1. Hospital racial segregation and racial disparity in mortality after injury Melanie Arthur University of Alaska Fairbanks

2. Acknowledgments Working group: –Richard Mullins, MD, Oregon Health & Science University –Jerris Hedges, MD, MS, University of Hawaii –Thomas LaVeist, PhD, Johns Hopkins University Funding provided by: –Agency for Healthcare Research and Quality

3. Background Our previous work shows racial disparity in mortality among adults hospitalized after injury (Medical Care 2008) Potential causes of this disparity –Different injury patterns –Systematic differences in hospital resources –Differential treatment within institutions

4. Patient population Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample 1998-2002 Approximately 20% sample of community hospitals All patients hospitalized with a primary diagnosis of injury Ages 18-64 Excluding patients transferred to an acute care hospital (2.4%) n=522510

5. Race Asian category includes Pacific Islanders Not reliably reported for Hispanics or Native Americans in this data 11 participating states do not report race Of the remaining patients, 6.4% were missing race information –2/3 of these came from hospitals which did not report race –An additional 5982 patients came from hospitals that reported race for less than 50% of patients –13481 patients without reported race were included in the analyses

6. Racial composition of sample

7. Injury Injury severity imputed as ICISS ICD-9 based injury severity score Survival probabilities assigned for each injury code Product of survival probabilities gives overall injury severity 0=negligible probability of survival 1=virtual certainty of survival

8. Injury characteristics of sample WhiteBlackHispanicAsianNative America n OtherMissing race ICISS.94±.11.93±.12.94±.11.94±.12.93±.12.91±.15 Mechanism Motor vehicle crash32.625.129.537.334.232.339.3 Fall from height12.96.910.39.69.210.111.7 Low fall17.310.410.514.911.711.513.3 Intentional injury6.426.916.410.720.016.210.1 Other unintentional injury15.614.418.016.213.315.815.1 Other mechanism4.04.22.93.25.33.44.7 Unspecified11.412.212.58.16.510.75.8

9. Comorbidity Morris (JAMA 1990) suggests 5 clinical conditions –COPD, coagulopathy, diabetes, liver disease, and ischemic heart disease

10. Hospital racial segregation Based on patient population for ALL hospital admissions Calculated % of all patients who were white

11. Hospital racial segregation of sample

12. Other covariates Age Gender Hospital location and teaching status (urban teaching, urban nonteaching, rural) Primary payer Median income of zip code of residence (<$25k, 25k-34999, 35k-44999, $45K+)

13. Multivariate models Not controlled for hospital segregation With hospital segregation Race WhiteReference Black1.17 (1.06-1.29)1.11 (1.00-1.22) Hispanic0.96 (0.82-1.11)0.87 (0.77-1.00) Asian1.35 (1.03-1.77)1.21 (0.93-1.57) Native0.87 (0.63-1.20)0.90 (0.65-1.23) Other1.17 (0.98-1.39)1.05 (0.88-1.25) Missing1.41 (1.21-1.64)1.35 (1.14-1.59) Hospital racial composition <20% white1.59 (1.28-1.98) 20-39% white1.16 (0.94-1.43) 40-59% white1.26 (1.06-1.49) 60-79% white1.07 (0.93-1.24) At least 80% whiteReference All models control for age, gender, injury severity, comorbid conditions, primary payer, hospital type, median income of zip code of residence. Models were estimated using generalized estimating equations to account for clustering of patients within hospitals

14. Limitations Limited data regarding patients’ clinical condition Race measure is inconsistent across racial groups and settings In-hospital mortality is an incomplete measure of injury mortality Limited data on therapeutic interventions that might also contribute to probability of mortality

15. Implications Racial disparity in injury mortality among hospitalized patients is largely attenuated by control for hospital racial segregation Much of the observed disparity in injury outcome is attributable to treatment at racially segregated facilities Among facilities with >80% white patients, higher mortality rates remain evident for black patients Further research is needed to explore other characteristics of hospitals treating high proportions of minority patients, including treatment resources and patterns of care