title: Impact of socioethnic factors on outcomes following traumatic brain injury.
abstract: BACKGROUND
  Ethnic minorities and low income families tend to be in poorer health and have worse outcomes for a spectrum of diseases. Health care provider bias has been reported to potentially affect the distribution of care away from poorer communities, minorities, and patients with a history of substance abuse. Trauma is perceived as a disease of the poor and medically underserved. Minorities are overrepresented in low income populations and are also less likely to possess health insurance leading to a potential overlapping effect. Traumatic brain injury (TBI) is a predominant cause of mortality and long-term morbidity, which imposes a considerable social and financial burden. We therefore sought to determine the independent effect on outcome after TBI from race, insurance status, intoxication on presentation, and median income.
  
  
  METHODS
  A 5-year retrospective chart review of admitted trauma patients aged 18 years and older to a Level I trauma center. Zip code of residency was a surrogate marker for socioeconomic status, because median income for each zip code is available from the US Census. Charts review included race, insurance status, mechanisms of trauma, and injuries sustained. Outcomes were placement of tracheostomy, hospital length of stay (HLOS), leaving Against Medical Advice (AMA), and discharge to home versus rehabilitation and mortality.
  
  
  RESULTS
  A total of 3,101 TBI patients were included in the analyses. Multivariable logistic and proportional hazard regression analyses were undertaken adjusting for age, gender, Injury Severity Score, and mechanism. Rates of tracheostomy placement were unaffected by race, median income, or insurance status. Race and median income did not affect HLOS, but private insurance was associated with shorter HLOS and intoxication was associated with longer HLOS. Neither race nor intoxication affected rates of AMA, but higher income and private insurance was associated with lower rates of AMA. Non-Caucasian race and lack of insurance had significantly lower likelihood of placement in a rehabilitation center. Mortality was unaffected by race, increased in intoxicated patients, was variably affected by median income, and was lowest in patients with private insurance.
  
  
  CONCLUSIONS
  An extremely complex interplay exists between socioethnic factors and outcomes after TBI. Few physicians would claim overt discrimination. Tracheostomy, the factor most directed by the surgeon, was unbiased by race, income, or insurance status. The likelihood of placement in a rehabilitation center was significantly impacted by both race and insurance status. Future prospective studies are needed to better address causation.
authors: Division Trauma and Surgical Critical Care, Department of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island 02903, USA. dheffernan@brown.edu
authors: Daithi S
authors: DS
authors: Heffernan
authors: Roberto M
authors: RM
authors: Vera
authors: Sean F
authors: SF
authors: Monaghan
authors: Rajan K
authors: RK
authors: Thakkar
authors: Matthew S
authors: MS
authors: Kozloff
authors: Michael D
authors: MD
authors: Connolly
authors: Shea C
authors: SC
authors: Gregg
authors: Jason T
authors: JT
authors: Machan
authors: David T
authors: DT
authors: Harrington
authors: Charles A
authors: CA
authors: Adams
authors: William G
authors: WG
authors: Cioffi