High-Mortality Trauma Centers Drive Racial Disparities in Surgical Outcomes

Trauma is the leading cause of death among all Americans between the ages of 1 and 44 years old, but it has also been identified as the third largest contributor to US healthcare disparities.

Statisticians who have examined disparities in outcomes for surgical conditions — including traumatic injury — suggest that black and uninsured patients are more likely to die following trauma, even after controlling for demographics, injury severity, comorbidities, and other factors. Nevertheless, hospitals can’t improve surgical outcomes for their minority patients until they find the cause. Fortunately, two researchers from the Johns Hopkins School of Medicine may have found a cause.

For their study published in the October 2013 issue of The Annals of Surgery, the researchers hypothesized that predominantly-minority hospitals are also likely to be high-mortality hospitals, which would drive racial disparities. The research team set out to determine if minority trauma patients tend to be treated at trauma centers with worse observed-to-expected (O/E) mortality ratios. Additionally, they examined survival rates among minority patients treated at facilities with low mortality rates.

Using National Trauma Bank data from 2007 through 2010, the study authors considered 556,720 white, black, and Hispanic patients aged 16 years or older who sustained blunt or penetrating injuries with an Injury Severity Score of nine or greater. The researchers analyzed 181 treatment centers and classified centers with 50 percent or more Hispanic or black patients as predominantly minority. After predicting each treatment center’s expected number of deaths and O/E mortality ratios, the researchers classified 86 treatment centers as low mortality, six as intermediate mortality, and 89 as high mortality.

At the conclusion of their analysis, the researchers found that predominantly-minority treatment centers were more likely to be classified as high mortality compared to the other centers (82 percent versus 44 percent). Approximately 64 percent of black patients, 54 percent of Hispanic patients, and 41 percent of white patients had surgery performed at high-mortality treatment centers, which also had larger clusters of uninsured and penetrating trauma patients.

The researchers also found that patients treated at any low-mortality treatment center were 40 percent less likely to die compared to other patients of the same race or ethnicity who were treated at high-mortality faculties. Thus, discrepancies in surgical care persist despite perceived universal access and increasing use of protocol in trauma management.

The study authors suggested that the best way to address care discrepancies is to improve the quality of care at individual facilities. However, the researchers acknowledged that the cost burden of quality improvement initiatives falls on hospitals that serve the greatest number of uninsured patients, so they called for greater financial support directed at quality initiatives for those facilities.