Estimating the US Baseline Distribution of Health Inequalities Across Race, Ethnicity, and Geography for Equity-Informative Cost-Effectiveness Analysis

Area deprivation index and social vulnerability index in Milwaukee County: Impact on hospital outcomes after traumatic injuries

BACKGROUND

Predisposing factors for traumatic injuries are complex and variable. Neighborhood environments may influence injury mechanism or outcomes. The Social Vulnerability Index (SVI) identifies areas at risk for emergencies; Area Deprivation Index (ADI) measures socioeconomic disadvantage. The objective was to assess the impact of SVI or ADI on hospital length of stay (LOS) and mortality for injured patients to determine whether SVI or ADI indicated areas where injury prevention may be most impactful.

METHODS

Adult patients who resided in Milwaukee County and were treated for injuries from 2015 to 2022 at a level I trauma center were included. Patients' addresses were geocoded and merged with 2020 state-level SVI and ADI measures. SVI ranks census tracts 0-100 from least to most vulnerable. ADI ranks census block groups 1-10 from least to most disadvantaged. ADI and SVI rankings were converted to deciles. Statistical analyses included descriptive statistics, chi-square tests, and regression models for LOS and in-hospital mortality, adjusted for either SVI or ADI within separate models, age, sex, race or ethnicity, mechanism of injury (MOI), injury severity score (ISS).

RESULTS

14,542 patients were included; 63 % were male. Mean total hospital LOS was 6.4 ± 9.8 days, and in-hospital mortalities occurred in 5.2 % of patients. Based on SVI and ADI, 5,280 (36 %) patients resided in high vulnerability areas and 5,576 (39 %) lived in highly disadvantaged areas, respectively. After adjusting for patient factors, SVI deciles #6, 9, 10 were associated with increased hospital LOS, and SVI decile #5 was associated with in-hospital mortality (OR = 2.22, 95 %CI:1.06-4.63; p = 0.034). When adjusted for ADI, the 7th-10th deciles were associated with increased hospital LOS. Greater age and ISS were associated with increased hospital LOS and mortality when adjusted for SVI and ADI.

CONCLUSIONS

SVI and ADI identified a similar proportion of patients in high vulnerability or disadvantaged areas. Higher SVI and ADI deciles were associated with longer hospital LOS, and only the 5th SVI decile was associated with in-hospital mortality. Highly disadvantaged or vulnerable areas may have a longer LOS, but SVI and ADI have limited influence on trauma mortality. Continued research on neighborhood and community factors and trauma outcomes is needed.

Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review

Importance

Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology.

Objective

To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting.

Evidence Review

A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus.

Findings

Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented.

Conclusions and Relevance

These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.