Racial, ethnic, and insurance status disparities in use of posthospitalization care after trauma

Abstract

Background: Posthospitalization care is important for recovery after trauma. Disadvantaged populations, like racial or ethnic minorities and the uninsured, make up substantial percentages of trauma patients, but their use of posthospitalization facilities is unknown.

Study design: This study analyzed National Trauma Data Bank admissions from 2007 for 18- to 64-year-olds and estimated relative risk ratios (RRR) of discharge to posthospitalization facilities--home, home health, rehabilitation, or nursing facility--by race, ethnicity, and insurance. Multinomial logistic regression adjusted for patient characteristics including age, sex, Injury Severity Score, mechanism of injury, and length of stay, among others.

Results: There were 136,239 patients who met inclusion criteria with data for analysis. Most patients were discharged home (78.9%); fewer went to home health (3.3%), rehabilitation (5.0%), and nursing facilities (5.4%). When compared with white patients in adjusted analysis, relative risk ratios of discharge to rehabilitation were 0.61 (95% CI 0.56, 0.66) and 0.44 (95% CI 0.40, 0.49) for blacks and Hispanics, respectively. Compared with privately insured white patients, Hispanics had lower rates of discharge to rehabilitation whether privately insured (RRR 0.45, 95% CI 0.40, 0.52), publicly insured (RRR 0.51, 95% CI 0.42, 0.61), or uninsured (RRR 0.20, 95% CI 0.17, 0.24). Black patients had similarly low rates: private (RRR 0.63, 95% CI 0.56, 0.71), public (RRR 0.72, 95% CI 0.63, 0.82), or uninsured (RRR 0.27, 95% CI 0.23, 0.32). Relative risk ratios of discharge to home health or nursing facilities showed similar trends among blacks and Hispanics regardless of insurance, except for black patients with insurance whose discharge to nursing facilities was similar to their white counterparts.

Conclusions: Disadvantaged populations have more limited use of posthospitalization care such as rehabilitation after trauma, suggesting a potential improvement in trauma care for the underprivileged.

Figure 1

Study inclusion criteria. NTDB, National Trauma Data Bank.

Figure 2

Adjusted relative risk ratio (RRR) of discharge to home health by race and insurance status. Multinomial logistic regression with “home” as reference outcome. * indicates reference group: non-Hispanic, white, privately insured patients. Error bars represent 95% CIs. White refers to non-Hispanic white; Hispanic refers to non-black Hispanic; n = 136,239 patients who had complete data for all variables in adjusted analysis. Variables adjusted for include age, sex, type of injury, extremity injury, head injury, intentional injury, Injury Severity Score, shock, Glasgow Coma Scale Motor Score, mechanism of injury, trauma level designation, and length of stay.

Figure 3

Adjusted relative risk ratio (RRR) of discharge to rehabilitation facility by race and insurance status. Multinomial logistic regression with home as reference outcome. * Reference group, non-Hispanic, white, privately insured patients. # Values that were not significant in all sensitivity analyses. Error bars represent 95% CIs. White refers to non-Hispanic white; Hispanic refers to non-black Hispanic; n = 136,239 patients who had complete data for all variables in adjusted analysis. Variables adjusted for include age, sex, type of injury, extremity injury, head injury, intentional injury, Injury Severity Score, shock, Glasgow Coma Scale Motor Score, mechanism of injury, trauma level designation, and length of stay.

Figure 4

Adjusted relative risk ratio (RRR) of discharge to nursing facility by race and insurance status. Multinomial logistic regression with home as reference outcome. * Reference group, non-Hispanic, white, privately insured patients. Error bars represent 95% CIs. White refers to non-Hispanic white; Hispanic refers to non-black Hispanic; n = 136,239 patients who had complete data for all variables in adjusted analysis. Variables adjusted for include age, sex, type of injury, extremity injury, head injury, intentional injury, Injury Severity Score, shock, Glasgow Coma Scale Motor Score, mechanism of injury, trauma level designation, and length of stay.