title: Minority trauma patients tend to cluster at trauma centers with worse-than-expected mortality: can this phenomenon help explain racial disparities in trauma outcomes?
abstract: OBJECTIVE
  To determine whether minority trauma patients are more commonly treated at trauma centers (TCs) with worse observed-to-expected (O/E) survival.
  
  
  BACKGROUND
  Racial disparities in survival after traumatic injury have been described. However, the mechanisms that lead to these inequities are not well understood.
  
  
  METHODS
  Analysis of level I/II TCs included in the National Trauma Data Bank 2007-2010. White, Black, and Hispanic patients 16 years or older sustaining blunt/penetrating injuries with an Injury Severity Score of 9 or more were included. TCs with 50% or more Hispanic or Black patients were classified as predominantly minority TCs. Multivariate logistic regression adjusting for several patient/injury characteristics was used to predict the expected number of deaths for each TC. O/E mortality ratios were then generated and used to rank individual TCs as low (O/E <1), intermediate, or high mortality (O/E >1).
  
  
  RESULTS
  A total of 556,720 patients from 181 TCs were analyzed; 86 TCs (48%) were classified as low mortality, 6 (3%) intermediate, and 89 (49%) as high mortality. More of the predominantly minority TCs [(82% (22/27) vs 44% (67/154)] were classified as high mortality (P < 0.001). Approximately 64% of Black patients (55,673/87,575) were treated at high-mortality TCs compared with 54% Hispanics (32,677/60,761) and 41% Whites (165,494/408,384) (P < 0.001).
  
  
  CONCLUSIONS
  Minority trauma patients are clustered at hospitals with significantly higher-than-expected mortality. Black and Hispanic patients treated at low-mortality hospitals have a significantly lower odds of death than similar patients treated at high-mortality hospitals. Differences in TC outcomes and quality of care may partially explain trauma outcomes disparities.
authors: *Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD †Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD ‡Department of Surgery, Howard University College of Medicine, Washington, DC.
authors: Adil H
authors: AH
authors: Haider
authors: Zain G
authors: ZG
authors: Hashmi
authors: Syed Nabeel
authors: SN
authors: Zafar
authors: Xuan
authors: X
authors: Hui
authors: Eric B
authors: EB
authors: Schneider
authors: David T
authors: DT
authors: Efron
authors: Elliott R
authors: ER
authors: Haut
authors: Lisa A
authors: LA
authors: Cooper
authors: Ellen J
authors: EJ
authors: MacKenzie
authors: Edward E
authors: EE
authors: Cornwell
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005260:Female; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000208:ethnology* / Q000706:statistics & numerical data; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D017052:Hospital Mortality / Q000208:ethnology*; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D054525:Minority Health / Q000706:statistics & numerical data*; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D014193:Trauma Centers / Q000592:standards / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology; D044465:White People / Q000706:statistics & numerical data; D014949:Wounds, Nonpenetrating / Q000208:ethnology* / Q000401:mortality; D014950:Wounds, Penetrating / Q000208:ethnology* / Q000401:mortality; D055815:Young Adult
references: Ann Surg. 2008 Nov;248(5):886-92
references: 18948819
references: Med Care. 2007 Jul;45(7):686-90
references: 17571018
references: Crit Care Med. 1995 Feb;23(2):294-300
references: 7867355
references: N Engl J Med. 2002 Nov 14;347(20):1585-92
references: 12432046
references: J Am Coll Surg. 2009 Oct;209(4):521-530.e1
references: 19801325
references: Arch Surg. 2009 Nov;144(11):1006-11
references: 19917936
references: Arch Surg. 2002 Jan;137(1):20-7
references: 11772210
references: Med Care. 2008 Feb;46(2):192-9
references: 18219248
references: JAMA. 2005 Oct 12;294(14):1765-72
references: 16219879
references: Milbank Q. 2005;83(4):691-729
references: 16279964
references: Curr Diab Rep. 2012 Dec;12(6):762-8
references: 22976538
references: J Trauma Acute Care Surg. 2013 May;74(5):1195-205
references: 23609267
references: Qual Saf Health Care. 2006 Dec;15 Suppl 1:i50-8
references: 17142610
references: Surg Clin North Am. 2012 Apr;92(2):441-54, x-xi
references: 22414421
references: Neurosurgery. 2010 Mar;66(3):427-37; discussion 437-8
references: 20124933
references: Ann Surg. 2011 Apr;253(4):647-54
references: 21475002
references: Circulation. 2010 Jun 1;121(21):2294-301
references: 20479153
references: N Engl J Med. 2006 Jan 26;354(4):366-78
references: 16436768
references: J Trauma. 2003 Jun;54(6 Suppl):S235-310
references: 12870403
references: Arch Intern Med. 2007 Jun 25;167(12):1233-9
references: 17592095
references: IARC Sci Publ. 1987;(82):1-406
references: 3329634
references: Cancer. 2010 Oct 1;116(19):4622-31
references: 20626015
references: J Am Coll Surg. 2006 Dec;203(6):787-94
references: 17116545
references: Surg Endosc. 2008 Sep;22(9):1977-86
references: 18594921
references: J Trauma. 2001 Feb;50(2):289-96
references: 11242294
references: J Health Econ. 1994 Oct;13(3):255-80; discussion 335-40
references: 10138854
references: J Clin Oncol. 2009 Aug 20;27(24):3945-50
references: 19470926
references: HERD. 2008 Spring;1(3):61-125
references: 21161908
references: Ann Surg Oncol. 2008 Mar;15(3):881-8
references: 17987341
references: J Nurs Care Qual. 2008 Jan-Mar;23(1):34-42
references: 18281874
references: J Trauma. 2008 Mar;64(3):599-604; discussion 604-6
references: 18332798
references: J Trauma. 2010 Feb;68(2):253-62
references: 20154535
references: Crit Care Med. 2010 Aug;38(8 Suppl):S282-91
references: 20647785
references: Circulation. 2005 Oct 25;112(17):2634-41
references: 16246963
references: Perspect Biol Med. 2005 Winter;48(1 Suppl):S42-53
references: 15842086
references: Arch Surg. 2012 Jan;147(1):63-70
references: 21930976
references: Med Care. 2010 Dec;48(12):1133-7
references: 21063225
references: Crit Care Med. 2007 Sep;35(9):2052-6
references: 17568333
references: Ergonomics. 2013;56(2):205-19
references: 23384283
references: Health Serv Res. 2013 Oct;48(5):1684-703
references: 23662602
references: BMJ Qual Saf. 2012 Oct;21(10):810-8
references: 22562873
references: J Trauma. 2008 Sep;65(3):628-35
references: 18784577
references: J Trauma. 2010 Jul;69(1):1-10
references: 20622572
references: Int J Pharm Pract. 2009 Feb;17(1):9-30
references: 20218026
references: Work. 2009;33(2):211-27
references: 19713631
references: Jt Comm J Qual Patient Saf. 2011 Oct;37(10):435-6
references: 22013815
references: Am J Med Qual. 2012 May-Jun;27(3):201-9
references: 22202557
references: Ann Surg. 2009 Jan;249(1):143-8
references: 19106690
references: HERD. 2007 Fall;1(1):58-62
references: 21157718
references: J Am Coll Surg. 2013 Jan;216(1):147-57
references: 23062519
references: J Surg Res. 2011 Jan;165(1):e37-41
references: 21067775
references: J Am Coll Surg. 2013 Mar;216(3):482-92.e12
references: 23318117
references: JAMA. 2000 May 17;283(19):2579-84
references: 10815125
references: JAMA. 1998 May 6;279(17):1351-7
references: 9582042
references: Ann Surg. 2006 Feb;243(2):281-6
references: 16432363
references: J Trauma. 2009 Apr;66(4):967-73
references: 19359900
references: N Engl J Med. 2005 Aug 18;353(7):692-700
references: 16107622
references: Int J Qual Health Care. 2011 Apr;23(2):151-8
references: 21224272
references: J Trauma. 2006 Feb;60(2):351-6
references: 16508495
references: Qual Saf Health Care. 2008 Oct;17(5):351-9
references: 18842974
references: Med Care. 2012 Nov;50 Suppl:S48-55
references: 23064277
references: J Am Coll Surg. 2012 Apr;214(4):539-47; discussion 547-9
references: 22321524