Mapping areas with concentrated risk of trauma mortality: a first step toward mitigating geographic and socioeconomic disparities in trauma

ABSTRACTBackgroundMany rural, low income, and historically underrepresented minority communities lack access to trauma center services, including surgical care and injury prevention efforts. Along with features of the built and social environment at injury incident locations, geographic barriers to trauma center services may contribute to injury disparities. This study sought to classify injury event locations based on features of the built and social environment at the injury scene, and to examine patterns in individual patient demographics, injury characteristics, and mortality by location class.MethodsData from the 2015 Maryland Adult Trauma Registry and associated prehospital records (n = 16,082) were used in a latent class analysis of characteristics of injury event locations, including trauma center distance, trauma center characteristics, land use, community-level per capita income, and community-level median age. Mortality effects of location class were estimated with logistic regression, with and without adjustment for individual patient demographics and injury characteristics.ResultsEight classes were identified: rural, exurban, young suburban, aging suburban, inner suburban, urban fringe, high income urban core, and low income urban core. Patient characteristics and odds of death varied across classes. Compared to inner suburban locations, adjusted odds of death were highest at rural (OR = 1.98, 95% CI: 1.36, 2.88), young suburb (OR = 1.57, 95% CI: 1.14, 2.17), aging suburb (OR = 1.36, 95% CI: 1.04, 1.78), and low income urban core (OR = 1.38, 95% CI: 1.04, 1.83) locations.ConclusionInjury incident locations can be categorized into distinguishable classes with varying mortality risk. Identification of location classes may be useful for targeted primary prevention and treatment interventions, both by identifying geographic areas with the highest risk of injury mortality, and by identifying patterns of individual risk within location classes.Level of EvidenceLevel III, Prognostic and Epidemiological Background Many rural, low income, and historically underrepresented minority communities lack access to trauma center services, including surgical care and injury prevention efforts. Along with features of the built and social environment at injury incident locations, geographic barriers to trauma center services may contribute to injury disparities. This study sought to classify injury event locations based on features of the built and social environment at the injury scene, and to examine patterns in individual patient demographics, injury characteristics, and mortality by location class. Methods Data from the 2015 Maryland Adult Trauma Registry and associated prehospital records (n = 16,082) were used in a latent class analysis of characteristics of injury event locations, including trauma center distance, trauma center characteristics, land use, community-level per capita income, and community-level median age. Mortality effects of location class were estimated with logistic regression, with and without adjustment for individual patient demographics and injury characteristics. Results Eight classes were identified: rural, exurban, young suburban, aging suburban, inner suburban, urban fringe, high income urban core, and low income urban core. Patient characteristics and odds of death varied across classes. Compared to inner suburban locations, adjusted odds of death were highest at rural (OR = 1.98, 95% CI: 1.36, 2.88), young suburb (OR = 1.57, 95% CI: 1.14, 2.17), aging suburb (OR = 1.36, 95% CI: 1.04, 1.78), and low income urban core (OR = 1.38, 95% CI: 1.04, 1.83) locations. Conclusion Injury incident locations can be categorized into distinguishable classes with varying mortality risk. Identification of location classes may be useful for targeted primary prevention and treatment interventions, both by identifying geographic areas with the highest risk of injury mortality, and by identifying patterns of individual risk within location classes. Level of Evidence Level III, Prognostic and Epidemiological Correspondence: Molly P. Jarman, PhD, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Center for Surgery and Public Health, Brigham and Women’s Hospital, mjarman@bwh.harvard.edu, One Brigham Circle, 1620 Tremont St 4-020, Boston, MA, 02120 Conflicts of Interest and Sources of Funding: M. P. Jarman’s work on this study was funded by a National Research Service Award from the Agency for Healthcare Research Quality (T32HS000029) and by the Johns Hopkins Center for Injury Research and Policy (William Haddon Jr. Fellowship). She is currently supported by a research grant from the Center for Orthopaedic Trauma Advancement ("Treatment of injury in the United States: Projections for an ideal system of trauma care"). E. R. Haut is the primary investigator of a grant from the Agency for Healthcare Research and Quality (AHRQ) (1R01HS024547-01, “Individualized Performance Feedback on Venous Thromboembolism Prevention Practice”). He is also a co-investigator for grants from the National Institutes of Health National Heart, Lung, and Blood Institute (NIH-NHLBI) (1R21HL129028-01A1, “Analysis of the impact of missed doses of venous thromboembolism prophylaxis”) and The Henry M. Jackson Foundation, Uniformed Services University of the Health Sciences (HU0001-14-0038, “Validation of Training for Cricothyroidotomy”). Dr. Haut is the primary investigator of two contracts with The Patient-Centered Outcomes Research Institute (PCORI) (CE-12-11-4489, “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology” & DI-1603-34596, “Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis”), and co-investigator for the PCORI contract titled “A Randomized Pragmatic Trial Comparing the Complications and Safety of Blood Clot Prevention Medicines Used in Orthopaedic Trauma Patients” (PCS-1511-32745). Dr. Haut receives royalties from Lippincott, Williams, Wilkins for a book - "Avoiding Common ICU Errors." For remaining authors, no conflicts were declared. Conference Presentations: Presented at the 31st Annual Meeting of the Eastern Association for the Surgery of Trauma, January 9-13, 2018 in Orlando, FL Study Funding Disclosure: This study was funded by the Agency for Healthcare Research Quality (T32HS000029). © 2018 Lippincott Williams & Wilkins, Inc.

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