Evaluation of Race and Ethnicity on Alcohol and Drug Testing of Adolescents Admitted with Trauma

Transcription

1 ACAD EMERG MED d November 2003, Vol. 10, No. 11 d Evaluation of Race and Ethnicity on Alcohol and Drug Testing of Adolescents Admitted with Trauma JamesP.Marcin,MD,MPH,RobertK.Pretzlaff,MD,MS,HollyL.Whittaker,MS, Alexander A. Kon, MD Abstract Objectives: To describe the incidence of alcohol and drug testing in adolescents admitted for traumatic injury and to analyze these results with reference to race, ethnicity, and gender differences. Methods: Data were collected on adolescents (aged 12 through 17 years) from the National Trauma Data Bank. Testing statuses for alcohol and drugs were the two primary outcome variables. The results of these tests were the secondary outcome variables. Additional casemix variables included: race, ethnicity, gender, age, Glasgow Coma Scale score, Injury Severity Score, day and time of arrival, and payment source. Hierarchical, multivariable logistic regression models were used to assess the relationship of race, ethnicity, and gender with the primary and secondary outcome variables. Results: Differences noted in the likelihood of alcohol and drug testing among the different racial, ethnic, and gender groups demonstrated an increased likelihood of Hispanic males and African American females to receive alcohol testing (odds ratio [OR]: 1.48; 95% CI ¼ 1.06 to 2.06; and OR: 1.30; 95% CI ¼ 1.01 to 1.67, respectively). Results of testing revealed that females of all races were less likely than males to test positive for alcohol and drugs. Drug and alcohol testing was more common during evenings, nights, and weekends, as well as in the presence of neurologic injury. Conclusions: Whereas small disparities in alcohol and drug testing were noted in some minority race-based groupings, systematic racial bias is not evident in adolescent trauma patients. Key words: trauma; alcohol testing; drug testing; adolescent; race; ethnicity. ACADEMIC EMERGENCY MEDICINE 2003; 10: Research has demonstrated that socioeconomic status (SES), gender, occupation, ethnicity, and race influence the provision of medical care. Racial and ethnic disparity has been documented in such diverse areas as research subject enrollment, renal transplantation, and cardiac care. 1 6 Unfortunately, a further reflection of current practice is that children are not immune to the effects of racial and ethnic bias. 7 This broad range of areas in which discriminatory conduct is observed makes it unlikely that such behavior is anomalous. Furthermore, such behavior runs counter to the training, ideals, and expressed desires of physicians Therefore, investigation into the manifestations and causes of racial and ethnic disparity in the delivery of health care is warranted. From the Department of Pediatrics, Section of Critical Care Medicine, University of California, Davis Medical Center, Sacramento, CA (JPM, RKP, AAK); and the Centers for Health Service Research in Primary Care (JPM), the Program in Bioethics (RKP, AAK), and the Graduate Group in Epidemiology (HLW) at the University of California, Davis. Received February 26, 2003; revisions received April 1 and 4, 2003; accepted April 7, Address for correspondence and reprints: Robert K. Pretzlaff, MD, MS, Department of Pediatrics, Section of Critical Care Medicine, University of California, Davis, 2516 Stockton Boulevard, Sacramento, CA Fax: ; rkpretzlaff@ucdavis.edu. doi: /s (03) Racial disparity in health care delivery can occur at multiple levels. At the societal level, barriers to health care can include discriminatory practices in managed care, a deficiency of medical facilities in urban areas, or a lack of necessary language support in areas that have large, non English-speaking populations. 7,11 The most fundamental level at which discriminatory practices can occur is that between physician and patient. Although physicians generally believe that they act in a manner free of bias, SES, race, and ethnicity play a role in a physician s perception of patients. 10,12,13 These perceptions may translate into a subconscious motivation to alter care based on race, ethnicity, SES, or gender. Unintentional and intentional injuries are the leading cause of death among American teenagers. 14 Assessing differences in testing for alcohol and drugs provides a useful means of evaluating racial and ethnic disparity in medical care because of its association with traumatic injury and the potential for race-, ethnicity-, and gender-based assumptions on their likely use and abuse. In adults, there is a wellestablished link between the presence of drug and alcohol use and trauma. 15,16 This study evaluates the incidence of drug and alcohol testing among adolescents admitted to the hospital for traumatic injuries. Our hypotheses were that alcohol and drug testing would be conducted equally among different racial, ethnic, and gender groups, and that the proportions of positive tests would be similar among these groups.

2 1254 Marcin et al. d RACIAL DIFFERENCES IN ALCOHOL/DRUG TESTING METHODS Study Design. Data were extracted from the National Trauma Data Bank (NTDB). This data source includes information on trauma patients from 64 institutions throughout the United States. Facility participation in the databank is voluntary, and the databank contains no unique subject identifiers. This analysis was conducted on the cohort of patients from January 1995 through December 1999 admitted to the hospital for care of their injuries. The research protocol was reviewed and approved by the Institutional Review Board at the University of California, Davis. Study Protocol. Outcome Variables. Testing status for alcohol (i.e., whether or not an alcohol test was performed) and testing status for drugs (i.e., whether or not a drug test was performed) were the two primary outcome variables. The results of those tests (i.e., positive or negative test for alcohol and/or drugs) were the secondary outcome variables. Independent Variables. Additional variables were chosen a priori from the data elements available in the NTDB. The variables included: race, ethnicity, gender, age, payment source, Glasgow Coma Scale score (GCS), Injury Severity Score (ISS), day of week, time of arrival in the emergency department, and facility. Whether there was a loss of consciousness from the injury was abstracted using the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes listed in the diagnoses fields of the database, and was also included in the analyses as a variable. 17 Inclusion Criteria. Patients included in the analysis were those adolescents, aged 12 years to younger than 18 years, with a race or ethnicity listed as white (not of Hispanic origin), African, American, or Hispanic, and an ICD-9-CM principal diagnosis code of (trauma), excluding 905 (late effects of injury), (foreign bodies), and 958 (complications), who were admitted to the hospital. Because of small numbers, the racial and ethnic groups of Asian/ Pacific Islander and Native American/Alaska Native were not included. Exclusion Criteria. Patients were excluded from analysis if, along with one of the included injuries, they suffered a burn injury (ICD-9-CM , ICD-9-CM , or injury type listed as burn ) or were pregnant (ICD-9-CM ; V22 V23). Patients from facilities at which either all patients were drug and/or alcohol-tested or no patients were drug and/or alcohol tested were excluded. Those patients with a payment source listed as no charge or liability were excluded because these patients could not be consistently grouped into an insurance type used to adjust for SES. Finally, patients with data missing from any variable field used in the multivariable analysis were excluded. Data Analysis. Descriptive statistics and univariable and multivariable analyses were performed with Stata 7.0 for Windows (College Station, TX). Univariable statistical analyses were performed to assess relationships of the independent variables with the primary outcome variables. For continuous and ordinal independent variables, logit plots were created to assess their relationship with the outcome variables. Transformations were performed when appropriate. Payment source was divided into eight categories: commercial insurance, managed care, Medicare, Medicaid, self-pay, worker s compensation, government insurance, and other payer. Because of their dichotomous relationships with the outcome variables in the univariate analysis, GCS was dichotomized into versus # 13, and day of week was dichotomized into Monday through Thursday (weekday) versus Friday through Sunday (weekend). Time of arrival was grouped as 7 AM 6:59 PM (day), 7 PM 12:59 AM (evening), and 1 AM 6:59 AM (night) based on similar rates of testing within these three time groupings in the univariate analysis. A fixed-effects multivariable logistic regression model was used to assess the relationship of race, ethnicity, and gender with the primary and secondary outcome variables. For the fixed-effects models, robust 95% confidence intervals (95% CIs) were used. Subjects then were stratified into three groups based on injury severity to corroborate the findings of the undivided subject analyses. Group I was defined as all subjects with an ISS score \8, which defines minor injuries. 18 Group III was defined as the 20% of subjects with the highest ISS scores. Group II was defined as all of those subjects not included in either group I or III. RESULTS Characteristics of the Study Population. Eleven thousand four hundred seventy-six patients met inclusion criteria. Patients with burn injuries were excluded (n ¼ 244). Subjects from two centers at which no patients were tested for alcohol, from three centers at which no patients were tested for drugs, and those from one center that reported drug testing of all patients were excluded (n ¼ 114). No facilities reported universal alcohol testing. Subjects with payment source listed as No Charge (n ¼ 1) or Liability/Under Litigation (n ¼ 72) were excluded. Subject with missing injury-type field (n ¼ 128), arrival time (n ¼ 259), ISS score (n ¼ 377), payment type (n ¼ 803), or GCS data (n ¼ 1,738) were excluded. There were no particular hospitals that were system-

3 ACAD EMERG MED d November 2003, Vol. 10, No. 11 d atically missing any of the individual fields. Statistical analyses were performed on a population of 7,740 adolescents, aged 12.0 to 17.9 years, after exclusions. Table 1 shows the analyses of the relative rates of testing and test positivity for alcohol and drugs by race, ethnicity, and gender. In general, males represent 68% of the persons in the study, with white males comprising 47% of the total population. The racial composition of the total study population is 72% white, 23% African American, and 5% Hispanic. Figure 1A presents an overview and graphic representation of the age and relative contribution of whites, African Americans, and Hispanics to the total population. Figure 1A also presents the relative contribution of those tested for alcohol and those who tested positive. Figure 1B shows the same data with reference to drug testing. As can be seen in Figure 1A and 1B, the likelihood of being admitted with an injury increases linearly with age (r 2 ¼ 0.94). The percentage tested for alcohol (range, 22.2% 43.5%) or drugs (range, 18.36% 47.5%), and the percentage testing positive for alcohol (range, 8.3% 27.7%) or drugs (range, 7.3% 26.6%) also increase linearly with age. All relationships have a coefficient of determination (r 2 )of$ Multivariable Analyses for Alcohol and Drug Testing. Table 2 presents the results of the multivariable analysis using robust 95% CIs for the likelihood of alcohol and drug testing of adolescents admitted for trauma. White males are used as the reference group. Hispanic males and African American females had an increased likelihood of being tested for alcohol when compared with white males (odds ratio [OR]: 1.48; 95% CI ¼ 1.08 to 2.05; and OR: 1.30; 95% CI ¼ 1.01 to 1.67, respectively). This was most pronounced in the minor-injury group (Hispanic males OR: 2.07; 95% CI ¼ 1.31 to 3.27, and African American females OR: 1.45; 95% CI ¼ 1.01 to 2.08). In addition, white females in the minor-injury group were seen to have an increased likelihood of being tested (OR: 1.36; 95% CI ¼ 1.07 to 1.73). Though not statistically significant, African American males and Hispanic females had an increased OR of testing when compared with White males. Injury severity did not have an effect on the rates of drug testing in any group. Of note, patients admitted during off-hours (evenings, weekends, and nights) all had a significant increase in alcohol testing. This increased testing ranged from an increased odds of testing on evenings and weekends of 1.18 (95% CI ¼ 1.05 to 1.32) to an increased odds of testing on nights of 1.85 (95% CI ¼ 1.55 to 2.20). However, with regard to drug testing, a significant increase only was seen on weekends (OR: 1.15; 95% CI ¼ 1.03 to 1.29), with a trend toward increased testing at night (OR: 1.18, 95% CI ¼ 0.99 to 1.41). Changes in mental status (GCS # 13 or history of a loss of consciousness) were associated with an increased likelihood of testing for alcohol and drugs. Multivariable Analysis for Alcohol and Drug Testing Results. The results of alcohol and drug testing can be seen in Table 3. Adolescent females of all racial and ethnic pairings were significantly less likely to test positive for alcohol than males (white [OR: 0.51; 95% CI ¼ 0.37 to 0.68], African American [OR: 0.45, 95% CI ¼ 0.23 to 0.87], or Hispanic [OR: 0.26, 95% CI ¼ 0.07 to 0.96]). Hispanic males trended toward an increase in positive alcohol testing, but this did not reach statistical significance (OR: 1.52, 95% CI ¼ 0.92 to 2.54). African American adolescent males had an increased odds of positive test results for drugs when compared with white adolescent males (OR: 1.54; 95% CI ¼ 1.12 to 2.12). Females were less likely to test positive for drugs, although only white females reached statistical significance (white OR: 0.76, 95% CI ¼ 0.55 to 0.99; African American OR: 0.66, 95% CI ¼ 0.41 to 1.07; Hispanic OR: 0.74; 95% CI ¼ 0.25 to 2.21). Increasing age correlated with a greater risk of positive test results for alcohol and drug testing (alcohol OR: 1.52; 95% CI ¼ 1.37 to 1.69; drugs OR: 1.27; 95% CI ¼ 1.18 to 1.38). There was no difference in the likelihood of alcohol and drug testing being positive with changing injury severity. DISCUSSION Unintentional and inflicted injuries are the leading cause of death in adolescents in the United States. 14 The combined mortality of accidental and inflicted injuries far outpaces all other causes of death in this group. Furthermore, it is recognized that alcohol and drug use are contributing factors to the establishment TABLE 1. Likelihood of Testing for Alcohol and Drugs by Race/Ethnicity and Gender Alcohol Testing Drug Testing Group n Percent Tested Percent Positive Percent Tested Percent Positive White male 3, African American male 1, Hispanic male White female 1, African American female Hispanic female

4 1256 Marcin et al. d RACIAL DIFFERENCES IN ALCOHOL/DRUG TESTING Figure 1. (A) Racial composition of adolescents admitted with traumatic injuries. Data are presented by age, race, and ethnicity (gray bars ¼ White, white bars ¼ African American, black bars ¼ Hispanic); the numbers tested for alcohol and those who tested positive. The small inset is an enlargement of the lower left-hand corner of the figure used to better illustrate the number tested and positive for alcohol in the 12- to 14-year-old age groups. (B) Racial composition of adolescents admitted with traumatic injuries. Data are presented by age, race, and ethnicity (gray bars ¼ White, white bars ¼ African American, black bars ¼ Hispanic); the numbers tested for drugs and those who tested positive. The small inset is an enlargement of the lower left-hand corner of the figure used to better illustrate the number tested and positive for drugs in the 12- to 14-year-old age groups. of high-risk behaviors and traumatic injuries. 19 Because of the toll exacted by trauma in the United States, trauma centers have been developed in an attempt to improve care. One result of this regionalization has been that the evaluation and treatment of trauma patients has become highly protocolized. The majority of trauma centers, particularly those with a Level 1 or Level 2 designation, have the ability to perform alcohol and drug testing on-site, although routine testing of patients is inconsistent. 20 The results of this study, an overall testing rate of 37% in adolescents aged 12 to 17 years and a rate of positive tests for alcohol of 18%, are in general agreement with a previous investigation that showed an overall testing rate of 50% and a test-positive rate of 13%. 21 The results of our analyses demonstrate that alcohol testing in adolescent trauma victims increases with patient age; evidence of neurologic injury; and admission during evenings, nights, and weekends. This increase in testing corresponds to an increase in

5 ACAD EMERG MED d November 2003, Vol. 10, No. 11 d TABLE 2. Multivariable Analysis for Adolescent Alcohol and Drug Testing Alcohol Testing Drug Testing Variable Odds Ratio* (95% CI) p-value Odds Ratio* (95% CI) p-value White male 1 (Reference) 1 African American male 1.10 (0.92, 1.30) NS 1.03 (0.86, 1.23) NS Hispanic male 1.48 (1.08, 2.05) (0.76, 1.41) NS White female 1.12 (0.99, 1.29) NS 1.09 (0.95, 1.25) NS African American female 1.30 (1.01, 1.67) (0.88, 1.46) NS Hispanic female 1.55 (0.90, 2.67) NS 1.37 (0.84, 2.25) NS Age 1.38 (1.33, 1.43) \ (1.23, 1.32) \0.001 ISSy 1.02 (1.01, 1.03) \ (1.01, 1.03) \0.001 Evening 1.18 (1.05, 1.32) (0.90, 1.15) NS Night 1.85 (1.55, 2.20) \ (0.99, 1.41) NS Weekend 1.18 (1.06, 1.32) (1.03, 1.29) GCSz 1.72 (1.45, 2.04) \ (1.44, 2.07) \0.001 LOC 1.44 (1.25, 1.66) \ (1.24, 1.66) \0.001 *Odds ratio is calculated using white (non-hispanic) male as the control group. yiss ¼ Injury Severity Score. zgcs ¼ Glasgow Coma Scale score was dichotomized into versus #13. LOC ¼ loss of consciousness versus no loss of consciousness. positive test results for increasing age and those adolescents presenting to the hospital at night. The significantly increased rates of alcohol testing among Hispanic males and African American females suggests, but certainly does not prove, the possibility of a pattern of differential testing among the different racial and ethnic groups. Drug testing demonstrates a pattern similar to alcohol testing with increases in testing with age, off-hours, and changes in mental status. This study did not find that differences in injury severity had a considerable effect on alcohol or drug testing, or on the results of those tests. As a group, adolescent girls were tested for alcohol and drugs at rates comparable with their male counterparts. However, they are less likely to be positive for alcohol and drug use. As mentioned, Hispanic males have a significantly increased likelihood of testing for alcohol compared with white adolescent males, and this is associated with a trend toward increased positive test results in this group. This increase in alcohol testing and test positivity in Hispanic males may be indicative of trends in this group as previously reported. 22 Finally, African American males were more likely to be positive with regard to drug testing, but they were not more likely to be tested. LIMITATIONS One of the limitations of this study was an inability to control for the SES of the patients through the trauma database. Whereas insurance type was used as a surrogate for SES, as has been used by other investigators for this purpose, the inability to precisely TABLE 3. Multivariable Analysis for the Results of Alcohol and Drug Testing Alcohol Positive Drug Positive Variable Odds Ratio* (95% CI) p-value Odds Ratio* (95% CI) p-value White male 1 (Reference) 1 (Reference) African American male 1.00 (0.70, 1.42) NS 1.54 (1.12, 2.12) Hispanic male 1.52 (0.92, 2.54) NS 1.02 (0.57, 1.82) NS White female 0.51 (0.37, 0.68) \ (0.55, 0.99) African American female 0.45 (0.23, 0.87) (0.41, 1.07) NS Hispanic female 0.26 (0.07, 0.96) (0.25, 2.21) NS Age 1.52 (1.37, 1.69) \ (1.18, 1.38) \0.001 ISSy 1.00 (0.98, 1.01) NS 1.00 (0.99, 1.01) NS Evening 2.13 (1.61, 2.82) \ (1.12, 1.74) Night 6.68 (4.88, 9.15) \ (1.53, 2.73) \0.001 Weekend 1.53 (1.21, 1.93) \ (0.76, 1.14) NS GCSz 1.09 (0.79, 1.49) NS 1.56 (1.19, 2.06) LOC 1.05 (0.79, 1.40) NS 0.89 (0.69, 1.15) NS *Odds ratio is calculated using white (non-hispanic) male as the control group. yiss ¼ Injury Severity Score. zgcs ¼ Glasgow Coma Scale score was dichotomized into versus #13. LOC ¼ loss of consciousness versus no loss of consciousness.

6 1258 Marcin et al. d RACIAL DIFFERENCES IN ALCOHOL/DRUG TESTING define the SES of the patients in this study may blur distinctions that are SES-based, rather than based on race or ethnicity In other studies that are able to use SES, as well as race and ethnicity as independent variables in looking at the disparity of care delivery, race and ethnicity continue to be significant factors even when SES is accounted for. 2,3 A further limitation is that in the NTDB, race and ethnicity are not self-assigned, but rather are coded by the trauma center staff. This has the effect of denying the existence of multiracial classifications and personal identity. However, it is felt that this method of assigning race and ethnicity increases the validity of the investigation, because it is the effects of perceived race and ethnicity that are important for the allocation of testing. Race and ethnicity are not a biologic category as much as they are a social category. 27 The effects of race and ethnicity on the delivery of health care often are enmeshed with the disparity in health care generated by differences in SES and educational attainment. The data presented, such as the increased alcohol testing rate of Hispanic males, may be influenced by unmeasured variable (e.g., language barriers in this population) that may cause an increase in testing because of an inability of the physician to use language cues in his or her assessment of the patient. However, racial disparity that exists independent of SES and educational attainment in the delivery of medical care is well established. 1,2,7 That racial and ethnic disparity does not appear to be pervasive in our evaluation of adolescent trauma victims is reassuring and may offer some clues as to how to improve the current system of delivery to make it more just. The protocolized nature of trauma care is applied, in theory, without reference to race or ethnicity, and an increase in standardized care that is racially and ethnically blind may improve current inequality. Protocolization does not offer a complete explanation, however, because testing for alcohol and drugs in trauma patients was performed in a minority of patients and has been shown in other studies to be applied inconsistently. 20 A second possible explanation is that because the patients studied were adolescents, they may have been viewed more generously than adults. This article offers novel additions to the available literature in two ways. In the first instance, this is one of the few articles to look for racial disparity in acute-care delivery in minors. Second, because this study examines data obtained for drug and alcohol testing of patients evaluated in the acute-care setting, as opposed to a study looking at the provision of care as an outpatient, it may eliminate explanations that account for racial disparity by access, educational level, patient preference, and medical suitability. CONCLUSIONS Whereas the hypothesis of this study, that African American and Hispanic adolescent trauma patients would be tested for alcohol and drugs equally with their white counterparts, was not fully upheld, there was no evidence of systematic, racially-based bias. References 1. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000; 283: Schneider EC, Zaslavsky AM, Epstein AM. Racial disparities in the quality of care for enrollees in medicare managed care. JAMA. 2002; 287: Alexander GC, Sehgal AR. 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7 ACAD EMERG MED d November 2003, Vol. 10, No. 11 d Bonomo Y, Coffey C, Wolfe R, Lynskey M, Bowes G, Patton G. Adverse outcomes of alcohol use in adolescents. Addiction. 2001; 96: Soderstrom CA, Dailey JT, Kerns TJ. Alcohol and other drugs: an assessment of testing and clinical practices in U.S. trauma centers. J Trauma. 1994; 36(1): Porter RS. Alcohol and injury in adolescents. Pediatr Emerg Care. 2000; 16: Cherpitel CJ. Acculturation, alcohol consumption, and casualties among United States Hispanics in the emergency room. Int J Addict. 1992; 27: Griffin JA, Cicchetti D, Leaf PJ. Characteristics of youths identified from a psychiatric case register as first-time users of services. Hosp Commun Psychiatry. 1993; 44(1): Schechter MS, Margolis PA. Relationship between socioeconomic status and disease severity in cystic fibrosis. J Pediatr. 1998; 132: Schechter MS, Shelton BJ, Margolis PA, Fitzsimmons SC. The association of socioeconomic status with outcomes in cystic fibrosis patients in the United States. Am J Respir Crit Care Med. 2001; 163: DelBello MP, Lopez-Larson MP, Soutullo CA, Strakowski SM. Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review. J Child Adolesc Psychopharmacol. 2001; 11(1): Braun L. Race, ethnicity, and health: can genetics explain disparities? Perspect Biol Med. 2002; 45: