创伤护理的社会决定因素：种族、保险状况和地点对阿片类药物处方、出院后转介和死亡率的影响。
Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality.
机构信息
From the Department of Surgery (E.G., M.K., C.I., A.K.), Department of Data Science (W.B.H.), University of Mississippi Medical Center, Jackson, Mississippi; Department of Anesthesiology (S.B.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Psychology (B.G.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Psychology (H.M.), Vanderbilt University, Nashville, Tennessee; Department of Psychiatry & Human Behavior and Center for Center for the Neurobiology of Learning and Memory (U.R.), University of California-Irvine, California; Children's Hospital of Orange County (U.R.), Orange, California; Department of Biochemistry, Cancer Biology, Neuroscience & Pharmacology (S.N.), Meharry Medical College, Nashville, Tennessee; and Department of Psychiatry and Human Behavior (K.K., H.D., M.C.M.), University of Mississippi Medical Center, Jackson, Mississippi.
出版信息
J Trauma Acute Care Surg. 2022 May 1;92(5):897-905. doi: 10.1097/TA.0000000000003506. Epub 2021 Dec 20.
BACKGROUND
Racial disparities in trauma care have been reported for a range of outcomes, but the extent to which these remain after accounting for socioeconomic and environmental factors remains unclear. The objective of this study was to evaluate the unique contributions of race, health insurance, community distress, and rurality/urbanicity on trauma outcomes after carefully controlling for specific injury-related risk factors.
METHODS
All adult (age, ≥18 years) trauma patients admitted to a single Level I trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed. Primary outcomes were mortality, rehabilitation referral, and receipt of opioids in the emergency department. Demographic, socioeconomic, and injury characteristics as well as indicators of community distress and rurality based on home address were abstracted from a trauma registry database.
RESULTS
Analyses revealed that Black patients (n = 13,073) were younger, more likely to be male, more likely to suffer penetrating injuries, and more likely to suffer assault-based injuries compared with White patients (n = 10,946; all p < 0.001). In adjusted analysis, insured patients had a 28% lower risk of mortality (odds ratio, 0.72; p = 0.005) and were 92% more likely to be referred for postdischarge rehabilitation than uninsured patients (odds ratio, 1.92; p = 0.005). Neither race- nor place-based factors were associated with mortality. However, post hoc analyses revealed a significant race by age interaction, with Black patients exhibiting more pronounced increases in mortality risk with increasing age.
CONCLUSION
The present findings help disentangle the social determinants of trauma disparities by adjusting for place and person characteristics. Uninsured patients were more likely to die and those who survived were less likely to receive referrals for rehabilitation services. The expected racial disparity in mortality risk favoring White patients emerged in middle age and was more pronounced for older patients.
LEVEL OF EVIDENCE
Prognostic and epidemiological, Level III.
背景
已有研究报告称，在一系列创伤治疗结果方面存在种族差异，但在充分考虑社会经济和环境因素后，这些差异在多大程度上仍然存在尚不清楚。本研究旨在评估种族、医疗保险、社区困境和城乡差异在仔细控制特定与损伤相关的风险因素后对创伤结果的独特影响。
方法
回顾性分析了 2010 年 1 月至 2020 年 12 月期间在一家位于全州范围、以农村为主的一级创伤中心收治的所有成年（年龄≥18 岁）创伤患者。主要结局是死亡率、康复转诊和在急诊科使用阿片类药物。从创伤登记数据库中提取人口统计学、社会经济学和损伤特征以及基于家庭住址的社区困境和城乡差异指标。
结果
分析结果显示，与白人患者（n=10946）相比，黑人患者（n=13073）更年轻，更可能是男性，更可能遭受穿透性损伤，更可能遭受基于攻击的损伤（所有 p<0.001）。在调整分析中，保险患者的死亡率风险降低 28%（比值比，0.72；p=0.005），与未保险患者相比，接受出院后康复治疗的可能性增加 92%（比值比，1.92；p=0.005）。种族和地点因素均与死亡率无关。然而，事后分析显示，年龄与种族之间存在显著的交互作用，黑人患者的死亡率风险随着年龄的增长而显著增加。
结论
本研究通过调整地点和个人特征，有助于厘清创伤差异的社会决定因素。未保险患者更有可能死亡，而那些存活下来的患者接受康复服务的可能性较小。白人患者的死亡率风险预期种族差异出现在中年，并且在年龄较大的患者中更为明显。
证据水平
预后和流行病学，III 级。
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