Association between hospitals caring for a disproportionately high percentage of minority trauma patients and increased mortality: a nationwide analysis of 434 hospitals

Abstract

Objective: To determine whether there is an increased odds of mortality among trauma patients treated at hospitals with higher proportions of minority patients (ie, black and Hispanic patients combined).

Design: Hospitals were categorized on the basis of the percentage of minority patients admitted with trauma. The adjusted odds of in-hospital mortality were compared between hospitals with less than 25% of patients who were minorities (the reference group) and hospitals with 25% to 50% of patients who were minorities and hospitals with more than 50% of patients who were minorities. Multivariate logistic regression (with generalized linear modeling and a cluster-correlated robust estimate of variance) was used to control for multiple patient and injury severity characteristics.

Setting: A total of 434 hospitals in the National Trauma Data Bank.

Participants: Patients aged 18 to 64 years whose medical records were included in the National Trauma Data Bank for the years 2007 and 2008 with an Injury Severity Score of 9 or greater and who were white, black, or Hispanic.

Main outcome measures: Crude mortality and adjusted odds of in-hospital mortality.

Results: A total of 311,568 patients were examined. Hospitals in which the percentage of minority patients was more than 50% also had younger patients, fewer female patients, more patients with penetrating trauma, and the highest crude mortality. After adjustment for potential confounders, patients treated at hospitals in which the percentage of minority patients was 25% to 50% and at hospitals in which the percentage of minority patients was more than 50% demonstrated increased odds of death (adjusted odds ratio, 1.16 [95% confidence interval, 1.01-1.34] and adjusted odds ratio, 1.37 [95% confidence interval, 1.16-1.61], respectively), compared with the reference group. This disparity increased further on subset analysis of patients with a blunt injury. Uninsured patients had significantly increased odds of mortality within all 3 hospital groups.

Conclusions: Patients treated at hospitals with higher proportions of minority trauma patients have increased odds of dying, even after adjusting for potential confounders. Differences in outcomes between trauma hospitals may partly explain racial disparities.

Figure 1

Flowchart of the patient-selection process of our study, in which we analyzed patients whose medical records were in the National Trauma Data Bank (NTDB). ISS indicates Injury Severity Score.

Figure 2

Patient insurance status by proportion of minorities in the hospital. All comparisons are statistically significant at P <.05, except for government insurance status among predominantly majority hospitals and mixed hospitals.

Figure 3

Crude mortality by proportion of minority patients in the hospital. There were 146 437 patients in the predominantly majority hospitals (<25% of patients are minority patients), 109 049 patients in the mixed hospitals (25%–50% of patients are minority patients), and 56 082 patients in the predominantly minority hospitals (>50% of patients are minority patients). Crude mortality was statistically significantly different across all 3 groups at P <.05.

Figure 4

Adjusted odds of death, by hospital category. Hospitals were stratified into 3 groups based on the proportion of minority patients. The predominantly majority hospitals, in which less than 25% of patients are minority patients, were used as the reference group (black line). The other 2 groups are the mixed hospitals (25%–50% of patients are minority patients) and the predominantly minority hospitals (>50% of patients are minority patients). There was a total of 311 568 patients. AOR indicates adjusted odds ratio.