D. Metcalfe1, C. K. Zogg1, J. W. Scott1, O. A. Olufajo1, A. H. Haider1, J. M. Havens1, A. J. Rios Diaz1, B. Yorkgitis1, A. Salim1 1Harvard Medical School,Center For Surgery And Public Health,Boston, MA, USA
Introduction:
Uninsured patients and those from historically disadvantaged racial/ethnic groups have higher odds of death following severe injury. However, the reasons for these disparities are not fully understood. ‘Failure to rescue’ (FTR) is an indirect measure of the effectiveness with which providers respond to patients that develop a major adverse event (MAE) while in hospital. This study explored whether there are racial and/or insurance disparities in FTR following injury.
Methods:
Patients admitted to hospital in California (2007-2011) with a primary injury diagnosis (ICD-9-CM 800-957) were identified from the California State Inpatient Database (SID). The SID provides a comprehensive population cohort inclusive of 98% of hospital admissions. Patients who developed a MAE (myocardial infarction, deep vein thrombosis, pulmonary embolism, acute renal failure, respiratory failure, pneumonia, or post-operative hemorrhage) were identified and used to define an ‘at-risk’ denominator group. Patients with a MAE who subsequently died comprised the numerator and were used to calculate FTR rates for categories based on race/ethnicity (White, Black, Hispanic) and primary payer status (privately insured, public insurance, uninsured). Multivariable logistic regression compared potential risk-adjusted differences in the odds of MAE and FTR, accounting for potential confounding associated with differences in patient- and hospital-level factors (Table 1).
Results:
A total of 744,584 trauma admissions were identified; 73,885 (9.9%) developed a MAE and 4,860 died, giving an overall FTR rate of 6.6%. Multivariable logistic regression found a lack of significant racial/ethnic differences in MAE and FTR (Table 1). The only significant difference was a protective effect reported in Hispanic relative to White patients (OR 0.88, 95% CI 0.83-0.93). Differences in MAE by payer status were only significant for publicly- (including Medicare) versus privately-insured patients. However, among patients with a MAE, differences in FTR were profound. Uninsured patients with a MAE had 59% higher odds of death (95% CI 1.25-2.02) relative to privately-insured patients – 28% for publically-insured patients (95% CI 1.14-1.44). These findings persisted for sub-group analyses using Injury Severity Score (ISS) thresholds of >9 and >15.
Conclusion:
FTR is a mechanism that could partially explain worse outcomes for trauma patients without private insurance. This study did not find any evidence of disparities in rates of FTR for historically disadvantaged racial/ethnic groups.