private insurance, public insurance or if they were uninsured, compared with privately insured, non-Hispanic white patients. In addition, privately insured African-American patients were less likely than privately insured white patients to be discharged to home health care specifically.
Each year, trauma accounts for 37 million emergency department visits and more than two million hospital admissions in the U.S.1, and causes 31 percent of all life years lostmore than cancer, heart disease, and HIV combined.2 Rehabilitation after traumatic injury is a fundamental part of the U.S. trauma system and essential for patients to regain functionality, independence, productivity, and an acceptable quality of life. Worse outcomes have been reported in studies of trauma patients who represent disadvantaged populations. Hispanic patients with traumatic brain injury (TBI), for example, are more likely to be severely disabled six months after injury;3 Hispanic patients with spinal cord injury are more likely to be unemployed one year after injury;4 and African-American children have worse functional outcomes after TBI, including speech, locomotion, and feeding impairments.5 Several studies have also indicated uninsured patients have higher mortality rates after trauma.6 7
This study used a retrospective analysis of patient information from 2007 collected by the National Trauma Data Bank (NTDB), which is operated by the American College of Surgeons and which receives information from more than 700 trauma centers and other hospitals around the country. The year 2007 was chosen because it was the first year that the NTDB used the National Trauma Data Standard, a uniform set of trauma registry variables and definitions developed by the NTDB Committee with the U.S. Health Resources and Services Administration (HRSA). The use of the NTDB Standard has significantly improved the reliability and fidelity of the NTDB data.
Researchers excluded pediatric patients (age 17 years or less) and geriatric patients (age 65 years or older) because of the high percentage of public insurance and low percentage of uninsured among these populations, and because of their unique responses to traumatic injury. Burn patients and patients who died in the hospital were also excluded from the study.
1 Centers for Disease Control, July 2009.
2 Finkelstein, E.A., Corso, P.S., & Miller, T.R. The Incidence and Economic Burden of Injuries in the United States. USA: Oxford University Press. 2006.
3 Marquez de la Plata C, Hewlitt M, de Oliveira A, et al. Ethnic Differences in Rehabilitation Placement and Outcome After TBI. J Head Trauma Rehabil. 2007;22:113.
4 Arango-Lasprilla JC, Ketchum JM, Stevens LF, et al. Ethnicity/Racial Differences in Employment Outcomes Following Spinal Cord Injury. NeuroRehabilitation. 2009;24:37.
5 Haider AH, Efron DT, Haut ER, et al. Mortality in Adolescent Girls vs Boys Following Traumatic Shock: An Analysis of the National Pediatric Trauma Registry. Arch Surg. 2007;142:875discussion 879.
6 Haas JS, Goldman L. Acutely Injured Patients With Trauma in Massachusetts: Differences in Care and Mortality, by Insurance Status. Am J Pub Health. 1994;84:1605.
7 Haider AH, Chang DC, Efron DT, et al. Race and Insurance Status as Risk Factors for Trauma Mortality. Arch Surg. 2008;143:945.