Trauma patients have a better chance of survival if they receive care at a trauma center in a hospital that treats primarily non-minority patients versus being treated in a hospital that provides care to primarily minority patients.
That's among the findings of study released in a paper (Association Between Hospitals Caring for a Disproportionately High Percentage of Minority Trauma Patients and Increased Mortality) published online Monday in the Archives of Surgery.
For the study, Adil H. Haider, MD , and a team of researchers looked at the medical records of 311,568 patients included in the National Trauma Data Bank in 2007 and 2008. The patients were from 434 hospitals with recognized trauma centers. More than 82% of the trauma centers were identified as level one or two centers.
The hospitals were placed into three categories depending on their patient mix: Primarily white--less than 25% minority (black and Hispanic) patients, mixed--25% to 50% minority patients, and primarily minority-- more than 50% minority patients.
What the team discovered is that a compared to treatment at a primarily white hospital, trauma patients of all races were 37% more likely to die if they were treated at a primarily minority hospital and 16% more likely to die when treated at a mixed hospital. In analyzing only patients with blunt trauma injuries, such as from a car crash, patients at predominantly minority hospitals were 45% more likely to die while at a mixed hospital the odds of death were 18% higher.
Haider noted that minority patients did not have worse outcomes at predominantly white hospitals.
Patients were adjusted for age, sex, insurance status, the presence of severe head and/or extremity injury, and hypotension on arrival at the ER. The patients had an injury severity of at least 9, which means the patient could die from the trauma injuries.
The paper is the latest in a series of studies about race and trauma survival conducted by Dr. Haider and the trauma outcomes research group at Johns Hopkins University School of Medicine in Baltimore.
In a telephone interview Haider said the results of the team's trauma studies have dispelled the long–held notion that trauma care has no disparities in treatment. "There always been this idea that any trauma victim could come to an ER and receive equal treatment without regard to race or insurance status. We've believed that the best outcome were at large trauma centers. That that makes sense because that's where there are 24-hour staffs with operating rooms always ready to go."
What Haider and his team discovered is that outcomes for both adult and children trauma victims were related to race and insurance status. "Minorities and the uninsured were more likely to die of trauma injury," stated Haider.
The next step was to look at the underlying causes of the outcome. Haider said that while they looked at a number of possible pre-hospital influencers such as primary care treatment and the health of the patient, it seemed more likely that systemic issues with the hospitals were at play.
In conversations with physicians and others, Haider learned that hospitals that underperform in terms of chronic disease outcomes are often underfunded and have a patient base that is largely uninsured. "We began to wonder if the same phenomena could be applied to trauma patients."
The study notes that the underachieving hospitals tend to serve a patient population that is largely uninsured. For primarily white hospitals 75% of the patient mix had private or government sponsored health insurance. At primarily minority hospitals the insured accounted for 55% of the patient mix. That mix is critical when taking into account the cost of treating trauma patients and the possibility that the hospital will need to absorb some portion of the costs.
Also, people without insurance tend to visit doctors less often and may arrive at the hospital with more preexisting health problems that complicate their serious traumas, problems that could impact recovery, Haider explained.
Among the indications that mixed and primarily minority hospitals may less money to devote to patient care— the median numbers of core trauma surgeons, orthopedic surgeons and neurosurgeons was the same across all hospital categories.
That despite the fact that only 30% of the primarily white hospitals housed level 1 trauma centers, that primarily minority hospitals tend to be teaching hospitals and that mixed and primarily minority hospitals tend to be larger hospitals than primarily white facilities.
Haider said the policy implications of the study are that "we need to strengthen and bolster the minority hospitals." He noted that improvements at mixed and minority hospitals have the potential to "provide more bang for the buck in terms of improved outcomes."
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
