- Email: [email protected]
Potential disparities in trauma: the undocumented Latino immigrant
Accepted Manuscript Potential Disparities in Trauma: The Undocumented Latino Immigrant Vincent E. Chong , M.D. Wayne S. Lee , M.D. Gregory P. Victorino , MD PII:
S0022-4804(14)00450-8
DOI:
10.1016/j.jss.2014.05.008
Reference:
YJSRE 12715
To appear in:
Journal of Surgical Research
Received Date: 2 January 2014 Revised Date:
6 March 2014
Accepted Date: 2 May 2014
Please cite this article as: Chong VE, Lee WS, Victorino GP, Potential Disparities in Trauma: The Undocumented Latino Immigrant, Journal of Surgical Research (2014), doi: 10.1016/j.jss.2014.05.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Revised 3/4/14 Article Title: Potential Disparities in Trauma: The Undocumented Latino Immigrant Running Title: Trauma and Undocumented Immigrants Subject Category: Shock/Sepsis/Trauma/Critical Care
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Vincent E. Chong, M.D.; Wayne S. Lee, M.D.; Gregory P. Victorino, MD
Department of Surgery, University of California, San Francisco – East Bay
Department of Surgery, Highland Hospital
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University of California, San Francisco – East Bay
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Please send correspondence to Gregory P. Victorino, MD:
1411 East 31st Street, Oakland, California, 94602 Email: [email protected] Telephone Number: (510) 437-8370
Author Contributions:
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Facsimile Number: (510) 437-5127
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Vincent E. Chong – Conception and Design, Analysis and Interpretation, Data Collection, Article Writing
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Wayne S. Lee – Conception and Design, Critical Revisions Gregory P. Victorino – Conception and Design, Analysis and Interpretation, Critical Revisions
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Abstract: Background: Little is known about the quality of trauma care undocumented immigrants receive. Documentation status may serve as a risk factor for health
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disparities. We hypothesized that undocumented Latino immigrants (UDLI) have an increased risk of mortality after trauma compared to Latinos with legal residence. Materials and Methods: The medical records for Latino trauma patients at our
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university-based trauma center between 2007 and 2012 were retrospectively reviewed.
Undocumented status was defined using two criteria: 1) lack of social security number,
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and 2) insurance status as either “county,” the local program that covers undocumented immigrants, or “self pay”. Regression models were used to estimate the comparable risks of in-hospital mortality.
Results: Out of 2,441 Latino trauma patients treated at our institution during the study
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period, 465 were undocumented. Latinos with legal residence and undocumented Latinos did not differ with regard to in-hospital mortality (3.4% versus 3.9%, respectively; p=0.61). We found no association between documentation status and in-hospital
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mortality after trauma (OR=1.12 [0.43, 2.9]; p=0.81). The independent predictors of inhospital mortality included age, ISS, penetrating mechanism, and lack of private
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insurance, but not documentation status. Conclusions: UDLI did not have an increased risk of in-hospital mortality after trauma; however, being uninsured was associated with a higher risk of death after trauma. For Latinos, we found no disparities based on immigration status for mortality after trauma, though disparities based on insurance status continue to persist. Keywords: Trauma, Immigrant Health, Outcome Assessment
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Introduction: Despite universal access to trauma care in mature trauma systems, racial disparities exist for mortality risk after trauma [1]. In general, trauma patients with
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minority status have an increased risk of mortality compared to white trauma patients;
however, this has not consistently held for Hispanic or Latino patients [2]. This lack of a consistent correlation may be partly due to the heterogeneity of the Latino population,
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particularly in regards to country of origin, socioeconomic status, number of years in the country, English language proficiency, and immigration status.
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There are reasons to believe that immigration status may serve as a risk factor for disparities in health outcomes for undocumented Latino immigrants (UDLI). Epidemiologic studies have shown that, when compared to Latinos that are native-born, naturalized, or legal residents, undocumented Latino immigrants are more likely to have
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lower income, less education, less English proficiency, and no insurance [3–5]. These factors may affect the care undocumented Latino immigrants receive in the hospital. Indeed, undocumented immigrants have reported receiving a perceived substandard care
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or having trouble navigating the health care system due to language barriers [3,6]. Furthermore, these factors include social determinants of health, such as low
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socioeconomic status, that have been found to place people at increased risk of worse health. As such, immigration status may serve as a surrogate, or composite variable, for these different factors that affect health outcomes. Lastly, undocumented immigrants may have a fear of discovery, a factor that influences their health care decision-making and can lead to refusal of emergency health care services [6]. However, this is less likely to occur in the setting of trauma.
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To date there have been no studies that measure the quality of care or health outcomes for undocumented immigrants treated at our nation’s trauma centers. Despite previous research on undocumented Latino immigrant access to ambulatory care [3,7,8],
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there have also been no studies characterizing this population’s interaction with trauma systems. As such, we conducted a retrospective review of our university-based urban
trauma center with a high proportion of undocumented immigrant patients. Because the
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large majority of undocumented immigrants in the United States as well as our catchment area are Hispanic or Latino, we decided to focus on this patient subgroup. Specifically,
Hispanic or Latino in origin [10].
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of the estimated 11.7 million undocumented immigrants in the United States [9], 80% are
Our purpose for conducting a review of our trauma center’s experience was twofold. First, we aimed to characterize the utilization of our trauma system by
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undocumented Latino immigrants and to measure their outcomes after injury. Second, we wanted to identify any disparities in outcomes that could exist for undocumented Latino immigrants after injury. Our hypothesis was that undocumented Latino
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immigrants (UDLI) have an increased risk of mortality after trauma compared to Latinos
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with legal residence1.
Materials and Methods: We conducted a retrospective review of the trauma registry at our university-
based, urban trauma center in Oakland, California. All trauma activations from 2007
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Latinos with legal residence includes US-born Latinos, as well as foreign-born Latinos that have been naturalized, that have been admitted to the US as refugees, or those with legal permanent and temporary residence. 4
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through 2012 were collected and further narrowed to our target population of Latino patients. Latino identification was defined by one of two methods: 1) self-reported data in our trauma registry, and 2) surname analysis using census data for those patients coded
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as “other” or “unknown.” Surname analysis has been shown to be a sensitive and specific technique for identifying Hispanic patients using lists developed by the US census [11]. In total, we identified a total of 2,697 Latino patients treated at our trauma center during
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the study period.
We used immigration status as an independent variable, with the premise that it
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served as a surrogate or composite marker of social determinants of disease discussed previously, as these social factors are difficult to measure. Status as “undocumented” was defined using combined data from our trauma registry and registration information. Using accepted methodology [12], a person was categorized as “undocumented” if they
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met the following two inclusion criteria: 1) lack of a social security number, and 2) insurance status as either “county,” the local program that covers undocumented immigrants, or “self pay”. Though undocumented immigrants are not eligible for state or
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federal benefits, any resident of Alameda County regardless of immigration status is eligible for safety-net health services through a program called HealthPAC. They are
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able to sign up for this program at our hospital, or through any number of community clinics in the county. Using these criteria, we identified 465 undocumented Latino immigrants treated at our trauma center during the study period. The undocumented Latino trauma population was compared to those patients with
legal residence. We used documentation status as our predictive variable, and potential confounding variables included age, gender, injury severity score (ISS), mechanism of
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injury (blunt vs. any penetrating), and insurance status (private, public, or self pay/uninsured). Outcome variables included in-hospital mortality and hospital length of stay. Patients with missing ISS (n=100; 3.7%), mechanism of injury (n=10; 0.4%),
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hospital length of stay (104; n=3.9%), or insurance status (n=42; 1.6%) were excluded. Most patients with missing ISS were persons without injuries that were activated into our hospital as traumas; as such, their ISS would have been zero.
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The two groups were compared using the t-test (continuous variable) or the chisquared test (categorical variable). Unadjusted odds ratios and 95% confidence intervals
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were calculated for all variables of interest in relation to in-hospital mortality and hospital length of stay. Regression models were then developed to test the independent contribution of each variable. Regression models included all variables that were statistically significant in unadjusted analyses, were considered clinically important based
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on a priori hypotheses, or whose addition to the models substantially changed the estimates of the effect of other factors. Regression models were confirmed with backwards stepwise multiple regression. Categorical variables are reported as n (%).
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Continuous variables are reported as mean ± SD. All analysis was done with Stata/SE 12
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statistical software (College Station, TX).
Results:
From January 2007 through December 2012, we treated 13,658 trauma patients at
our institution. There were 2,697 Latino patients, and 256 of these were excluded from further analyses due to missing data. As such, our study cohort included a total of 2,441 patients, of which 465 (19%) were undocumented Latino immigrants (Figure 1).
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Undocumented Latino immigrants comprised 3.4% of the total trauma population. During the study period, the number of Latino patients treated at our trauma center by year decreased slightly (Figure 2). This was true for both undocumented Latino
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immigrants and Latinos with legal residence. However, the proportion of Latino trauma patients at our hospital that was undocumented remained relatively stable, between 14 and 21 percent (Figure 3).
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Undocumented Latino trauma patients and Latinos with legal status differed with respect to gender, age, ISS, and proportion without insurance (Table 1). Undocumented
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Latino patients were more likely to be younger males, and they presented with a lower ISS. There were a greater percentage of uninsured patients in the undocumented group. The mean hospital stay for the overall cohort was 3.57 ±0.14 days. The mortality rate for the overall sample was 3.5%. This did not differ between
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groups (Table 1). Table 2 shows the results for in-hospital mortality in both unadjusted and adjusted analyses. Documentation status was not a significant contributor to inhospital mortality in either unadjusted or adjusted analyses. Penetrating mechanism, lack
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of private insurance, and higher presenting ISS were significant predictors of in-hospital mortality. Age went from non-significant to significant after adjustment for other
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variables. Tests for collinearity were performed, and undocumented status was not significantly associated with any other factors. Specifically, the variation inflation factor for undocumented status and insurance was 1.04, with a tolerance of 0.96.
Discussion: Undocumented Latino immigrants rely on safety net hospitals and our nation’s
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trauma centers for medical care, yet there is little to no information regarding the care and outcomes of injured undocumented immigrants cared for by these institutions. Furthermore, their immigration status may place undocumented Latinos at higher risk of
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disparate outcomes after trauma. To our knowledge, this is the first study in the literature addressing health care utilization and health outcomes for undocumented Latino
immigrants after trauma. We hypothesized that undocumented Latino immigrants would
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be at a higher risk of in-hospital mortality after trauma, compared to Latinos with legal residence. Contrary to this hypothesis, we found no disparities based on immigration
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status for mortality after trauma, though disparities based on insurance status continue to persist.
Our study population of undocumented Latino trauma patients mirrors previous epidemiological research about undocumented Latino immigrants in general. For
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example, in our sample, and nationally, undocumented Latino immigrants are most likely to be young, male, and uninsured [5]. Notably though, insurance coverage in our sample differed from previous research. Rates of uninsurance from county-level and national
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samples have been estimated at 68-71% [5,13]. In contrast, 54% of our undocumented Latino patients were uninsured. Furthermore, our sample contained a very high
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percentage of patients with public insurance (46%), compared with 8% from a study based in Los Angeles County [13]. Lastly, in our study, despite only being eligible for county-level public insurance, rather than state and federal coverage, there was no difference between undocumented immigrants and their counterparts in public insurance enrollment, which speaks to the strength of our county insurance program.
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Our findings also add to knowledge from previous research illustrating the underutilization of health care by undocumented Latino immigrants [3,7,14]. In our current study, undocumented immigrants make up 3.4% of the total trauma population
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seen at our institution. In Alameda County, our hospital’s catchment area, undocumented immigrants make up 8.4% of the total county population [15]. This suggests that
undocumented Latino immigrants consume proportionally less trauma care than would be
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expected. The reason for this, however, is unclear; moreover, it may be different for trauma patients than what is postulated in previous studies on undocumented Latino
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immigrants. It has been suggested that underutilization of ambulatory and non-trauma emergency department care by undocumented Latino immigrants is a reflection of structural constraints, such as lack of insurance and low socioeconomic status [8]. In other words, barriers to health care exist and limit access. In our county, access to trauma
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services is universal for injured patients. As such, structural factors should theoretically not limit a person’s access and utilization of our trauma center. Despite our hypothesis that documentation status would place an undocumented
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Latino trauma patient at increased risk of in-hospital mortality, we did not find documentation status to be an independent predictor of this. As such, there was no
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appreciable disparity between groups based on presence or lack of legal residence. This may partly be due to the epidemiology of undocumented Latino immigrants, as they are more likely to be young and healthy. Some suggest that patient comorbidities, being more prevalent in uninsured patients of low socioeconomic status, contribute to disparities in trauma outcomes [2]. Being a young and healthy population subgroup, it is possible that undocumented Latino immigrants may not bear these same burdens. The
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lack of significance may also reflect the high number of patients in the undocumented group with public insurance, which was found to be protective in multivariate analysis. However, the presence of public insurance was adjusted for in our model, and there was
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no significant collinearity between the two variables.
Another potential explanation may be the lack of implicit bias in the care of undocumented immigrants. Implicit bias refers to subconscious or unrecognized
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physician beliefs based on a patient’s social characteristics, such as gender, race, age,
ability, and socioeconomic status. It has been suggested that implicit bias contributes to
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disparities in outcomes as it may influence physician decision-making regarding processes of care, such as whether a patient needs an operation or intervention due to their condition [16,17]. Documentation status, however, does not carry with it identifiable individual characteristics. Moreover, hospital care providers rarely, if ever,
manner do not exist.
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inquire about a patient’s immigration status. As such, the conditions for bias in this
Though we did not find immigration status to be associated with disparate
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mortality outcomes, our current study corroborates prior research in trauma disparities, illustrating that lack of insurance is an independent predictor of mortality after trauma
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[1,18,19]. Indeed, being uninsured has been almost universally linked to an increased risk of death after trauma, verified in national, regional, and single-center studies, as well as meta-analyses [2]. The reasons for this have yet to be elucidated. Though lack of insurance may predispose to undiagnosed comorbidities, insurance status affects the risk of mortality even in younger age groups that are usually healthy [19]. It is more likely that being uninsured reflects the influence of the social environment and social
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determinants of health, such as social isolation and chronic stress, as has also been previously suggested [18]. Surprisingly, public insurance was independently protective in our model. A possible explanation lies in the different amount of effort and time
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needed to obtain public insurance. For example, enrolling in public insurance may be
harder or more time-consuming than private insurance, which often is a benefit of being employed. This extra effort may represent a patient who also extends extra effort in their
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health care decisions and health habits, thereby positively affecting their downstream health outcomes.
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Our results find significance within the current context of healthcare reform and its expected effects on trauma center funding. Trauma centers depend on federal reimbursement via the “disproportionate share hospital” (DSH) program, which is to be discontinued as part of the Patient Protection and Affordable Care Act (PPACA) [20].
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As undocumented Latino immigrants are not eligible for the increased health coverage benefits of PPACA [21], they will continue to rely on safety net hospitals and trauma centers for their emergency surgical and trauma care. Trauma centers that serve a higher
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proportion of undocumented Latino immigrants may thus face a substantial increase in the amount of uncompensated care provided to this population. Though we did not find
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disparities in mortality after trauma for undocumented Latino immigrants, diminished trauma center funding may create the conditions from which such disparities develop. Furthermore, disparities for uninsured patients may be exacerbated by this changing financial landscape.
Our current study is limited by our focus on trauma patients as the population of interest and in-hospital mortality as the outcome of interest. Disparities in outcomes may
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exist for undocumented Latino immigrants for non-trauma visits to the emergency department, such as for acute cholecystitis or other general surgery issues. Additionally, the use of other outcome variables, such as processes of care, failure to rescue, functional
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outcomes, and patient-centered outcomes [22,23], might lead to different conclusions.
However, this would require a prospective study with qualitative components. Our study is also limited by the difficulty in identifying undocumented Latino immigrants, a group
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often referred to as a “shadow population.” In accordance with previous studies [12], we used a combination of insurance and registration data to determine which Latino patients
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were undocumented. This methodology likely underestimates the number of undocumented patients in our cohort, as some may have had falsified social security numbers or employee-sponsored private insurance. This would result in misclassification of undocumented patients into the comparison group. Lastly, there exists the possibility
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for type II error given our sample size. We did not collect data prior to 2007, as that was the first year we had reliable data for social security numbers. As such, aiming for better data accuracy left us with a smaller sample size.
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In conclusion, to our knowledge this is the first study in the literature that describes the undocumented Latino trauma population and its post-injury mortality
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outcomes. Like previous studies that highlight the underutilization of health care by this population, we found that undocumented Latino immigrants access our trauma center less than would be expected by their proportion in the total county population. Once admitted, they also have shorter lengths of stay. We also found that there are no disparities in regards to in-hospital mortality after trauma for undocumented Latino immigrants, though such disparities did exist for uninsured patients. In order to prevent
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the development of disparities for undocumented Latino immigrants, or the exacerbation of disparities for patients without insurance, trauma centers and safety net hospitals should continue to receive financial support for the high quality of care they currently
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provide to our nation’s underserved.
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References: [1]
Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell EE. Race and insurance status as risk factors for trauma mortality. Arch Surg 2008;143:945–9. Haider AH, Weygandt PL, Bentley JM, Monn MF, Rehman KA, Zarzaur BL, et al.
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[2]
Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis. J Trauma Acute Care Surg 2013;74:1195–205.
Ortega AN, Fang H, Perez VH, Rizzo J a, Carter-Pokras O, Wallace SP, et al.
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[3]
Health care access, use of services, and experiences among undocumented
[4]
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Mexicans and other Latinos. Arch Intern Med 2007;167:2354–60. Passel JS, Cohn D. A Portrait of Unauthorized Immigrants in the United States. Washington: 2009. [5]
Capps R, Bachmeier JD, Fix M, Hook J Van. A Demographic, Socioeconomic,
Washington: 2013. [6]
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and Health Coverage Profile of Unauthorized Immigrants in the United States.
Maldonado CZ, Rodriguez RM, Torres JR, Flores YS, Lovato LM. Fear of
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discovery among Latino immigrants presenting to the emergency department. Acad Emerg Med 2013;20:155–61. Berk ML, Schur CL, Chavez LR, Frankel M. Health care use among
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[7]
undocumented Latino immigrants. Health Aff 2000;19:51–64.
[8]
Chavez LR. Undocumented immigrants and their use of medical services in
Orange County, California. Soc Sci Med 2012;74:887–93.
[9]
Passel JS, Cohn D, Gonzalez-Barrera A. Population Decline of Unauthorized Immigrants Stalls, May Have Reversed. Washington: 2013.
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[10]
Passel JS, Cohn D. Unauthorized Immigrant Population: National and State Trends, 2010. Washington: 2011.
[11]
Fiscella K, Fremont AM. Use of geocoding and surname analysis to estimate race
[12]
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and ethnicity. Health Serv Res 2006;41:1482–500.
Mitchell CD, Truitt MS, Shifflette VK, Johnson V, Mangram AJ, Dunn EL. Who
Surg 2012;72:609–12; discussion 612–3. [13]
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will cover the cost of undocumented immigrant trauma care? J Trauma Acute Care
Goldman DP, Smith JP, Sood N. Legal status and health insurance among
[14]
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immigrants. Health Aff (Millwood) 2005;24:1640–53.
Goldman DP, Smith JP, Sood N. Immigrants and the cost of medical care. Health Aff (Millwood) 2006;25:1700–11.
[15]
Hill LE, Johnson HP, Ezekiel D, Hayes JM. Unauthorized Immigrants in
[16]
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California: Estimates for Counties. San Francisco: 2011.
Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for
[17]
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black and white patients. J Gen Intern Med 2007;22:1231–8. Santry HP, Wren SM. The role of unconscious bias in surgical safety and
[18]
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outcomes. Surg Clin North Am 2012;92:137–51. Dozier KC, Miranda M a, Kwan RO, Cureton EL, Sadjadi J, Victorino GP.
Insurance coverage is associated with mortality after gunshot trauma. J Am Coll Surg 2010;210:280–5.
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[19]
Greene WR, Oyetunji T a, Bowers U, Haider AH, Mellman T a, Cornwell EE, et al. Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma. Am J Surg 2010;199:554–7. Khoury AL, Charles AG, Sheldon GF. The trauma safety-net hospital under the
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[20]
Affordable Care Act: will it survive? J Trauma Acute Care Surg 2013;75:512–5. [21]
U.S. House. 111th Congress 2nd Session. HR 3590, The Patient Protection and
[22]
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Affordable Care Act. Washington: Government Printing Office: 2010.
Glance LG, Dick AW, Mukamel DB, Osler TM. Association between trauma
Mabry CD. Time to Turn the Page: Moving on to Write New Chapters for Trauma
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Care. Arch Surg 2013;147:315–6.
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[23]
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quality indicators and outcomes for injured patients. Arch Surg 2012;147:308–15.
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Figure Legends: Figure 1.
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Our study sample consisted of 1,976 Latino patients with legal residence and 465 undocumented Latino immigrants. Figure 2.
The annual number of Latinos with legal residence treated at our trauma center ranged from 274 to 458. The range for undocumented Latino immigrants was 44 to 111.
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Figure 3.
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The annual percentage of Latinos treated at our trauma center that were undocumented ranged from 14 to 21%.
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Figure 1. Inclusion Criteria for Study Population
2,697 Latino Patients
2,441 Latino Patients
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265 Excluded (Missing Data)
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10,961 Non-Latino Patients
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13,658 Activations
465 Undocumented
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1,976 with Legal Residence
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Figure 2. Number of Latino Trauma Patients Treated at our Trauma Center
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Figure 3. Percentage of Latino Trauma Patients That Were Undocumented
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Table 1. Demographic and Clinical Characteristics of Latino Trauma Patients Groups Undocumented Latinos (n=465)
Female
356 (18%)
41 (9%)
Male
1620 (82%)
424 (91%)
ISS*
8.53 ± 0.22
7.46 ± 0.41
Age
32.5 ± 0.35
30.7 ± 0.50
Blunt
1332 (67%)
Penetrating
644 (33%)
Insurance 451 (23%)
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Private
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Mechanism
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Gender
Public Uninsured
< 0.001 0.03 0.02
327 (70%) 138 (30%)
0.23
0 (0%)
947 (48%)
214 (46%)
0.46
578 (29%)
251 (54%)
< 0.001
67 (3.4%)
18 (3.9%)
0.61
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Mortality
P Value
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Latinos with Legal Status (n=1,976)
Variable
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*ISS = Injury Severity Score
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Table 2. Unadjusted and Adjusted Results for In-Hospital Mortality Unadjusted OR (95% CI)
p value
OR (95% CI)
1.01 (0.998, 1.025)
0.09
1.04 (1.01, 1.06)
Gender
Male ISS*
1.91 (0.91, 3.97)
0.09
1.2 (1.17, 1.23)
< 0.001
Mechanism Blunt
1 [Reference]
Penetrating
5.13 (3.2,0 8.20)
Insurance Type
0.002
1 [Reference]
0.92 (0.29, 2.88)
0.88
1.24 (1.19, 1.28)
< 0.001
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1 [Reference]
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Female
p value
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Age
Adjusted
1 [Reference]
< 0.001
5.57 (2.45, 12.64)
< 0.001
1 [Reference]
Public
0.29 (0.168, 0.483)
< 0.001
0.20 (0.07, 0.59)
0.004
Uninsured
3.75 (2.38, 5.89)
< 0.001
5.37 (1.98, 14.61)
0.001
Undocumented
1.15 (0.675, 1.95)
0.612
1.12 (0.43, 2.90)
0.811
1 [Reference]
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Private
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*ISS = Injury Severity Score
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S0022-4804(14)00450-8
DOI:
10.1016/j.jss.2014.05.008
Reference:
YJSRE 12715
To appear in:
Journal of Surgical Research
Received Date: 2 January 2014 Revised Date:
6 March 2014
Accepted Date: 2 May 2014
Please cite this article as: Chong VE, Lee WS, Victorino GP, Potential Disparities in Trauma: The Undocumented Latino Immigrant, Journal of Surgical Research (2014), doi: 10.1016/j.jss.2014.05.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Revised 3/4/14 Article Title: Potential Disparities in Trauma: The Undocumented Latino Immigrant Running Title: Trauma and Undocumented Immigrants Subject Category: Shock/Sepsis/Trauma/Critical Care
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Vincent E. Chong, M.D.; Wayne S. Lee, M.D.; Gregory P. Victorino, MD
Department of Surgery, University of California, San Francisco – East Bay
Department of Surgery, Highland Hospital
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University of California, San Francisco – East Bay
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Please send correspondence to Gregory P. Victorino, MD:
1411 East 31st Street, Oakland, California, 94602 Email: [email protected] Telephone Number: (510) 437-8370
Author Contributions:
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Facsimile Number: (510) 437-5127
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Vincent E. Chong – Conception and Design, Analysis and Interpretation, Data Collection, Article Writing
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Wayne S. Lee – Conception and Design, Critical Revisions Gregory P. Victorino – Conception and Design, Analysis and Interpretation, Critical Revisions
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Abstract: Background: Little is known about the quality of trauma care undocumented immigrants receive. Documentation status may serve as a risk factor for health
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disparities. We hypothesized that undocumented Latino immigrants (UDLI) have an increased risk of mortality after trauma compared to Latinos with legal residence. Materials and Methods: The medical records for Latino trauma patients at our
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university-based trauma center between 2007 and 2012 were retrospectively reviewed.
Undocumented status was defined using two criteria: 1) lack of social security number,
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and 2) insurance status as either “county,” the local program that covers undocumented immigrants, or “self pay”. Regression models were used to estimate the comparable risks of in-hospital mortality.
Results: Out of 2,441 Latino trauma patients treated at our institution during the study
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period, 465 were undocumented. Latinos with legal residence and undocumented Latinos did not differ with regard to in-hospital mortality (3.4% versus 3.9%, respectively; p=0.61). We found no association between documentation status and in-hospital
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mortality after trauma (OR=1.12 [0.43, 2.9]; p=0.81). The independent predictors of inhospital mortality included age, ISS, penetrating mechanism, and lack of private
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insurance, but not documentation status. Conclusions: UDLI did not have an increased risk of in-hospital mortality after trauma; however, being uninsured was associated with a higher risk of death after trauma. For Latinos, we found no disparities based on immigration status for mortality after trauma, though disparities based on insurance status continue to persist. Keywords: Trauma, Immigrant Health, Outcome Assessment
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Introduction: Despite universal access to trauma care in mature trauma systems, racial disparities exist for mortality risk after trauma [1]. In general, trauma patients with
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minority status have an increased risk of mortality compared to white trauma patients;
however, this has not consistently held for Hispanic or Latino patients [2]. This lack of a consistent correlation may be partly due to the heterogeneity of the Latino population,
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particularly in regards to country of origin, socioeconomic status, number of years in the country, English language proficiency, and immigration status.
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There are reasons to believe that immigration status may serve as a risk factor for disparities in health outcomes for undocumented Latino immigrants (UDLI). Epidemiologic studies have shown that, when compared to Latinos that are native-born, naturalized, or legal residents, undocumented Latino immigrants are more likely to have
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lower income, less education, less English proficiency, and no insurance [3–5]. These factors may affect the care undocumented Latino immigrants receive in the hospital. Indeed, undocumented immigrants have reported receiving a perceived substandard care
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or having trouble navigating the health care system due to language barriers [3,6]. Furthermore, these factors include social determinants of health, such as low
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socioeconomic status, that have been found to place people at increased risk of worse health. As such, immigration status may serve as a surrogate, or composite variable, for these different factors that affect health outcomes. Lastly, undocumented immigrants may have a fear of discovery, a factor that influences their health care decision-making and can lead to refusal of emergency health care services [6]. However, this is less likely to occur in the setting of trauma.
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To date there have been no studies that measure the quality of care or health outcomes for undocumented immigrants treated at our nation’s trauma centers. Despite previous research on undocumented Latino immigrant access to ambulatory care [3,7,8],
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there have also been no studies characterizing this population’s interaction with trauma systems. As such, we conducted a retrospective review of our university-based urban
trauma center with a high proportion of undocumented immigrant patients. Because the
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large majority of undocumented immigrants in the United States as well as our catchment area are Hispanic or Latino, we decided to focus on this patient subgroup. Specifically,
Hispanic or Latino in origin [10].
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of the estimated 11.7 million undocumented immigrants in the United States [9], 80% are
Our purpose for conducting a review of our trauma center’s experience was twofold. First, we aimed to characterize the utilization of our trauma system by
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undocumented Latino immigrants and to measure their outcomes after injury. Second, we wanted to identify any disparities in outcomes that could exist for undocumented Latino immigrants after injury. Our hypothesis was that undocumented Latino
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immigrants (UDLI) have an increased risk of mortality after trauma compared to Latinos
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with legal residence1.
Materials and Methods: We conducted a retrospective review of the trauma registry at our university-
based, urban trauma center in Oakland, California. All trauma activations from 2007
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Latinos with legal residence includes US-born Latinos, as well as foreign-born Latinos that have been naturalized, that have been admitted to the US as refugees, or those with legal permanent and temporary residence. 4
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through 2012 were collected and further narrowed to our target population of Latino patients. Latino identification was defined by one of two methods: 1) self-reported data in our trauma registry, and 2) surname analysis using census data for those patients coded
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as “other” or “unknown.” Surname analysis has been shown to be a sensitive and specific technique for identifying Hispanic patients using lists developed by the US census [11]. In total, we identified a total of 2,697 Latino patients treated at our trauma center during
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the study period.
We used immigration status as an independent variable, with the premise that it
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served as a surrogate or composite marker of social determinants of disease discussed previously, as these social factors are difficult to measure. Status as “undocumented” was defined using combined data from our trauma registry and registration information. Using accepted methodology [12], a person was categorized as “undocumented” if they
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met the following two inclusion criteria: 1) lack of a social security number, and 2) insurance status as either “county,” the local program that covers undocumented immigrants, or “self pay”. Though undocumented immigrants are not eligible for state or
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federal benefits, any resident of Alameda County regardless of immigration status is eligible for safety-net health services through a program called HealthPAC. They are
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able to sign up for this program at our hospital, or through any number of community clinics in the county. Using these criteria, we identified 465 undocumented Latino immigrants treated at our trauma center during the study period. The undocumented Latino trauma population was compared to those patients with
legal residence. We used documentation status as our predictive variable, and potential confounding variables included age, gender, injury severity score (ISS), mechanism of
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injury (blunt vs. any penetrating), and insurance status (private, public, or self pay/uninsured). Outcome variables included in-hospital mortality and hospital length of stay. Patients with missing ISS (n=100; 3.7%), mechanism of injury (n=10; 0.4%),
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hospital length of stay (104; n=3.9%), or insurance status (n=42; 1.6%) were excluded. Most patients with missing ISS were persons without injuries that were activated into our hospital as traumas; as such, their ISS would have been zero.
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The two groups were compared using the t-test (continuous variable) or the chisquared test (categorical variable). Unadjusted odds ratios and 95% confidence intervals
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were calculated for all variables of interest in relation to in-hospital mortality and hospital length of stay. Regression models were then developed to test the independent contribution of each variable. Regression models included all variables that were statistically significant in unadjusted analyses, were considered clinically important based
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on a priori hypotheses, or whose addition to the models substantially changed the estimates of the effect of other factors. Regression models were confirmed with backwards stepwise multiple regression. Categorical variables are reported as n (%).
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Continuous variables are reported as mean ± SD. All analysis was done with Stata/SE 12
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statistical software (College Station, TX).
Results:
From January 2007 through December 2012, we treated 13,658 trauma patients at
our institution. There were 2,697 Latino patients, and 256 of these were excluded from further analyses due to missing data. As such, our study cohort included a total of 2,441 patients, of which 465 (19%) were undocumented Latino immigrants (Figure 1).
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Undocumented Latino immigrants comprised 3.4% of the total trauma population. During the study period, the number of Latino patients treated at our trauma center by year decreased slightly (Figure 2). This was true for both undocumented Latino
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immigrants and Latinos with legal residence. However, the proportion of Latino trauma patients at our hospital that was undocumented remained relatively stable, between 14 and 21 percent (Figure 3).
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Undocumented Latino trauma patients and Latinos with legal status differed with respect to gender, age, ISS, and proportion without insurance (Table 1). Undocumented
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Latino patients were more likely to be younger males, and they presented with a lower ISS. There were a greater percentage of uninsured patients in the undocumented group. The mean hospital stay for the overall cohort was 3.57 ±0.14 days. The mortality rate for the overall sample was 3.5%. This did not differ between
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groups (Table 1). Table 2 shows the results for in-hospital mortality in both unadjusted and adjusted analyses. Documentation status was not a significant contributor to inhospital mortality in either unadjusted or adjusted analyses. Penetrating mechanism, lack
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of private insurance, and higher presenting ISS were significant predictors of in-hospital mortality. Age went from non-significant to significant after adjustment for other
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variables. Tests for collinearity were performed, and undocumented status was not significantly associated with any other factors. Specifically, the variation inflation factor for undocumented status and insurance was 1.04, with a tolerance of 0.96.
Discussion: Undocumented Latino immigrants rely on safety net hospitals and our nation’s
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trauma centers for medical care, yet there is little to no information regarding the care and outcomes of injured undocumented immigrants cared for by these institutions. Furthermore, their immigration status may place undocumented Latinos at higher risk of
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disparate outcomes after trauma. To our knowledge, this is the first study in the literature addressing health care utilization and health outcomes for undocumented Latino
immigrants after trauma. We hypothesized that undocumented Latino immigrants would
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be at a higher risk of in-hospital mortality after trauma, compared to Latinos with legal residence. Contrary to this hypothesis, we found no disparities based on immigration
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status for mortality after trauma, though disparities based on insurance status continue to persist.
Our study population of undocumented Latino trauma patients mirrors previous epidemiological research about undocumented Latino immigrants in general. For
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example, in our sample, and nationally, undocumented Latino immigrants are most likely to be young, male, and uninsured [5]. Notably though, insurance coverage in our sample differed from previous research. Rates of uninsurance from county-level and national
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samples have been estimated at 68-71% [5,13]. In contrast, 54% of our undocumented Latino patients were uninsured. Furthermore, our sample contained a very high
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percentage of patients with public insurance (46%), compared with 8% from a study based in Los Angeles County [13]. Lastly, in our study, despite only being eligible for county-level public insurance, rather than state and federal coverage, there was no difference between undocumented immigrants and their counterparts in public insurance enrollment, which speaks to the strength of our county insurance program.
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Our findings also add to knowledge from previous research illustrating the underutilization of health care by undocumented Latino immigrants [3,7,14]. In our current study, undocumented immigrants make up 3.4% of the total trauma population
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seen at our institution. In Alameda County, our hospital’s catchment area, undocumented immigrants make up 8.4% of the total county population [15]. This suggests that
undocumented Latino immigrants consume proportionally less trauma care than would be
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expected. The reason for this, however, is unclear; moreover, it may be different for trauma patients than what is postulated in previous studies on undocumented Latino
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immigrants. It has been suggested that underutilization of ambulatory and non-trauma emergency department care by undocumented Latino immigrants is a reflection of structural constraints, such as lack of insurance and low socioeconomic status [8]. In other words, barriers to health care exist and limit access. In our county, access to trauma
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services is universal for injured patients. As such, structural factors should theoretically not limit a person’s access and utilization of our trauma center. Despite our hypothesis that documentation status would place an undocumented
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Latino trauma patient at increased risk of in-hospital mortality, we did not find documentation status to be an independent predictor of this. As such, there was no
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appreciable disparity between groups based on presence or lack of legal residence. This may partly be due to the epidemiology of undocumented Latino immigrants, as they are more likely to be young and healthy. Some suggest that patient comorbidities, being more prevalent in uninsured patients of low socioeconomic status, contribute to disparities in trauma outcomes [2]. Being a young and healthy population subgroup, it is possible that undocumented Latino immigrants may not bear these same burdens. The
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lack of significance may also reflect the high number of patients in the undocumented group with public insurance, which was found to be protective in multivariate analysis. However, the presence of public insurance was adjusted for in our model, and there was
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no significant collinearity between the two variables.
Another potential explanation may be the lack of implicit bias in the care of undocumented immigrants. Implicit bias refers to subconscious or unrecognized
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physician beliefs based on a patient’s social characteristics, such as gender, race, age,
ability, and socioeconomic status. It has been suggested that implicit bias contributes to
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disparities in outcomes as it may influence physician decision-making regarding processes of care, such as whether a patient needs an operation or intervention due to their condition [16,17]. Documentation status, however, does not carry with it identifiable individual characteristics. Moreover, hospital care providers rarely, if ever,
manner do not exist.
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inquire about a patient’s immigration status. As such, the conditions for bias in this
Though we did not find immigration status to be associated with disparate
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mortality outcomes, our current study corroborates prior research in trauma disparities, illustrating that lack of insurance is an independent predictor of mortality after trauma
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[1,18,19]. Indeed, being uninsured has been almost universally linked to an increased risk of death after trauma, verified in national, regional, and single-center studies, as well as meta-analyses [2]. The reasons for this have yet to be elucidated. Though lack of insurance may predispose to undiagnosed comorbidities, insurance status affects the risk of mortality even in younger age groups that are usually healthy [19]. It is more likely that being uninsured reflects the influence of the social environment and social
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determinants of health, such as social isolation and chronic stress, as has also been previously suggested [18]. Surprisingly, public insurance was independently protective in our model. A possible explanation lies in the different amount of effort and time
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needed to obtain public insurance. For example, enrolling in public insurance may be
harder or more time-consuming than private insurance, which often is a benefit of being employed. This extra effort may represent a patient who also extends extra effort in their
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health care decisions and health habits, thereby positively affecting their downstream health outcomes.
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Our results find significance within the current context of healthcare reform and its expected effects on trauma center funding. Trauma centers depend on federal reimbursement via the “disproportionate share hospital” (DSH) program, which is to be discontinued as part of the Patient Protection and Affordable Care Act (PPACA) [20].
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As undocumented Latino immigrants are not eligible for the increased health coverage benefits of PPACA [21], they will continue to rely on safety net hospitals and trauma centers for their emergency surgical and trauma care. Trauma centers that serve a higher
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proportion of undocumented Latino immigrants may thus face a substantial increase in the amount of uncompensated care provided to this population. Though we did not find
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disparities in mortality after trauma for undocumented Latino immigrants, diminished trauma center funding may create the conditions from which such disparities develop. Furthermore, disparities for uninsured patients may be exacerbated by this changing financial landscape.
Our current study is limited by our focus on trauma patients as the population of interest and in-hospital mortality as the outcome of interest. Disparities in outcomes may
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exist for undocumented Latino immigrants for non-trauma visits to the emergency department, such as for acute cholecystitis or other general surgery issues. Additionally, the use of other outcome variables, such as processes of care, failure to rescue, functional
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outcomes, and patient-centered outcomes [22,23], might lead to different conclusions.
However, this would require a prospective study with qualitative components. Our study is also limited by the difficulty in identifying undocumented Latino immigrants, a group
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often referred to as a “shadow population.” In accordance with previous studies [12], we used a combination of insurance and registration data to determine which Latino patients
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were undocumented. This methodology likely underestimates the number of undocumented patients in our cohort, as some may have had falsified social security numbers or employee-sponsored private insurance. This would result in misclassification of undocumented patients into the comparison group. Lastly, there exists the possibility
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for type II error given our sample size. We did not collect data prior to 2007, as that was the first year we had reliable data for social security numbers. As such, aiming for better data accuracy left us with a smaller sample size.
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In conclusion, to our knowledge this is the first study in the literature that describes the undocumented Latino trauma population and its post-injury mortality
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outcomes. Like previous studies that highlight the underutilization of health care by this population, we found that undocumented Latino immigrants access our trauma center less than would be expected by their proportion in the total county population. Once admitted, they also have shorter lengths of stay. We also found that there are no disparities in regards to in-hospital mortality after trauma for undocumented Latino immigrants, though such disparities did exist for uninsured patients. In order to prevent
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the development of disparities for undocumented Latino immigrants, or the exacerbation of disparities for patients without insurance, trauma centers and safety net hospitals should continue to receive financial support for the high quality of care they currently
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provide to our nation’s underserved.
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References: [1]
Haider AH, Chang DC, Efron DT, Haut ER, Crandall M, Cornwell EE. Race and insurance status as risk factors for trauma mortality. Arch Surg 2008;143:945–9. Haider AH, Weygandt PL, Bentley JM, Monn MF, Rehman KA, Zarzaur BL, et al.
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[2]
Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis. J Trauma Acute Care Surg 2013;74:1195–205.
Ortega AN, Fang H, Perez VH, Rizzo J a, Carter-Pokras O, Wallace SP, et al.
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Health care access, use of services, and experiences among undocumented
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Mexicans and other Latinos. Arch Intern Med 2007;167:2354–60. Passel JS, Cohn D. A Portrait of Unauthorized Immigrants in the United States. Washington: 2009. [5]
Capps R, Bachmeier JD, Fix M, Hook J Van. A Demographic, Socioeconomic,
Washington: 2013. [6]
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and Health Coverage Profile of Unauthorized Immigrants in the United States.
Maldonado CZ, Rodriguez RM, Torres JR, Flores YS, Lovato LM. Fear of
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discovery among Latino immigrants presenting to the emergency department. Acad Emerg Med 2013;20:155–61. Berk ML, Schur CL, Chavez LR, Frankel M. Health care use among
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undocumented Latino immigrants. Health Aff 2000;19:51–64.
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Chavez LR. Undocumented immigrants and their use of medical services in
Orange County, California. Soc Sci Med 2012;74:887–93.
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Passel JS, Cohn D, Gonzalez-Barrera A. Population Decline of Unauthorized Immigrants Stalls, May Have Reversed. Washington: 2013.
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[10]
Passel JS, Cohn D. Unauthorized Immigrant Population: National and State Trends, 2010. Washington: 2011.
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Fiscella K, Fremont AM. Use of geocoding and surname analysis to estimate race
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and ethnicity. Health Serv Res 2006;41:1482–500.
Mitchell CD, Truitt MS, Shifflette VK, Johnson V, Mangram AJ, Dunn EL. Who
Surg 2012;72:609–12; discussion 612–3. [13]
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will cover the cost of undocumented immigrant trauma care? J Trauma Acute Care
Goldman DP, Smith JP, Sood N. Legal status and health insurance among
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immigrants. Health Aff (Millwood) 2005;24:1640–53.
Goldman DP, Smith JP, Sood N. Immigrants and the cost of medical care. Health Aff (Millwood) 2006;25:1700–11.
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Hill LE, Johnson HP, Ezekiel D, Hayes JM. Unauthorized Immigrants in
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California: Estimates for Counties. San Francisco: 2011.
Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for
[17]
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black and white patients. J Gen Intern Med 2007;22:1231–8. Santry HP, Wren SM. The role of unconscious bias in surgical safety and
[18]
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outcomes. Surg Clin North Am 2012;92:137–51. Dozier KC, Miranda M a, Kwan RO, Cureton EL, Sadjadi J, Victorino GP.
Insurance coverage is associated with mortality after gunshot trauma. J Am Coll Surg 2010;210:280–5.
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[19]
Greene WR, Oyetunji T a, Bowers U, Haider AH, Mellman T a, Cornwell EE, et al. Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma. Am J Surg 2010;199:554–7. Khoury AL, Charles AG, Sheldon GF. The trauma safety-net hospital under the
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[20]
Affordable Care Act: will it survive? J Trauma Acute Care Surg 2013;75:512–5. [21]
U.S. House. 111th Congress 2nd Session. HR 3590, The Patient Protection and
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Affordable Care Act. Washington: Government Printing Office: 2010.
Glance LG, Dick AW, Mukamel DB, Osler TM. Association between trauma
Mabry CD. Time to Turn the Page: Moving on to Write New Chapters for Trauma
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quality indicators and outcomes for injured patients. Arch Surg 2012;147:308–15.
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Figure Legends: Figure 1.
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Our study sample consisted of 1,976 Latino patients with legal residence and 465 undocumented Latino immigrants. Figure 2.
The annual number of Latinos with legal residence treated at our trauma center ranged from 274 to 458. The range for undocumented Latino immigrants was 44 to 111.
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Figure 3.
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The annual percentage of Latinos treated at our trauma center that were undocumented ranged from 14 to 21%.
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Figure 1. Inclusion Criteria for Study Population
2,697 Latino Patients
2,441 Latino Patients
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265 Excluded (Missing Data)
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10,961 Non-Latino Patients
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13,658 Activations
465 Undocumented
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1,976 with Legal Residence
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Figure 2. Number of Latino Trauma Patients Treated at our Trauma Center
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Figure 3. Percentage of Latino Trauma Patients That Were Undocumented
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Table 1. Demographic and Clinical Characteristics of Latino Trauma Patients Groups Undocumented Latinos (n=465)
Female
356 (18%)
41 (9%)
Male
1620 (82%)
424 (91%)
ISS*
8.53 ± 0.22
7.46 ± 0.41
Age
32.5 ± 0.35
30.7 ± 0.50
Blunt
1332 (67%)
Penetrating
644 (33%)
Insurance 451 (23%)
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Private
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Mechanism
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Gender
Public Uninsured
< 0.001 0.03 0.02
327 (70%) 138 (30%)
0.23
0 (0%)
947 (48%)
214 (46%)
0.46
578 (29%)
251 (54%)
< 0.001
67 (3.4%)
18 (3.9%)
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Mortality
P Value
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Latinos with Legal Status (n=1,976)
Variable
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*ISS = Injury Severity Score
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Table 2. Unadjusted and Adjusted Results for In-Hospital Mortality Unadjusted OR (95% CI)
p value
OR (95% CI)
1.01 (0.998, 1.025)
0.09
1.04 (1.01, 1.06)
Gender
Male ISS*
1.91 (0.91, 3.97)
0.09
1.2 (1.17, 1.23)
< 0.001
Mechanism Blunt
1 [Reference]
Penetrating
5.13 (3.2,0 8.20)
Insurance Type
0.002
1 [Reference]
0.92 (0.29, 2.88)
0.88
1.24 (1.19, 1.28)
< 0.001
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1 [Reference]
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Female
p value
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Age
Adjusted
1 [Reference]
< 0.001
5.57 (2.45, 12.64)
< 0.001
1 [Reference]
Public
0.29 (0.168, 0.483)
< 0.001
0.20 (0.07, 0.59)
0.004
Uninsured
3.75 (2.38, 5.89)
< 0.001
5.37 (1.98, 14.61)
0.001
Undocumented
1.15 (0.675, 1.95)
0.612
1.12 (0.43, 2.90)
0.811
1 [Reference]
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Private
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*ISS = Injury Severity Score
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