A National Study of the Effect of Race, Socioeconomic Status, and Gender on Burn Outcomes

The Scalding Truth: Geospatial Analysis Identifies Communities at Risk for Pediatric Scald Burns

INTRODUCTION

Pediatric scald burns account for 12% of all U.S. burn center admissions and are the most common type of burn in children. We hypothesized that geospatial analysis of burn registry data could identify specific geographic areas and risk factors to focus injury prevention efforts.

METHODS

The burn registry of a U.S. regional burn center was used to retrospectively identify pediatric scald burn patients ages 0-17, from January 2018 to June 2023. Geocoding of patient home addresses with census tract data was performed. Area Deprivation Index (ADI) was assigned to patients at the census block group level. Burn incident hot spot analysis to identify statistically significant burn incident clusters was done using the Getis Ord Gi∗ statistic.

RESULTS

There were 950 pediatric scald burn patients meeting study criteria. The cohort was 52% male and 36% White, with median age of 3 y and median total body surface area of 1.5%; 23.8% required hospital admission. On multivariable logistic regression, increased child poverty levels (P = 0.004) and children living in single-parent households (P = 0.009) were associated with increased scald burn incidence. Geospatial analysis identified burn hot spots, which were associated with higher ADI (P < 0.001). Black patients were more likely to undergo admission compared to White patients.

CONCLUSIONS

Geospatial analysis of burn registry data identified geographic areas at high risk of pediatric scald burn. ADI, poverty, and children in single-parent households were the greatest predictors of injury. Addressing these inequalities requires targeted injury prevention education, enhanced outpatient support systems and more robust community resources.

Examination of Pediatric Burn Incidence and the Impact of Social Determinants of Health in Florida

Introduction Burn injuries are a major mechanism of trauma worldwide, caused by friction, cold, heat, radiation, chemical, or electric sources. Most often, burn injuries occur due to heat contact from hot liquids, solids, or fire, termed scald burns and flame burns, respectively. These types of injuries are complex and carry major injury and mortality risks, especially in pediatric populations. Burn trauma prevention has been a major focus in the US, with initiatives to increase public health outreach and safety measures. Unfortunately, children in socioeconomically disadvantaged situations may face these types of injuries at disproportionately higher rates, and we aim to highlight these disparities, if any, within our Florida community. Materials and methods This study was designed as a retrospective observational analysis using publicly available data from the Florida Health Community Health Assessment Resource Tool Set (CHARTS). Data was extracted for nonfatal burn injuries resulting in ED visits in the years 2018-2020. This data was limited to those ranging from 0 to 19 years old and converted to rates of burn injuries per 100,000. Sociodemographic details for each county were recorded from County Health Rankings & Roadmaps and compared with burn data in each respective county. Frequencies were generated for categorical data, and statistical analyses for burn rates and sociodemographic details were performed with a generalized linear model using a Poisson distribution and bivariate correlation for a p < 0.05. Results In Florida, the median annual burn rate per 100,000 was 136 (IQR: 96-179), with Jackson county holding the highest rate of 323 and Glades, Hardee, and Lafayette each holding a rate of 0. Of the 18 socioeconomic factors examined, a total of five were found to have no statistically significant effect on nonfatal burn injury ED visits: severe housing problems, percentage of Asians, teen births, percentage of children (<18 years) in poverty, and severe housing cost burden. The two most important factors to be found in nonfatal burn ED visits of pediatric patients were the percentage of those younger than 19 years old without health insurance and the average grade level performance of third-grader reading scores. When adjusting for the small sample size using Firth's bias-adjusted estimates and overdispersion, both reading scores and those without insurance play a significant role in pediatric burn injuries. For each increase in a single point in reading scores, the incidence rate ratio decreases by 97.1% (95% CI). For every percentage increase in children insured, there is a 28.8% decrease in pediatric burn injuries (95% CI). Conclusions This analysis highlights increased pediatric burn rates across multiple social determinants of health (SDOH) in all 67 Florida counties. The findings here demonstrate that there may continue to be a disproportionate distribution of burn rates among lower and higher sociodemographic areas. This study further highlights this trend within the Florida community, and continued research will be necessary to meet the needs of lower sociodemographic areas to improve burn rates in vulnerable populations, such as children, who are at increased risk of injury.

Association of race and ethnicity with pediatric burn outcomes: A population study of the Kids' Inpatient Database

BACKGROUND

While most studies on burn outcomes have focused on adults, it is unclear if the same socioeconomic and environmental inequalities affect paediatric patients. This study aims to investigate the impact of race and ethnicity on outcomes in paediatric burn patients.

METHODS

The Kids' Inpatient Database is released by Agency for Healthcare Research and Quality, and is the largest publicly available database for the United States inpatient paediatric population. All paediatric burned patients in 2016 and 2019 were identified. Race and/or ethnicity was the primary exposure variable, and the primary outcome was a composite of several in-hospital morbidities. Secondary outcomes included death, non-routine disposition, and length of stay. Fine-Gray competing risks regression and multivariable logistic regression were used to analyze length of stay and all other outcomes, respectively. Analysis also isolated subgroups related to socioeconomic status and case severity.

RESULTS

We included12,582 pediatric burn patients in this study. No difference was found in composite morbidity between White patients and those of other race or ethnicity groups. Hispanic ethnicity was associated with longer lengths of stay and increased odds of routine (i.e. home) discharge. Black patients had increased length of stay compared to White patients only in severe burn cases.

CONCLUSIONS

Our study implies that race- or ethnicity-associated mechanisms driving outcome disparities in adults does not necessarily apply in paediatric burn patients.

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.

Adult Burn Inpatients Have Increased Burn Severity and Mortality Compared to Children in Retrospective Analysis of National Inpatient Sample 2017

INTRODUCTION

Socioeconomic status and comorbidities are associated with increased mortality in patients with external surface burn patients, however differences between pediatric and adult burn populations have not been adequately studied.

OBJECTIVES

Our objectives were to explore the presentation, management, and outcomes of external surface burns across age groups.

METHODS

The 2017 National Inpatient Sample (NIS) was queried for patients with any diagnosis of external body surface burns. Demographics, comorbidities, complications, total charges, length of stay (LOS), number of procedures undergone (NPU), and time from admission to first procedure (TFP) were identified. Univariate and multivariable analyses were used to identify statistical associations with age.

RESULTS

52,335 inpatients were identified with burns, with the majority male (63.6%) and adults (81.8%). Mean age was 50.5 (standard error [SE] 0.1) and 5.5 (SE 0.1) years for adults and children, respectively. Adults had higher prevalence of hypertensive disease (43.5% versus. 1.4%), diabetes mellitus (24.1% versus 0.3%), and obesity (11.7% versus 1.6%) than children (P < 0.001). Adults versus children had higher odds for mortality (odds ratio [OR] 4.26, 95% confidence interval [CI] 3.08-5.89), sepsis (OR 5.16, 95% CI 4.10-6.48), and pneumonia (OR 4.26, 95% CI 3.30-5.50).

CONCLUSIONS

In this national cohort of inpatients with external surface burns, comorbidities, and odds for mortality and complications varied by age. Pediatric patients more often had lower household incomes; however, adults had significantly higher odds for mortality suggesting that age and comorbidity status are more impactful on burn outcomes than socioeconomic status.

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.

C-reactive protein elevation is associated with increased morbidity and mortality in elderly burned patients

BACKGROUND

C-reactive protein (CRP) is an acute-phase protein produced in response to inflammation after traumatic injury. We posit that C-reactive protein (CRP) is reliable in predicting morbidity and mortality following severe burn. In this study, we explored the relationship between serum CRP values and clinical outcomes in the severely burned.

METHODS

Using the Research Network within the TriNetX database, we queried de-identified burn patient data across the United States and enrolled 36,556 burn patients with reported CRP values from 2006 to 2020.

RESULTS

Circulating CRP levels were elevated significantly in patients ≥60 years as well as in males and African Americans (p < 0.05). CRP levels reached the zenith on the first day after burn, and were highest when burn size reached 60% total body surface area (TBSA). After bisecting the data at 10 mg/L of CRP, we compared clinical findings between patient groups (n = 16,284/18,647 in high/low CRP levels). The risk of patient death doubled in the high CRP group from 4.687% to 9.313%, with higher incidences of sepsis, skin infection, and myocardial infarction (p < 0.05). Moreover, mortality increased from 0.9% to 1.926% in those younger than 20 years when comparing the low and high CRP groups, whereas mortality significantly increased from 8.84% to 15.818% in those ≥60 years old (p < 0.05). Both elderly and paediatric groups had significant increases in the diagnosis of sepsis-associated with increased CRP expression. However, incidences of skin infection, pneumonia, and acute kidney injury increased significantly only in the elderly group (p < 0.05).

CONCLUSION

Elevated CRP expression is common in burn patients. The factor of age influenced the association of CRP expression to clinical outcomes.

Impact of community-level socioeconomic disparities on quality of life after burn injury: A Burn Model Systems Database study

INTRODUCTION

Individual-level socioeconomic disparities impact burn-related incidence, severity and outcomes. However, the impact of community-level socioeconomic disparities on recovery after burn injury is poorly understood. As a result, we are not yet able to develop individual- and community-specific strategies to optimize recovery. Therefore, we aimed to characterize the association between community-level socioeconomic disparities and long-term, health-related quality of life after burn injury.

METHODS

We queried the Burn Model System National Longitudinal Database for participants who were> 14 years with a zip code and who had completed a health-related quality of life (HRQOL) questionnaire (VR-12) 6 months after injury. BMS data were deterministically linked by zip code to the Distressed Communities Index (DCI), which combines seven census-derived metrics into a single indicator of economic well-being, education, housing and opportunity at the zip code level. Hierarchical linear models were used to estimate the association between community deprivation and HRQOL 6 months after burn injury, as measured by mental (MCS) and physical (PCS) component summary scores of the SF12/VR12.

RESULTS

342 participants met inclusion criteria. Participants were mostly male (n = 239, 69 %) and had a median age of 48 years (IQR 33-57 years). Median %TBSA was 10 (IQR 3-28). More than one-third of participants (n = 117, 34 %) lived in a community within the highest two distress quintiles. After adjusting for age, race/ethnicity, number of trips to the operating room (OR) and pre-injury PCS, neighbourhood distress was negatively associated with 6-month PCS (ß-0.05, 95 % CI [-0.09,-0.01]). Increasing age and lower pre-injury PCS were also negatively associated with 6-month PCS. There was no observed association between neighbourhood distress and 6-month MCS after adjustment for age, participant race/ethnicity, number of trips to the OR and pre-injury MCS. Higher pre-injury MCS was associated with 6-month MCS (ß0.54, 95 % CI [-0.41,0.67]).

CONCLUSIONS

Community distress is associated with lower PCS at 6 months after burn injury but no association with MCS was identified. Pre-injury HRQOL is associated with both PCS and MCS after injury. Further study of the factors underlying the relationship between community distress and physical functional recovery (e.g., access to rehabilitation services, availability of adaptations) is required to identify potential interventions.

Black and White Patients With Staphylococcus aureus Bacteremia Have Similar Outcomes but Different Risk Factors

BACKGROUND

Staphylococcus aureus bacteremia (SAB) disproportionately affects Black patients. The reasons for this disparity are unclear.

METHODS

We evaluated a prospectively ascertained cohort of patients with SAB from 1995 to 2020. Clinical characteristics, bacterial genotypes, and outcome were compared among Black and White patients with SAB. Multivariable logistic regression models were used to determine factors independently associated with the outcomes.

RESULTS

Among 3068 patients with SAB, 1107 (36%) were Black. Black patients were younger (median, 56 years vs 63 years; P < .001) and had higher rates of diabetes (47.5% vs 34.5%, P < .001), hemodialysis dependence (40.0% vs 7.3%, P < .001), and human immunodeficiency virus (6.4% vs 0.6%, P < .001). Black patients had higher rates of methicillin-resistant S. aureus (49.3% vs 44.9%, P = .020), including the USA300 hypervirulent clone (11.5% vs 8.4%, P = .007). White patients had higher rates of corticosteroid use (22.4% vs 15.8%, P < .0001) and surgery in the preceding 30 days (28.1% vs 18.7%, P < .001). Although the median Acute Physiology Score (APS) at the time of initial SAB diagnosis was significantly higher in Black patients (median APS, 9; interquartile range [IQR], 5-14 vs median APS, 7; IQR, 4-12; P < .001), race was not associated with 90-day mortality (risk ratio, 1.02; 95% confidence interval, .93-1.12), and rates of metastatic infection were lower among Black patients (37.2% vs 41.3% White, P = .029).

CONCLUSIONS

Despite differences in Black patients' higher APS on presentation and more risk factors, including a 5 times higher risk of hemodialysis dependence, 90-day mortality among Black and White patients with SAB was similar.

Impact of the Social Determinants of Health on Adult Trauma Outcomes

Social determinants of health (SDOHs) have been well studied within the literature in the United States but the effects of these determinants of health on patients with trauma have garnered less attention. The interaction between patients with SDOHs and patients with trauma requires clinicians caring for this population to view patients with trauma through a multifaceted lens. The purpose of this article will be to illuminate the drivers of trauma in the adult population and how the SDOHs and the health-care system come together to contribute to disparities in trauma outcomes.

A Comprehensive, Retrospective Analysis of Variables for Potential Mortality Impact in Patients With Thermal or Inhalation Injury

Age, percentage TBSA burned, and the presence of inhalation injury have been used historically in the prediction of mortality in thermally injured patients despite other factors being also associated with mortality. Recent literature has identified novel factors associated with increased length of stay (LOS) and may provide a better prediction model for mortality in burn patients. The study objective was to perform a subset analysis of a multitude of known and novel variables for potential association with mortality. Demographics and injury characteristics along with during stay variables were collected and analyzed. This study is a re-analysis of a retrospective study examining variables associated with increased LOS. Of the 629 patients screened, 396 were included in the analysis. After univariable analysis, 35 variables had significant associations with mortality, including age, house fire, acute kidney injury, heart failure, inhalation injury, and history of diabetes. After multivariable analysis, the best performing model included heart failure, acute kidney injury, admission Glasgow Coma Scale score, and revised Baux score. Quantile analysis of age revealed greater than 60 years was most predictive of mortality. The best multivariable model for patients greater than 60 years old included heart failure, vasopressor use, acute respiratory distress syndrome, and TBSA burned. Considering only variables present on admission, the best multivariable model for patients greater than 60 years old included heart failure, % TBSA burned, and inhalation injury. The addition of variables into current prediction models and databases may be warranted.

Palliative Care Utilization in Burn Patients

Background: Burn injuries are a common cause for hospitalization, and severe burns have an increased risk of death in patients with advanced age, inhalational injury, comorbid conditions. Very little is known about the utilization of palliative care consultation in burn patients. Objective: The aim of this study was to evaluate the factors influencing the utilization of inpatient palliative care consultation for patients with severe burn injuries. Methods: This was a retrospective chart review study at a single burn center. Results: Seventeen out of 191 patients (8.9%) received a palliative care consultation with the average time for consultation of 10.3 days. Factors that appear to impact consultation were age, presence of inhalational injury, and multiple comorbid conditions. Conclusion: Inpatient palliative care consultation was underutilized in patients with severe burn injurie. Further research into the outcomes of palliative care consultation could help further support the utility of early involvement in burn patients.

Social determinants of health in pediatric scald burns: Is food access an issue?

BACKGROUND

Burn injury risk, severity, and outcomes have been associated with socioeconomic status. Limited data exist to evaluate health access-related influences at a structural population level. This study evaluated factors at the Census-tract level, specifically evaluating food access and social vulnerability in pediatric scald burns.

METHODS

A single-institution retrospective review using the trauma registry and electronic medical record was conducted of pediatric burns between 2016 and 2020. Home address was coded to the Census-tract level and bulk analyzed. Socioeconomic metrics of the home environment were evaluated from publicly available databases, the United States Food and Drug Administration Food Access Research Atlas, and the Centers for Disease Control's Social Vulnerability Index.

RESULTS

There were 840 patients that met inclusion criteria (49.8% scald, N = 418). The mean total body surface area for scalds was 6.6% with an age of 10.2 years; 76% (n = 317) of scalds had Medicaid, and 15% (n = 63) were due to hot noodles. Scalds occurred more in females (45.7%, N = 191 vs 28.0%, N = 118; P < .0001), non-White race (62.7%, N = 262 vs 29.1%, N = 123; P < .0001), and low-income and low-food access populations (39.8%, N = 147 vs 30.4%, N = 116; P = .007). Low-food access Black populations showed increased scald injury (18% [interquartile range 6-35] vs 10% [interquartile range 4-25]), whereas all other populations showed no association. The patients with scalds had a higher overall social vulnerability index (0.67 vs 0.62, P = .008).

CONCLUSION

Often related to poverty, health access, and health equity, population-level social determinants of health like social vulnerability and food access have significant impact on health care and should influence health outreach and systems improvement.

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.

The relation between satisfaction with appearance and race and ethnicity: A National Institute on Disability, Independent Living, and Rehabilitation Research burn model system study

Research supports that people of color in the U.S. have poorer outcomes after burn injury compared to White individuals. The current study sought to explore burn health disparities by testing the relationship between racial and ethnic minority status, a proxy for systemic discrimination due to race and ethnicity, with two key constructs linked to functional outcomes, satisfaction with appearance and social community integration. Participants included 1318 burn survivors from the Burn Model System National Database (mean age = 40.2, SD = 12.7). Participants completed measures of satisfaction with appearance and social community integration at baseline, 6-, 12-, and 24-months after burn injury. Linear regressions revealed that racial and ethnic minority status significantly related to lower satisfaction with appearance and social community integration compared to White individuals at all time points. In addition, satisfaction with appearance continued to significantly relate to greater social community integration even while accounting for race and ethnicity, age, sex, burn size, and physical disability at 6-, 12-, and 24-month time points. Overall, the study supports that racial and ethnic minority burn survivors report greater dissatisfaction with their appearance and lower social community reintegration after burn injury.

Does Socioeconomic Status or Methamphetamine use Impact Discharge Opioid Requirements in Burn Injured Patients?

Methamphetamine (MA) use is associated with lower socioeconomic status (SES) and increased opioid use. Though MA use itself has been linked to larger burn injuries and increased length of stay, studies examining the effect of SES on opioid use in this patient population remain limited. The aim of this work was to examine how both SES and/or MA use in burn patients impacted discharge opioid requirements. Records of burn patients admitted to an ABA verified burn center were reviewed from January 2016 to December 2017. Patients were grouped into MA positive (MPOS) or negative groups (MNEG) based on admission urine toxicology screening. Pain scores, oral morphine opioid equivalents (OE), and adjunct pain medication use reported within 24 hours of discharge were examined. SES was determined by zip code. No difference was found between MPOS and MNEG groups regarding discharge OE (p=0.4), OE/TBSA (p=0.79), or pain score (p=0.09). Low SES was more prevalent in MPOS patients (p&lt;0.0001) but low SES was not a predictor of discharge OE (p=0.7), OE/TBSA (p=0.7), or pain score (p = 0.15). Discharge OE and OE/TBSA requirements correlated with discharge pain score (p&lt;0.0001) and LOS (p&lt;0.01), but not SES. Multivariate linear regression found that MNEG status (p=0.005), pain score (p &lt; 0.0001), concurrent use of benzodiazepines and gabapentin (p&lt;0.001), but not low SES, were independently associated with increased OE. Although lower SES was seen in patients using MA, SES was not associated with discharge opioid use or pain scores. Additional work will be necessary to determine factors affecting opioid use in this population.

Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study

BACKGROUND

We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels.

METHODS

In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality.

RESULTS

Among 6431 burn patients (38 % female; 62 % male), females less frequently received surgical treatment during index hospitalization (49 % vs 56 %, p < 0.001), and more frequently died in-hospital (26 % vs 16 %, p < 0.001) than males. Odds of in in-hospital death was 2.16 (95 % CI: 1.73-2.71) times higher among females compared to males in middle-income countries.

CONCLUSIONS

Across national income levels, there appears to be important gender-based disparities among burn injury epidemiology, treatment received and outcomes that require redress. Multinational registries can be utilized to track and to evaluate initiatives to reduce gender disparities at national, regional and global levels.

The Costs of Burn Victim Hospital Care around the World: A Systematic Review

BACKGROUND

Burn injuries are very common and fire-related burns account for over 300,000 deaths per year globally. The costs of the treatment of these patients change around the world. The aim of the present study was to conduct a systematic literature review to identify the costs related to hospital stays of burn victims in countries with different Human Development Index (HDIs).

METHODS

PubMed, CINAHL and BVIS databases were searched using the following terms: "burn," treatment" and "costs". The review included articles that presented cost studies or economic assessments of burn victims in which the costs were reported, and published between 2012 and 2019. The quality of the evidence was assessed using the Consensus on Health Economic Criteria. This review presents register in Prospero (CRD42019137580).

RESULTS

The review included 19 economic studies conducted in 13 countries, most with a very high HDIs. Most studies estimated direct acute burn care costs through bottom-up costing and institutional data. Total hospital care costs ranged from US$ 10.58 to US$ 125,597.86 per patient, the cost of 1% of total body surface area burned ranged from US$ 2.65 to US$ 11,245.04, and the cost of hospital care per day, from US$ 24.23 to US$ 4,125.50.

CONCLUSION

The costs are high and show wide discrepancies among countries. Medical costs and other losses caused by fatal and non-fatal burn injuries differ considerably among demographic groups, care protocols, and country HDIs.

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.

Burns and socioeconomic deprivation: the experience of an adult burns centre

INTRODUCTION

Burns incidence, mortality and complication rates have been shown to be directly correlated by race, gender and socioeconomic status. As such, socioeconomic status (SES) has been previously highlighted as a target for burn prevention in the UK and abroad. The Queen Elizabeth Hospital, Birmingham (QEHB) is the regional Burns Centre for the Midlands Burn Network, supporting a population of 13.7 million METHODS: 16-year retrospective review was performed of all acute adult burns assessed by the Burns and Plastics Department, QEHB. The data included patient demographics (age, gender, ethnic origin and postcode), mechanism of injury, total body surface area (TBSA) affected and whether first aid was given. IMD Rank, IMD Scores were obtained from individual postcodes, as well as incidence data per electoral ward.

RESULTS

In our analyses there were 3369 total acute admissions and acute assessments. 812 patients (24.1%) were in the most deprived decile. 1715 patients (50.9%) live within the 3 most deprived deciles. The deciles with the lowest completion of first aid were the first (524, 70.72%), third (257, 72.39%) and second (351, 72.82%).

CONCLUSIONS

This study shows patients from the most deprived areas are over-represented in burns incidence and are less likely to perform first aid. We feel this should be highlighted in burns prevention and education strategies.

Peritraumatic Vitamin D levels predict chronic pain severity and contribute to racial differences in pain outcomes following Major Thermal Burn Injury

Major thermal burn injuries result in approximately 40,000 hospitalizations in the United States each year. Chronic pain affects up to 60% of burn survivors, Black Americans have worse chronic pain outcomes than White Americans. Mechanisms of chronic pain pathogenesis after burn injury, and accounting for these racial differences, remain poorly understood. Due to socioeconomic disadvantage and differences in skin absorption, Black Americans have an increased prevalence of Vitamin D deficiency. We hypothesized that peritraumatic Vitamin D levels predict chronic pain outcomes after burn injury and contribute to racial differences in pain outcomes. Among burn survivors (n=77, 52% White, 48% Black, 77% male), peritraumatic Vitamin D levels were more likely to be deficient in Blacks vs. Whites (27/37 (73%) vs. 14/40 (35%), p<.001). Peritraumatic Vitamin D levels were inversely associated with chronic post-burn pain outcomes across all burn injury survivors, including those who were and were not Vitamin D deficient, and accounted for approximately 1/3 of racial differences in post-burn pain outcome. Future studies are needed to evaluate potential mechanisms mediating the effect of Vitamin D on post-burn pain outcomes and the potential efficacy of Vitamin D in improving pain outcomes and reducing racial differences.

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.

Interhospital variation of inpatient versus outpatient pediatric burn treatment after emergency department evaluation

BACKGROUND

Approaches to burn care in the pediatric population are highly variable and can be targeted as a potential measure in cost-reduction. We hypothesized that institutions vary significantly in treatment allocation of nonsevere burns to either inpatient or outpatient care.

METHODS

We queried the PHIS database for fiscal year 2017 to quantify small pediatric burn admissions and Emergency Department visits (ED). The ICD-10 code T31.0 was used to identify burns involving <10% of total body surface area (TBSA). Centers were categorized by burn center status and length of stay, readmissions, and charges were compared.

RESULTS

Inpatient versus outpatient management distribution was significantly different across the included pediatric children's hospitals (n = 34, p < 0.00001). When data were analyzed with respect to outpatient care, a bimodal distribution distinguished two groups: high hospital utilizers with an average of 30% outpatient burn care and low-utilizers averaging 87%. Median inpatient charge per patient was greater than 31-fold compared to ED burn management (p < 0.0001).

CONCLUSIONS

Variability of inpatient versus outpatient pediatric burn management in small burns was significant. Compared to outpatient burn care, inpatient care is significantly more costly. Implementing protocols and personnel to provide adequate attention to small burns in the ED could be an important cost-saving measure.

TYPE OF STUDY

Retrospective analysis.

LEVEL OF EVIDENCE

Level III.

Racial/Ethnic Disparities in Longitudinal Trajectories of Community Integration After Burn Injury

OBJECTIVES

The aim of this study was to examine potential racial/ethnic disparities in community integration for the 2 yrs after burn injury.

DESIGN

A sample of 1773 adults with burn injury from the Burn Model Systems database was used with data on community integration collected at discharge (preinjury recall), 6, 12, and 24 mos after discharge.

METHODS

Four sets of hierarchal linear models determined the most appropriate model for understanding racial/ethnic differences in Community Integration Questionnaire trajectories over time.

RESULTS

Data indicated a decrease in community integration between discharge and 6 mos, a slight increase between 6 mos and 1 yr, and then a plateau between 1 and 2 yrs. White individuals had higher community integration score trajectories over time than black (b = 0.53, P < 0.001) and Hispanic (b = 0.58, P < 0.001) individuals, and community integration scores were similar between black and Hispanic individuals (b = -0.05, P = 0.788). These racial/ethnic disparities remained after accounting for age, sex, total burned surface area, number of days in rehabilitation, and active range of motion deficits.

CONCLUSIONS

Additional rehabilitation resources should be targeted to helping black and Hispanic individuals integrate back into their communities after burn injury.

Sex-Based Differences in Inpatient Burn Mortality

BACKGROUND

Among burn patients, research is conflicted, but may suggest that females are at increased risk of mortality, despite the opposite being true in non-burn trauma. Our objective was to determine whether sex-based differences in burn mortality exist, and assess whether patient demographics, comorbid conditions, and injury characteristics explain said differences.

METHODS

Adult patients admitted with burn injury-including inhalation injury only-between 2004 and 2013 were included. Inverse probability of treatment weights (IPTW) and inverse probability of censor weights (IPCW) were calculated using admit year, patient demographics, comorbid conditions, and injury characteristics to adjust for potential confounding and informative censoring. Standardized Kaplan-Meier survival curves, weighted by both IPTW and IPCW, were used to estimate the 30-day and 60-day risk of inpatient mortality across sex.

RESULTS

Females were older (median age 44 vs. 41 years old, p < 0.0001) and more likely to be Black (32% vs. 25%, p < 0.0001), have diabetes (14% vs. 10%, p < 0.0001), pulmonary disease (14% vs. 7%, p < 0.0001), heart failure (4% vs. 2%, p = 0.001), scald burns (45% vs. 26%, p < 0.0001), and inhalational injuries (10% vs. 8%, p = 0.04). Even after weighting, females were still over twice as likely to die after 60 days (RR 2.87, 95% CI 1.09, 7.51).

CONCLUSION

Female burn patients have a significantly higher risk of 60-day mortality, even after accounting for demographics, comorbid conditions, burn size, and inhalational injury. Future research efforts and treatments to attenuate mortality should account for these sex-based differences. The project was supported by the National Institutes of Health, Grant Number UL1TR001111.

Bacterial infection profile and predictors among patients admitted to a burn care center: A retrospective study

BACKGROUND

Infection is the main cause of mortality and complications in burn patients. The present study was the first to examine the local profile and antecedents of bacterial infections among patients admitted to a Lebanese burn care center.

METHODS

The present study was a retrospective analysis of the occurrence and recurrence of infection, its characteristics as well as antimicrobial susceptibility among 475 patients admitted to the Burn Centre at the Lebanese Geitaoui Hospital between January 2014 and December 2018.

RESULTS

55% of patients contracted at least one infection during their hospitalization. Length of stay (LOS), sepsis, wound dressing under anesthesia, blood transfusion and female sex independently and positively predicted infection in burn patients. Infection was predominately caused by Staphylococcus aureus (48.7%), followed by Pseudomonas aeruginosa (22.6%) and Acinetobacter baumannii (15.7%). Bacterial isolates were predominately multi-drug or extensively drug resistant and showed variable antimicrobial susceptibility patterns. Recurrent infections occurred in 44.1% of infected burn patients, and were independently predicted by LOS (p = 0.004), sepsis (p = 0.001), surgery (p = 0.003), burn excision and skin grafting (p = 0.019), and central line insertion (p = 0.004).

CONCLUSION

Existing burn management and infection control measures must be revised in order to reduce the incidence and improve the treatment of infections in burn patients.

Racial inequality in the trauma of women: A disproportionate decade

BACKGROUND

Historically, women have been largely underrepresented in the body of medical research. Given the paucity of data regarding race and trauma in women, we aimed to evaluate the most common types of traumas incurred by women and analyze temporal racial differences.

METHODS

A 10-year review (2007-2016) of the National Trauma Data Bank was conducted to identify common mechanisms of injuries among women. Trends of race, intent of injury, and firearm-related assaults were assessed using the Cochran-Armitage Trend test. Multivariable multinomial logistic regressions were utilized to examine the association between race and trauma subtypes.

RESULTS

Of the 2,082,768 women identified as a trauma during this study period, the majority presented due to an unintentional intent (94.5%), whereas fewer presented secondary to an assault (4.4%) or self-inflicted injury (1.1%). While racioethnic minority women encompassed a small percentage of total traumas (19%), they accounted for roughly three fifths of assault-related traumas (p < 0.001). Though total assaults decreased by 20.8% during the study period, black and Hispanic women saw a disproportionately smaller decrease of 15.1% and 15.8%, respectively. On regression analysis, compared with white women, black women had more than four times the odds of being an assault-related trauma compared with unintentional trauma (odds ratio, 4.48; 95% confidence interval, 4.41-4.55). On subset analysis, firearm-related assault was 17.3 times more prevalent among black women (white, 0.3% vs. black: 5.2%; p < 0.001). In fact, history of alcohol abuse was found to be an effect modifier of the association of race/ethnicity and firearm-related trauma.

CONCLUSION

Compelling data highlight a disproportionate trend in the assault-related trauma of minority women. Specifically, minority women, especially those with a history of alcohol abuse, were at increased risk of being involved in a firearm assault. Further studies are essential to help mitigate disparities and subsequently develop preventative services for this diverse population.

LEVEL OF EVIDENCE

Epidemiological, Level III.

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.

Associations between clinical characteristics and the development of multiple organ failure after severe burns in adult patients

To determine the association between potential risk factors and multiple organ failure (MOF) in severe burn adult patients, we performed a secondary analysis of data from the "Inflammation and the Host Response to Injury" database, which included patients from six burn centers in the United States between 2003 and 2009. Three hundred twenty-two adult patients (aged ≥16 years) with severe burns (≥20.0% total body surface area [TBSA]) were included. MOF was defined according to the Denver score. Potential risk factors were analyzed for their association with MOF. Models were built using multivariable logistic regression analysis. Eighty-eight patients (27.3%) developed MOF during the study period. We found that TBSA, age, and inhalation injury were significant risk factors for MOF. This predictive model showed good performance, with the total area under the receiver operating characteristic curve being 0.823. Moreover, among patients who developed MOF, inhalation injury was significantly associated with the development of MOF in the acute phase (within three days of injury) (adjusted odds ratio 3.1; 95% confidence interval 1.1-8.3). TBSA, age, lactate, and Denver score within 24h were associated with the late phase development of MOF. Thus, we have identified key risk factors for the onset of MOF after severe burn injury. Our findings contribute to the understanding of individualized treatment and will potentially allow for efficient allocation of resources and a lower threshold for admission to an intensive care unit, which can prevent the development of MOF and eventually reduce mortality.

Health Disparities and Sepsis: a Systematic Review and Meta-Analysis on the Influence of Race on Sepsis-Related Mortality

RATIONALE

Racial disparities in sepsis outcomes have been previously reported. However, recently, there have been inconsistencies in identifying which socioeconomic variables, such as race, account for these disparities. The objective of this study was to perform a systematic review in order to examine the impact of race on sepsis-attributable mortality.

METHODS

Systematic searches for English-language articles identified through MEDLINE, EBSCOhost, PubMed, ERIC, and Cochrane Library databases from 1960 to 1 February 2017. Included studies examined sepsis outcomes in the context of sepsis incidence and/or mortality. Two investigators independently extracted data and assessed study quality. The meta-analysis was performed in accordance with the Cochrane Collaboration guidelines.

RESULTS

Twenty-one studies adhered to the predefined selection criteria and were included in the review. Of the 21 studies, we pooled data from 6 studies comparing African American/Black race as a risk factor for sepsis-related mortality disparities (reference group being Caucasian/White). From the meta-analysis on these six studies, African American/Black race was found to have no statistical significant relationship with sepsis-related mortality (odds ratio 1.20, 95% CI, 0.81 to 1.77). Similar results were found for other races (Native Americans, Asians) and ethnicities (Hispanic/Latinos).

CONCLUSION

On the basis of available evidence from a limited number of observation retrospective studies, race alone cannot fully explain sepsis-related disparities, especially sepsis-attributable mortality.

Analysis of factors impacting length of stay in thermal and inhalation injury

OBJECTIVES

Several studies have analyzed single or combinations of variables for impact on length of stay (LOS) in thermally-injured patients. The objective of this study was to evaluate a multitude of established variables and potentially identify novel variables associated with LOS in a single study.

METHODS

This two-year, retrospective study included all patients admitted to the burn center between January 2015 and December 2016. Exclusions included death during admission, lack of thermal or inhalation injury, age less than 18 years, readmission(s), and if pregnant or incarcerated. Baseline demographics and pertinent data were collected using electronic medical records. Regression analysis was used to determine the most predictive variables.

RESULTS

Six hundred twenty-nine patients were admitted during the inclusion period and 354 patients remained for analysis after exclusion. Univariable analysis revealed 32 variables significantly associated with LOS. Using multivariable regression, the best-fit baseline demographic model included: percent total body surface area (TBSA) injured, lower/middle socioeconomic status, clotting disorders, anemia, admission serum creatinine, and percent third degree injured (r² = 0.557). The best-fit combined model (incorporating baseline demographics and early in-hospital variables) included: acute kidney injury, infection and received vasopressor(s), percent TBSA injured, admission serum ethanol level, maximum C-reactive protein, and maximum total bilirubin (r² = 0.828).

CONCLUSIONS

There are multiple factors associated with the increased LOS seen in patients with thermal and inhalation injury. This study confirmed and identified novel factors not previously discussed in the literature that were significantly associated with LOS. Expansion of the data submitted to the National Burn Repository and the Burn Quality Improvement Program may be warranted. This study confirms claims from previous studies on inadequacy of current data submitted for benchmarking and under-reimbursement for the care of such a complex population.

Are There Changes in Inequalities in Injuries? A Review of Evidence in the WHO European Region

Decreases in injury rates globally and in Europe in the past decades, although encouraging, may mask previously reported social inequalities between and within countries that persist or even increase. European research on this issue has not been systematically reviewed, which is the aim of this article. Between and within-country studies from the WHO European Region that investigate changes in social inequalities in injuries over time or in recent decades were sought in PubMed, Scopus, and Web of Science. Of the 27 studies retained, seven were cross-country and 20 were country-specific. Twelve reported changes in inequalities over time and the remaining 15 shed light on other aspects of inequalities. A substantial downward trend in injuries is reported for all causes and cause-specific ones—alongside persisting inequalities between countries and, in a majority of studies, within countries. Studies investigate diverse questions in different population groups. Depending on the social measure and injury outcome considered, many report inequalities in injuries albeit to a varying degree. Despite the downward trends in risk levels, relative social inequalities in injuries remain a persisting public health issue in the European Region.

Racial disparities exist among burn patients despite insurance coverage

BACKGROUND

Age, total burn surface area (TBSA), and inhalation injury are proven predictors of mortality and morbidity following burn injury. Most previous studies have also found that African Americans and females with burns also fare worse. We sought to determine whether these disparities were reduced when burn victims were analyzed separately by categories of insurance coverage.

METHODS

We evaluated records in the National Burn Registry (NBR) from 2002 to 2011. Multivariate logistic regression was performed to determine factors associated with inpatient mortality, including age, TBSA, inhalation injury, race, and sex, and allowing for clustering by hospital. Separate models were constructed for each category of insurance. 95% confidence intervals (CI) not including 1 for any odds ratio were considered evidence of statistical significance (designated by * in the table below).

RESULTS

NBR included records from 172,640 patients (55.8% Caucasian, 18.1% African American, 14.2% Hispanic, 6.4% other minority groups, 5.4% unknown). Age, TBSA, and inhalation were strong predictors of mortality as expected. Non-African American males were the largest group for all insurance categories, and had the lowest mortality. Controlling for these factors, and compared with non-African American males, African American males had consistently increased odds of mortality regardless of insurance coverage. African American females had increased odds of mortality if they had Private, Medicare, or Medicaid insurance, and Non-African American females had increased odds of mortality if they had Private or Medicaid insurance. The association of Hispanic ethnicity with mortality was inconsistent or insignificant, and other minority groups had too few members to evaluate. Most patients were missing comorbidity data, and no other socioeconomic or hospital data were available in NBR.

CONCLUSIONS

African American males with burn injury are at increased risk of mortality regardless of insurance coverage, and most females are at increased risk regardless of race. Analyzing the reasons for these disparities will require databases containing more complete comorbidity, socioeconomic, and/or hospital data.

Multi-institutional analysis of independent predictors for burn mortality in the United States

Background

Previous reports individually identified different factors that predict death after burns. The authors employed the multi-center American Burn Association's (ABA) National Burn Repository (NBR) to elucidate which parameters have the highest negative impact on burn mortality.

Methods

We audited data from the NBR v8.0 for the years 2002-2011 and included 137,061 patients in our study. The cases were stratified into two cohorts based on the primary outcome of death/survival and then evaluated for demographic data, intraoperative details, and their morbidity after admission. A multivariable regression analysis aimed to identify independent risk factors associated with mortality.

Results

A total of 3.3% of patients in this analysis did not survive their burn injuries. Of those, 52.0% expired within 7 days after admission. Patients in the mortality cohort were of older age (p < 0.001), more frequently female (p < 0.001), and had more pre-existing comorbidities (p < 0.001). Total body surface area (TBSA), inhalation injury, hospitalization time, and occurrence of complications were higher compared to survivors (p < 0.001). Lack of insurance (odds ratio (OR) = 1.84, confidence interval (CI) 1.38-2.46), diabetes (OR = 1.24, CI 1.01-1.53), any complication (OR = 4.09, CI 3.27-5.12), inhalation injury (OR = 3.84, CI 3.38-4.36), and the need for operative procedures (OR = 2.60, CI 2.20-3.08) were the strongest independent contributors to mortality after burns (p < 0.001). Age (OR = 1.07, CI 1.06-1.07) and TBSA (OR = 1.09, CI 1.09-1.09) were significant on a continuous scale (p < 0.001) while overall comorbidities were not a statistical risk factor.

Conclusion

Uninsured status, inhalation injury, in-hospital complications, and operative procedures were the strongest mortality predictors after burns. Since most fatal outcomes (52.0%) occur within 7 days after injury, physicians and medical staff need to be aware of these risk factors upon patient admission to a burn center.

Predictors of Early Onset Multiple Organ Dysfunction in Major Burn Patients with Ventilator Support: Experience from A Mass Casualty Explosion

Organ dysfunction is common in patients with major burns and associated with poor outcomes. The risk factors for early onset multiple organ dysfunction syndrome (MODS) in major burn patients with invasive ventilator support has rarely been evaluated before. In this study, major burn patients with invasive ventilator support from 499 victims suffered in a mass casualty color dust explosion were retrospectively enrolled. The development of early MODS that occurred within 5 days after burn injury was determined and the risk factors associated with early MODS were analyzed. A total of 88 patients from five medical centers were included. Their mean total body surface area (TBSA) was 60.9 ± 15.8%, and 45 (51.1%) patients had early MODS. Hematologic failure was the most common organ failure (68.6%), followed by respiratory failure (48.9%). Independent clinical factors associated with early MODS included TBSA ≥55% (OR: 3.83; 95% CI: 1.29-11.37) and serum albumin level <2.1 g/dL upon admission (OR: 3.43; 95% CI: 1.01-11.57). Patients with early MODS had prolonged ventilator dependence and longer ICU admission than those without early MODS. Our results showed that early MODS in major burn patients with invasive ventilator support is very common and can be predicted early on admission.

Impact of primary payer status on outcomes among patients with burn injury: A nationwide analysis

OBJECTIVE

To study the relationship between insurance provider and important outcomes among patients with burn injury.

METHODS

Adults with burn injury were selected from the National Inpatient Sample. The primary outcome was inpatient mortality. Secondary outcomes were morbidity (septic shock and prolonged mechanical ventilation (PMV)), treatment metrics (time to surgery and parenteral or enteral nutrition (P/E-nutrition)) and resource utilization (length of stay (LOS) and total hospitalization costs and charges). Confounders were adjusted for using multivariate regression analysis.

RESULTS

Insurance did not affect in-hospital mortality rate. Compared with private insurance, Medicaid was associated with higher septic shock rate (aOR: 2.14 (1.04-4.39), longer LOS (adjusted mean difference (aMD): 2.79 (0.50-5.08) days) and higher costs (aMD: $16,161 ($4789-$27,534) while uninsured patients has shorter LOS (aMD: -2.57 (-4.59--0.55) days), lower charges (aMD: $-37,792 $(-65,550-$-10,034) and costs (aMD: $-8563 ($15,581-$-1544)). Insurance did not affect PMV rates or time to surgery or P/E-nutrition.

CONCLUSIONS

Primary payer does not affect in-hospital mortality or treatment metrics among patients admitted for burn injury. However, compared with private insurance, Medicaid was associated with both higher morbidity and resource utilization, whereas uninsured patients had lower resource utilization.

Influence of Insurance Status on Hospital Length of Stay and Discharge Location in Burn Patients

Insurance status affects many aspects of healthcare in America, from access to delivery to outcomes. Our goal in this study was to determine whether different subtypes of insurance status affected hospital lengths of stay (LOS) and/or the location to which patients were discharged. The National Burn Repository was used to examine a total of 119,509 burn patients. Patients with noncommercial insurance (NONCOM) have increased LOS and are more likely to be discharged to a nonhome location, compared with no insurance or other insurance subtypes. Patients with no insurance have similar injury characteristics and comorbidities as patients with NONCOM, but have a shorter LOS and are more likely to be discharged home rather than to a skilled nursing facility or rehabilitation facility.

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

BACKGROUND

Although racial disparities have been well described in trauma and medical literature, less is known about disparities in the burn population, especially the Native American, Hispanic, Black, and Asian minority groups. This study seeks to identify at-risk populations for differences in patient and social characteristics that may link certain race groups to disparate burn outcomes.

METHODS

Data was reviewed from the National Burn Repository. Information regarding patient demographics, co-morbidities, complications, and clinical outcomes was recorded. Student's T-test, ANOVA, and binary logistic regression were used to assess relationships between patient factors and outcomes.

RESULTS

The Native American cohort had higher rates of alcoholism, drug abuse, and homelessness compared to all patients. Native Americans also had significantly longer hospital lengths of stay, and higher rates of respiratory failure, pneumonia, sepsis, and wound complications. The Black population demonstrated the highest percentage of injury at home, child abuse, and non-insurance. Mortality was highest in the Black population compared to all patients.

CONCLUSIONS

These findings suggest that outcome disparities exist in burn-injured patients in multiple minority groups.