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Original Investigation | SURGICAL CARE OF THE AGING POPULATION

Association Between Race and Age in Survival After Trauma

Caitlin W. Hicks, MD, MS1; Zain G. Hashmi, MBBS1; Catherine Velopulos, MD1; David T. Efron, MD1; Eric B. Schneider, PhD1; Elliott R. Haut, MD1; Edward E. Cornwell III, MD1; Adil H. Haider, MD, MPH1
[+] Author Affiliations
1Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
JAMA Surg. 2014;149(7):642-647. doi:10.1001/jamasurg.2014.166.
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Importance  Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information.

Objective  To determine whether racial disparities in trauma survival persist in patients 65 years or older.

Design, Setting, and Participants  Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index.

Main Outcomes and Measures  In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index.

Results  A total of 1 073 195 patients were included (502 167 patients 16-64 years of age and 571 028 patients ≥65 years of age). Most older patients were white (547 325 [95.8%]), female (406 158 [71.1%]), and insured (567 361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323 741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods.

Conclusions and Relevance  Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes.

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Figure.
Odds Ratio for Mortality: Blacks vs Whites by Age Category

There was a higher unadjusted odds of death for blacks vs whites for patients younger than 65 years but not for patients 65 years or older. After coarsened exact matching (CEM), racial disparities in survival persisted in the younger black group but were reversed in the older group. These findings were consistent across 3 different analysis techniques. Error bars indicate 95% CIs; dotted line, reference group.

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