BOX 4-2Case Study: Trauma Care in the United States

Circumstances in the United States could affect the ability of the health care system to render aid to victims of transportation-related injuries and violence, two leading contributors to the U.S. health disadvantage relative to other high-income countries. These circumstances illustrate not only the role of the health care system, as discussed in this chapter, but the important interconnections with socioeconomic factors and public policy as discussed in subsequent chapters. This interdependence is illustrated by two barriers to trauma care services in the United States—lack of health insurance and the geography of the United States—both of which may affect survival and rehabilitation (Greene et al., 2010).

Lack of Health Insurance: Case-fatality rates from the National Trauma Data Bank indicate that injury victims are more likely to die at hospitals with a large percentage of minority patients, and this risk is compounded if they are uninsured (Haider et al., 2012). A separate study reported that risk of death on the first hospital day after injury differs by insurance status, and this disparity becomes more pronounced throughout the hospital stay (Downing et al., 2011). After excluding on-scene deaths, Harris and colleagues (2012) found that U.S. assault victims brought to high-level trauma centers were more likely to die if they were black, even after adjusting for other variables.

These associations raise as many questions as they answer and point to “upstream” factors examined in subsequent chapters of the report. For example, disparities in the outcomes of trauma care do not always appear to relate to the quality of care provided at the institutions themselves (Vettukattil et al., 2011). The trauma literature points to the socioeconomic status of patients and the infrastructure and resources available to trauma centers operating in underserved areas. For example, as Haider and colleagues (2012, p. 68) explain:

[t]he underinsured population with likely much less resources, which is seen at predominantly minority hospitals, may bring significant residual confounding that could not be controlled for. Issues such as treatment delay, health illiteracy, and differential rates of follow-up and access to rehabilitation services have been implicated as potential reasons for the worse quality of care and worse outcomes among uninsured patients. Additional issues at public hospitals include nurse staffing shortages, constrained budgets, and lack of capital and technical support.

This analysis points directly to the relevance of the socioeconomic conditions of trauma victims (see Chapter 6) and to the role of public policies in shaping conditions that affect health (see Chapter 8).

Geography: The large rural expanses in the United States have relevance to the death toll from transportation-related injuries, because 61 percent of traffic fatalities occur in rural locations (Zwerling et al., 2005). Trauma outcomes appear to be worse for U.S. patients in nonurban areas (Sihler and Hemmila, 2009; Zwerling et al., 2005). Although factors unrelated to health care could contribute greatly to crash survival (e.g., rural road design and vehicles, speed limits, and the age, alcohol levels, and health status of rural drivers) (Transportation Research Board, 2011; Zwerling et al., 2005), an important factor is how quickly victims can be stabilized and transported to trauma centers by emergency medical personnel. Both time and distance have been shown to inversely affect survival from major trauma in rural areas (Durkin et al., 2005; Grossman et al., 1997; Howell et al., 2010). An analysis in the 1990s reported that emergency response time, scene time, and transportation time to the hospital were longer for rural victims of major trauma than for urban victims. Trauma victims transported by helicopter have lower mortality rates than those conveyed by ground transportation (Sullivent et al., 2011).

Rural physicians and hospitals that are close to crash sites may lack capacity to stabilize patients. One study demonstrated that mortality from motor vehicles crashes was lower in counties with 24-hour availability of a general surgeon, orthopedic surgeon, neurosurgeon, computed tomographic scanner, and operating room and in those with trauma centers (Melton et al., 2003). The absence of onsite specialists can be consequential. For example, survival from traumatic brain injury is improved if there is less than a 4-hour delay between arrival in the emergency department and the performance of a craniotomy or the drainage of a hematoma (Kim, 2011).

Helicopter transportation can therefore be important in saving time and reaching qualified trauma centers, but resources for such services are uneven across rural U.S. counties and are determined by diverse stakeholders. This, too, illustrates the interconnections between health care and public policy. The same applies to the staffing of medical helicopters, which differs in the United States. In a survey of emergency medical services for mountain areas of 14 countries in Europe and North America, Brugger and colleagues (2005) found that 63 percent of European helicopters have a physician on board and 18 percent are staffed with a paramedic, as compared with 32 percent and 60 percent, respectively, of North American helicopters. Policy challenges, among them limited budgets (see Chapter 8), may make it difficult to place more physicians on medical helicopters, especially in rural areas.

Finally, survival from transportation-related injuries or violence cannot be evaluated in isolation from other conditions responsible for the U.S. health disadvantage, such as obesity or diabetes, because comorbidity from chronic illnesses increases the risk of death from injuries (Morris et al., 1990).

From: 4, Public Health and Medical Care Systems

Cover of U.S. Health in International Perspective
U.S. Health in International Perspective: Shorter Lives, Poorer Health.
National Research Council (US); Institute of Medicine (US); Woolf SH, Aron L, editors.
Washington (DC): National Academies Press (US); 2013.
Copyright © 2013, National Academy of Sciences.

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