Patient and social characteristics contributing to disparities in outcomes after burn injury: application of database research to minority health in the burn population

The impact of burn injuries on indigenous populations: A literature review

INTRODUCTION

Ethnic minorities experience disparities in prevention and treatment of burn injury. Research focused on burn injuries in Indigenous populations is limited. This review summarizes literature on burn injuries in Indigenous populations to be considered to inform new research.

METHODS

A search was conducted in CINAHL, Ovid MEDLINE, PSYCinfo and SocINDEX. for "burn OR scars OR scald OR deformity OR disfigurement" and "Aboriginal OR Indigenous OR First Nation OR American Indian OR Maori OR Native OR Torres Strait Islander OR Amerindian OR Inuit OR Metis OR Pacific Islander". Inclusion 1) peer reviewed studies of burns in Indigenous persons 2) in English. Exclusion 1) no data specific to Indigenous burns 2) not peer reviewed 3) not in full text 4) protocol publications.

RESULTS

The search identified 1091 studies with 51 for review. Sixteen were excluded. The 35 included publications were published between 1987 and 2022. Findings indicated higher incidence of injury and poorer outcomes amongst Indigenous people. Indigenous people suffered more flame and inhalation burns, had longer lengths of stay, and more complications including hypertrophic scarring. Australian Indigenous patients struggle with a lack of culturally safe communication and support for aftercare.

CONCLUSION

Racial disparities exist in burn injury incidence and outcome for Indigenous persons. Qualitative research in this area will help providers better understand the experiences of Indigenous burn patients to develop more culturally competent care. We are currently developing a study using qualitative hermeneutic methodology to learn about the experiences of Indigenous burn survivors' injuries, recovery, and social reintegration.

Worse Itch and Fatigue in Racial and Ethnic Minorities: A Burn Model System Study

Racial and ethnic minority patients experience worse hypertrophic scars after burn injury than White patients. Subsequently, minority patients encounter differences in scar-related recovery domains such as itch and fatigue. This study examines disparities regarding postburn injury itch and fatigue in minority patients to better inform counseling and treatment considerations. From the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System Database (2015-2019), outcomes were analyzed at three time-points (discharge from index hospitalization, 6- and 12-months post-injury) using the 5D Itch and PROMIS-29 Fatigue measures. Multilevel linear mixed effects regression modeling analyzed associations between race/ethnicities and outcomes over time. Of 893 total patients, minority patients reported higher/worse itch scores at all time points compared to White patients. Itch scores were significantly higher for Black patients at 6 months (β = 1.42, P = .03) and 12 months (β = 3.36, P < .001) when compared to White patients. Black patients reported higher fatigue scores than White patients at all time points. Fatigue scores were significantly higher for Hispanic/Latino patients at discharge (β = 6.17, P < .001), 6 months (β = 4.49, P < .001), and 12 months (β = 6.27, P < .001) than White patients. This study supports investigation of potential factors leading to increased itch and fatigue such as sociocultural factors, disparities in healthcare access, and psychosocial impacts of these symptoms. In the short-term, minority patients may benefit from additional counseling and focused treatments addressing itch and fatigue after burn injury.

Integrating Palliative Care into Burn Care: A Retrospective Application of Criteria for Appropriate Referral

Burn injuries often require complex interdisciplinary care. Despite potential benefits, consultation with specialist palliative care typically occurs in 2% of burn admissions, due largely to lack of availability and misconceptions concerning palliative care. Criteria to guide consultation with specialist palliative care have been developed at this institution. The purpose of this study was to quantify the sensitivity and specificity of these criteria, and then optimize them. Retrospective examination of 388 admissions over 15 months at this adult and pediatric Burn Center were conducted. Chi-square or Fisher's exact test for categorical variables and Wilcoxon Rank Sum test for continuous variables were used to test for between-group differences in demographic and clinical characteristics. Logistic regression model was built to determine modified Baux cut-off score using Youden index (J) value. Criteria were sensitive (0.96) and specific (0.90), though with a low positive predictive value (0.43). Persons with lengths of stay greater than one week, advanced directives, Allow Natural Death orders, and/or deterioration events were significantly more likely to have had palliative care consulted. There were significant between-group differences (with/without palliative care consultation) based on burn surface area, modified Baux score, and mortality risk. Potential criteria revisions are proposed. Prospective adherence to revised criteria could provide useful guidance to providers and benefit to patients and families.

Race and Ethnicity Influences Outcomes of Adult Burn Patients

Outcomes of burn survivors is a growing field of interest; however, there is little data comparing the outcomes of burn survivors by ethnicity. This study seeks to identify any inequities in burn outcomes by racial and ethnic groups. A retrospective chart review of an ABA Certified burn center at a large urban safety net hospital identified adult inpatient admissions from 2015 to 2019. A total of 1142 patients were categorized by primary ethnicity: 142 black or African American, 72 Asian, 479 Hispanic or Latino, 90 white, 215 other, and 144 patients whose race or ethnicity was unrecorded. Multivariable analyses evaluated the relationship between race and ethnicity and outcomes. Covariate confounders were controlled by adjustment of demographic, social, and prehospital clinical factors to isolate differences that might not be explained by other factors. After controlling for covariates, black patients had 29% longer hospital stays (P = .043). Hispanic patients were more likely to be discharged to home or to hospice care (P = .005). Hispanic ethnicity was associated with a 44% decrease in the odds of discharge to acute care, inpatient rehabilitation, or a ward outside the burn unit (P = .022). Black and Hispanic patients had a higher relative chance of having publicly assisted insurance, versus private insurance, than their white counterparts (P = .041, P = .011 respectively). The causes of these inequities are indeterminate. They may stem from socioeconomic status not entirely accounted for, ethnic differences in comorbidity related to stressors, or inequity in health care delivery.

Disparities in surgical health service delivery and outcomes for indigenous children

BACKGROUND

Evidence of health disparities for Indigenous children requiring surgical care is lacking. We present a systematic review of the literature examining possible disparities in surgical care and outcomes for pediatric patients of Indigenous ethnicity.

DATA SOURCES

PubMed, Cochrane, MEDLINE, gray literature.

METHODS

Literature review, using PubMed, Cochrane, MEDLINE, and gray literature was conducted to identify articles published more than 2010-2020 examining children's surgical health service delivery (epidemiology, access, operations provided) and outcomes for pediatric patients of Indigenous ethnicity compared with others. Extracted data included study design, setting, participant race/ethnicity, operations examined, and surgical outcomes. Article quality was assessed using the Newcastle-Ottawa Scales.

RESULTS

From 411 abstracts, 125 articles were reviewed and 33 included for data abstraction. These were cohort and cross-sectional studies investigating a wide range of patient populations and procedures across the United States, Canada, Australia, and New Zealand. Articles were organized naturally by theme into birth malformations (15 articles), trauma (6 articles), pediatric general surgery/appendicitis (5 articles), pediatric otolaryngology (6 articles), and renal transplant (1 article) surgery. Four articles also described access and resource utilization related to inpatient care. Notable disparities observed included apparent increased prevalence of gastroschisis, rates of traumatic fatality, non accidental injury, and self harm among North American Indigenous children.

CONCLUSIONS

Indigenous children appear to be vulnerable to a number of health and treatment outcome disparities related to conditions treated by surgeons. Surgeons are thus uniquely poised to act in identifying and eliminating Indigenous ethnicity-based pediatric health disparities.

Length of Stay per Total Body Surface Area Burn: A Validation Study Using the National Burn Registry

A length of stay (LOS) of one day per percent total body surface area (TBSA) burn has been generally accepted but not validated in current pediatric burn studies. The primary objective of this study is to validate previous Pediatric Injury Quality Improvement Collaboration (PIQIC) findings by using a national burn registry to evaluate LOS per TBSA burn relative to burn mechanism, sociodemographic characteristics, and clinical factors which influence this ratio. We evaluated patients 0-18 years old who sustained a burn injury and whose demographics were submitted to the National Burn Registry (NBR) dataset from July 2008 through June 2018. Mixed effects generalized additive regression models were performed to identify characteristics associated with the LOS per TBSA burn ratio. Among 51,561 pediatric burn patients, 45% were Non-Hispanic White, 58% were male, and median age was 3.0 years old (IQR: 1.0, 9.0). The most common burn mechanism was scald (55.9%). The median LOS per TBSA burn ratio across all cases was 0.9 (IQR: 0.4, 1.75). In adjusted models, scald burns had a mean predicted LOS per TBSA burn value of 1.2 while chemical burns had the highest ratio (4.8). Non-Hispanic White patients had lower LOS per TBSA burn ratios than all other races and ethnicities (p&lt;0.05). These data substantiate evidence on variance in LOS per TBSA burn relative to burn mechanism and race/ethnicity. Knowing these variations can guide expectations in hospital LOS for patients and families and help burn centers benchmark their clinical performance.

Burn Registries State of Affairs: A Scoping review

Registry science allows for the interpretation of disease-specific patient data from secondary databases. It can be utilized to understand disease and injury, answer research questions, and engender benchmarking of quality-of-care indicators. Numerous burn registries exist globally, however, their contributions to burn care have not been summarized. The objective of this study is to characterize the available literature on burn registries. The authors conducted a scoping review, having registered the protocol a priori. A thorough search of the English literature, including grey literature, was carried out. Publications of all study designs were eligible for inclusion provided they utilized, analyzed, and/or critiqued data from a burn registry. Three hundred twenty studies were included, encompassing 16 existing burn registries. The most frequently used registries for peer-reviewed publications were the American Burn Association Burn Registry, Burn Model System National Database, and the Burns Registry of Australia and New Zealand. The main limitations of existing registries are the inclusion of patients admitted to burn centers only, deficient capture of outpatient and long-term outcome data, lack of data standardization across registries, and the paucity of studies on burn prevention and quality improvement methodology. Registries are an invaluable source of information for research, delivery of care planning, and benchmarking of processes and outcomes. Efforts should be made to stimulate other jurisdictions to build burn registries and for existing registries to be improved through data linkage with administrative databases, and by standardizing one international minimum dataset, in order to maximize the potential of registry science in burn care.

The Impact of Race/Ethnicity on the Outcomes of Burn Patients: A Systematic Review of the Literature

Racial and ethnic disparities are endemic to the United States and are only beginning to attract the attention of researchers. With an increasingly diverse population, focused and tailored medicine to provide more equitable care is needed. For surgical trauma populations, this topic is a small but expanding field and still rarely mentioned in burn medicine. Disparities in prevention, treatment, and recovery outcomes between different racial and ethnic minorities who are burned are rarely discussed. The purpose of this study is to determine the current status of identified disparities of care in the burn population literature and areas of future research. A systematic review was conducted of literature utilizing PubMed for articles published between 2000 and 2020. Searches were used to identify articles that crossed the burn term (burn patient OR burn recovery OR burn survivor OR burn care) and a race/ethnicity and insurance status-related term (race/ethnicity OR African-American OR Black OR Asian OR Hispanic OR Latino OR Native American OR Indigenous OR Mixed race OR 2 or more races OR socioeconomic status OR insurance status). Inclusion criteria were English studies in the United States that discussed disparities in burn injury outcomes or risk factors associated with race/ethnicity. One thousand one hundred and sixty-nine papers were populated, 55 were reviewed, and 36 articles met inclusion criteria. Most studies showed minorities had poorer inpatient and outpatient outcomes. While this is a concerning trend, there is a paucity of literature in this field and more research is needed to create culturally tailored medical care and address the needs of disadvantaged burn survivors.

Validation of PROMIS-29 domain scores among adult burn survivors: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study

BACKGROUND

Patient-reported outcomes are important for understanding recovery after burn injury, benchmarking service delivery and measuring the impact of interventions. Patient-Reported Outcomes Measurement Information System (PROMIS)-29 domains have been validated for use among diverse populations though not among burn survivors. The purpose of this study was to examine validity and reliability of PROMIS-29 scores in this population.

METHODS

The PROMIS-29 scores of physical function, anxiety, depression, fatigue, sleep disturbance, ability to participate in social roles, and pain interference were evaluated for validity and reliability in adult burn survivors. Unidimensionality, floor and ceiling effects, internal consistency, and reliability were examined. Differential item functioning was used to examine bias with respect to demographic and injury characteristics. Correlations with measures of related constructs (Community Integration Questionnaire, Satisfaction with Life Scale, Post-Traumatic Stress Checklist-Civilian, and Veteran's Rand-12) and known-group differences were examined.

RESULTS

Eight hundred and seventy-six burn survivors with moderate to severe injury from 6 months to 20 years postburn provided responses on PROMIS-29 domains. Participants' ages ranged from 18 years to 93 years at time of assessment; mean years since injury was 3.4. All PROMIS domain scores showed high internal consistency (Cronbach's α = 0.87-0.97). There was a large ceiling effect on ability to participate in social roles (39.7%) and physical function (43.3%). One-factor confirmatory factor analyses supported unidimensionality (all comparative fit indices >0.95). We found no statistically significant bias (differential item functioning). Reliability was high (>0.9) across trait levels for all domains except sleep, which reached moderate reliability (>0.85). All known-group differences by demographic and clinical characteristics were in the hypothesized direction and magnitude except burn size categories.

CONCLUSION

The results provide strong evidence for reliability and validity of PROMIS-29 domain scores among adult burn survivors. Reliability of the extreme scores could be increased and the ceiling effects reduced by administering PROMIS-43, which includes six items per domain, or by administering by computerized adaptive testing.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, level III.

Social determinants of poor outcomes following frostbite injury: a study of the National Inpatient Sample

Severe frostbite injury can result in significant disability from amputation of limbs and digits which may be mitigated through prompt medical care. The reported rates of amputation vary widely between centers. Our aim is to describe the incidence and factors associated with amputation secondary to frostbite injury in the United States using a national sample of hospitalizations. Admissions for frostbite injury were identified in the National Inpatient Sample (2016-18). Factors associated with amputation were assessed by multivariable logistic regression and clustered by hospital. The overall incidence of frostbite injury in the U.S. is 0.83/100,000 people. Of the social factors associated with frostbite injury, homelessness and Black race were independently associated with a higher likelihood of amputation at the primary admission. Diagnosis of cellulitis was a predictor of amputation. Homeless frostbite patients more frequently discharged AMA and were less likely to discharge with supportive medical care, despite having a higher rate of more severe injury. Disability from amputation following frostbite injury impacts at least 20% of frostbite injured patients and disproportionally impacts the homeless population. Further study is needed to ascertain the decision-making that leads to early amputation following frostbite injury, especially in the homeless and Black population. Outreach and education efforts should be initiated to promote salvage of functional limb length following frostbite injury.

Burn model system national longitudinal database representativeness by race, ethnicity, gender, and age

INTRODUCTION

Representativeness of research populations impacts the ability to extrapolate findings. The Burn Model System (BMS) National Database is one of the largest prospective, longitudinal, multi-center research repositories collecting patient-reported outcomes after burn injury.

OBJECTIVE

To assess if the BMS Database is representative of the population that is eligible to participate.

DESIGN

Data on adult burn survivors who were eligible for the BMS Database from 2015 to 2019 were analyzed.

SETTING

Not applicable.

PARTICIPANTS

Burn survivors treated at BMS centers meeting eligibility criteria for the BMS Database. Eligibility for the database is based on burn size and receipt of autografting surgery.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Race, ethnicity, gender, and age were compared between individuals who did and did not enroll. Regression analysis examined the correlation between demographic characteristics and study enrollment. Additional regression analysis examined the association between enrollment and the intersection of race, ethnicity, and gender.

RESULTS

A total of 982 adult burn survivors were eligible for the BMS database during the study period. Of those who were eligible, 72.1% Enrolled and 27.9% were Not Enrolled. The Enrolled group included more female and more younger survivors compared to the Not Enrolled group. In regression analyses, Black/African American burn survivors were less likely and individuals identifying as female were more likely to enroll in the BMS Database. Furthermore, White men and women were more likely to enroll compared to Black/African American men and women, and non-Hispanic/Latino men were more likely to enroll compared to Hispanic/Latino men.

CONCLUSIONS

This study found differences in BMS Database enrollment by race, ethnicity, and gender. Further research is warranted to investigate causes for the disparities found in this study. In addition, strategies are needed to improve enrollment to ensure future representativeness.

Racial And Socioeconomic Differences Affect Outcomes in Elderly Burn Patients

BACKGROUND

Race and socioeconomic status influence outcomes for adult and pediatric burn patients, yet the impact of these factors on elderly patients (Medicare eligible, 65 years of age) remains unknown.

METHODS

Data pooled from three verified burn centers from 2004 to 2014 were reviewed retrospectively. Age, race, gender, percent total body surface area (%TBSA) burn, mortality, length of stay (LOS), LOS per %TBSA burn, and zip code which provided Census data on race, poverty, and education levels within a community were collected. Data were analyzed using logistic and generalized linear models in SAS version 9.4 (SAS Institute, Cary, NC, USA).

RESULTS

Our population was mainly Caucasian (63%), African American (18%), Hispanic (7.6%), and Asian (3.5%). Mean age was 76.3 ± 8.3 years, 52.5% were male. Mean %TBSA was 9 ± 13.8%; 15% of the patients sustained an inhalation injury. The mortality rate was 14.4%. Inhalation injury was significantly associated with mortality and discharge to a skilled nursing facility (SNF) (p < 0.05). Race was significantly associated with socioeconomic disparities and affected LOS/TBSA, but not discharge to SNF or mortality on univariate analysis. Poverty level, education level, and insurance status (others vs. public) independently predicted SNF discharge, while median income and insurance type independently predicted LOS/TBSA.

CONCLUSION

In this elderly cohort, race did not predict standard markers of burn outcome (mortality and discharge to SNF). Socioeconomic status independently predicted LOS and discharge to SNF, suggesting a relationship between socioeconomic status and recovery from a burn injury. Better understanding of racial and socioeconomic disparities is necessary to provide equitable treatment of all patients.

Amputation Following Burn Injury

Amputation following burn injury is rare. Previous studies describe the risk of amputation after electrical burn injuries. Therefore, we describe the distribution of amputations and evaluate risk factors for amputation following burn injury at a large regional burn center. We conducted a retrospective analysis of patients ≥17 years admitted from January 2002 to December 2015. Patients who did and did not undergo an amputation procedure were compared. A multivariate logistic regression model was used to determine the risk factors for amputation. Amputations were further categorized by extremity location and type (major, minor) for comparison. Of the 8313 patients included for analysis, 1.4% had at least one amputation (n = 119). Amputees were older (46.7 ± 17.4 years) than nonamputees (42.6 ± 16.8 years; P = .009). The majority of amputees were white (47.9%) followed by black (39.5%) when compared with nonamputees (white: 57.1%, black: 27.3%; P = .012). The most common burn etiology for amputees was flame (41.2%) followed by electrical (23.5%) and other (21.9%). Black race (odds ratio [OR]: 2.29; 95% confidence interval [CI]: 1.22-4.30; P = .010), electric (OR: 13.54; 95% CI: 6.23-29.45; P < .001) and increased %TBSA (OR: 1.03; 95% CI: 1.02-1.05; P < .001) were associated with amputation. Burn etiology, the presence of preexisting comorbidities, black race, and increased %TBSA increase the odds of post burn injury. The role of race on the risk of amputation requires further study.

Stimulant Abuse in Burn Patients Is Associated With an Increased Use of Hospital Resources

Stimulant (cocaine, methamphetamine, and amphetamine) abuse compromises the peripheral vasculature through endothelial injury. In combination with the physiologic derangements seen in burn injuries, patients abusing stimulants may have additional impairments in wound healing. A retrospective review from July 1, 2015 to July 1, 2018 was performed at an American Burn Association-verified burn center. Patients with positive urine toxicology results for stimulants (ST(+)), and those without (ST(-)), who sustained burn injuries were identified and matched by age and TBSA. The primary outcome was mortality, and secondary outcomes included total length of stay (LOS), and need-for-surgery (grafting). In total, 130 patients ST(+) and 133 ST(-) patients were identified. There were no significant differences in age (40.9 ± 13.5 vs 39.2 ± 23.7 years, P = 0.46), Inhalation Injury (12.3 vs 9.0%, P = 0.39), or nutritional status (prealbumin: 17.3 ± 6.1 vs 17.1 ± 12.7 mg/dl, P = 0.66; albumin: 3.5 ± 0.6 vs 3.6 ± 0.7 g/dl, P = 0.45). There were no differences in mortality (6.1 vs 4.5%, P = 0.55), intensive care unit LOS (9.3 ± 16.5 vs 10.2 ± 20.9 days, P = 0.81), wound infections (15.4 vs 23.9%, P = 0.07), or wound conversion (6.9 vs 3.0%, P = 0.14). ST(+) patients had a significantly longer LOS (15.0 ± 16.9 vs 10.7 ± 17.3 days, P = 0.04), greater tobacco use (56.9 vs 18.0%, P = 0.00001), and greater need for grafting (54.6 vs 33.1%, P = 0.0004). ST(+) patients require more hospital resources-surgical operations and hospital days-than ST(-) patients. The increased need for surgical intervention may partially explain the increase in hospital days, in addition to the observation that ST(+) patients had more complex disposition issues than ST(-) patients.

An Examination of Follow-up Services Received by Vulnerable Burn Populations: A Burn Model System National Database Study

While disparities in healthcare outcomes and services for vulnerable populations have been documented, the extent to which vulnerable burn populations demonstrate disparities in long-term care is relatively underexplored. This study's goal was to assess for differences in long-term occupational or physical therapy (OT/PT) and psychological service use after burn injury in vulnerable populations. Data from the Burn Model System National Database (2006-2015) were analyzed. The vulnerable group included participants in one or more of these categories: 65 years of age or older, nonwhite, no insurance or Medicaid insurance, preinjury receipt of psychological therapy or counseling, preinjury alcohol and/or drug misuse, or with a preexisting disability. Primary outcomes investigated were receipt of OT/PT and psychological services. Secondary outcomes included nine OT/PT subcategories. Outcomes were examined at 6, 12, and 24 months postinjury. One thousand one hundred thirty-six burn survivors (692 vulnerable; 444 nonvulnerable) were included. The vulnerable group was mostly female, unemployed at time of injury, and with smaller burns. Both groups received similar OT/PT and psychological services at all time points. Adjusted regression analyses found that while the groups received similar amounts services, some vulnerable subgroups received significantly more services. Participants 65 years of age or older, who received psychological therapy or counseling prior to injury, and with a preexisting disability received more OT/PT and psychological or peer support services at follow-up. Overall, vulnerable and nonvulnerable groups received comparable OT/PT and psychological services. The importance of long-term care among vulnerable subgroups of the burn population is highlighted by this study. Future work is needed to determine adequate levels of follow-up services.