1. Clinical Scholarship
Racial Disparities in Acute Outcomes of
Life-Threatening Injury
Elizabeth G. NeSmith
Purpose: To critically analyze racial and ethnic disparities in acute outcomes of life-threatening
injury in the United States (US).
Design: Integrative review of literature.
Methods: A search of Medline (1966–2005) and CINAHL (Cumulative Index to Nursing
and Allied Health Literature; 1982–2002) scientific literature databases was undertaken
to identify research aimed at correlating minority race and ethnicity to acute outcomes of
life-threatening injury in the US.
Results: Although injury is the leading cause of death for adults 15 to 44 years of age, racial
and ethnic health disparities in acute outcomes of life-threatening injury have been relatively
unexplored: only seven of 352 (2%) studies. The findings from these studies were mixed.
Four studies indicated significant relationships between race or ethnicity to acute outcomes
in injury morbidity and mortality, but three studies showed no significant relationships
between these variables. Other variables associated with health disparities, such as income
and education were rarely (income) or not (education) addressed.
Conclusions: These inconclusive results indicate the need for more research aimed at inves-
tigating racial and ethnic disparities in acute outcomes of life-threatening injury.
JOURNAL OF NURSING SCHOLARSHIP, 2006; 38:3, 1-6. C 2006 SIGMA THETA TAU INTERNATIONAL.
[Key words: critical care, outcome evaluation, injury, trauma, health
disparities, race]
* * *
I
njury is the number one killer of adults aged 15–44 and is
one of the most expensive threats to health and produc-
tivity, second only to cardiac disease (Agency for Health-
care Research and Quality [AHRQ], 2002; Centers for
Disease Control and Prevention [CDC], 2003). Injury affects
36 million people across all races and classes, and is respon-
sible for nearly 40 billion dollars in annual costs (AHRQ,
2002). Estimates indicate that by 2020, injury will surpass
communicable disease as the leading cause of disability-
adjusted life years around the world (Meyer, 1998).
Because of the large societal and economic consequences
of severe injury, many studies have been aimed at identi-
fying determinants of outcomes in life-threatening injury.
However, few studies have been focused on identifying dis-
parities in these outcomes for racial and ethnic minorities.
Eliminating health disparities for minorities and other vul-
nerable populations is a U.S. national priority (Institute
of Medicine [IOM], 2003; Kelley, Moy, Stryer, Burstin, &
Clancy, 2005; U.S. Department of Health and Human Ser-
vices [USDHHS], 2003). Research to identify differential
outcomes among populations in all areas of health care can
reveal critical information about pathology. Such research
can aid in providing increased opportunities for treatment
and prevention (National Institutes of Health, [NIH], 2000).
The aim of this integrative review was to determine the
state of the science related to acute outcomes following life-
threatening injury, with the focus on people in racial and
ethnic minority groups.
Background
Minorities and Injury
People in racial and ethnic minority groups sustain in-
juries at disproportionate rates (IOM, 1999). In the US, rates
Elizabeth G. NeSmith, RN, MSN, Beta Omicron, Nursing Doctoral Student,
Medical College of Georgia, Augusta, GA. The author thanks and acknowl-
edges the following for their guidance, encouragement, and assistance
in the preparation and review of this manuscript: Dr. Jeannette Andrews,
Dr. Shelia Bunting, Dr. Patricia Humbles, Dr. Sally Weinrich, Mrs. Gayle
Bentley, and Mrs. Laurie Landrum. Correspondence to Ms. NeSmith, Med-
ical College of Georgia, School of Nursing, 1120 15th St., Augusta, GA
30912. E-mail: bnesmith@students.mcg.edu
Accepted for publication December 7, 2005.
Journal of Nursing Scholarship Third Quarter 2006 1

2. Racial Disparities in Injury Outcomes
of injury are higher for African Americans (AA) and Amer-
ican Indian/Alaskan Natives than for other members of the
population (IOM, 1999). Violent crime is a serious people
for AAs, with homicide rates being highest among this pop-
ulation (CDC, 2003). Injuries that require hospitalization
occur in AA males (ages<64 years) at twice the rate of that
for White men of the same age range (IOM, 1999).
Governmental initiatives such as “Healthy People
2010” and the National Institutes of Health “Road Map”
make clear that the discovery and elimination of health
disparities is a national priority in the US (NIH, 2004;
USDHHS, 2003). Despite these initiatives, and evidence
that income and education are related to health dispari-
ties, the gap in health care and outcomes between minority
and nonminority populations is increasing. The difference
in life expectancies between AA and White men increased
by 8 years from 1960 to 1996 (IOM, 2003). Infant mor-
tality rates for AAs and American Indians are 2.5 and 1.5
times greater than are those for Whites (IOM, 2003). For
nearly all leading causes of morbidity and mortality, includ-
ing cardiovascular disease, cancer, cerebrovascular disease,
diabetes, maternal and infant health, mental health, and dis-
orders of the immune system, disparities in health outcomes
for minority populations continue to be documented (IOM,
2003).
Racial and ethnic disparities have also been documented
in areas of health that have a close association with acute in-
jury, and those that have potential implications for the exis-
tence of disparities in acute trauma outcomes. Researchers in
critical care have found that minority race is correlated with
greater incidence and mortality from sepsis occurring from
a variety of causes (Felix-Aaron et al., 2005; Martin, Spain,
& Richardson, 2003). Increased incidence of shock and
respiratory failure have also been correlated with minority
race (Felix-Aaron et al., 2005; Wheat et al., 2000). Dispar-
ities in nonacute outcomes of injury have been linked with
minority status in social integration, productivity, physical
functioning, and general health after serious injury (Brown,
McCauley, Levin, Contant, & Boake, 2004; Rosenthal et al.,
1996; Wagner, Hammond, Sasser, Wiercisiewski, & Norton,
2000). Although above-average risk for disparities in health
care has been identified for racial and ethnic minorities in
many healthcare sectors, it is only beginning to be identified
in the literature on serious injury (Barber & O’Keefe, 2003;
Gannon, Napolitano, Pasquale, Tracy, & McCarter, 2002;
IOM, 2003).
Thus, evidence to date shows that: (a) injury affects
people in minority groups disproportionately; (b) people in
minority groups experience disparities in multiple areas of
health; and (c) the literature about injury contains little in-
formation on health disparities. This evidence indicates the
need for increased research to discover and eliminate dispar-
ities in acute outcomes of life-threatening injury. The pur-
pose of this integrative review was to analyze knowledge of
health disparities among ethnic minorities in acute outcomes
of life-threatening injury.
Methods
A search protocol was designed with the assistance of
a research librarian based at a university health sciences
institution. Medline (1966–2005), CINAHL (1982–2002),
and Cochrane Database of Systemic Reviews were searched
to identify published and unpublished research focused on
acute outcomes of trauma. Key words used in the search
were: injury, trauma, multiple trauma, multisystem trauma,
level one trauma center, injury severity score (ISS), trauma
severity indices, critical care, intensive care unit (ICU), mor-
bidity, mortality, outcomes, acute outcomes, length of stay,
complications, adverse events, sentinel events, patient satis-
faction, cost, and charges.
A literature search and a review of study reference
lists produced 352 citations for review. Criteria for in-
clusion were data-based papers published in U.S. journals
and focused on acute injury outcomes as dependent vari-
ables in adults (age >18) with life-threatening injuries. Life-
threatening injury was defined as injury(ies) with an ISS of
greater than 15, or injury(ies) severe enough to require ad-
mission to the ICU for >24 hours. The ISS is a scoring system
used to assess severity of injury; it has been shown to be a
valid predictor of injury mortality, morbidity, and hospital
length of stay (Van Natta & Morris, 2000). Race must have
been reported as an independent variable. Studies were ex-
cluded if they were focused on children, nonacute outcomes,
or critical care outcomes other than injury. A code sheet was
used to organize study findings (Mulrow & Oxman, 1997).
Variables documented in the code sheet included study, pur-
pose, design, sample size, setting, independent variables, de-
pendent variables, methods, and conclusions.
Initial review of the 352 citations resulted in 171 (49%)
articles focused on acute injury outcomes. Of these, 17 (5%)
studies were focused on acute care outcomes in severely in-
jured patients and included information about race. How-
ever, race was analyzed in relation to acute outcomes in less
than half of the 17 studies, resulting in a total of 7 (2%)
studies included in this analysis.
Findings
Study Characteristics
Data during the acute phase of care were collected for
all seven studies from records of patients admitted to Level
1 trauma centers (American College of Surgeons Committee
on Trauma, 1998). Patients who meet criteria for care at
Level 1 trauma centers are routed to these centers during
transport for initial assessment and treatment, regardless of
their ability to pay for care. Time to treatment for patients
was not reported in any of the studies reviewed.
Four of the seven studies were prospective, and three
were retrospective. Physician investigators conducted the
studies. Most (n=5) sample sizes were larger than 1,000,
and ranged from 151 to 20,000. Outcomes of interest were
2 Third Quarter 2006 Journal of Nursing Scholarship

3. Racial Disparities in Injury Outcomes
mortality and morbidity, hospital and ICU length of stay,
acute care disposition, and hospital costs or charges. Al-
though race was correlated to outcomes and was reported
in in the results, the primary aims of the studies were
not focused on racial disparities in acute outcomes of life-
threatening injury. Other variables associated with health
disparities in the literature were rarely reported. Income and
health insurance status were correlated to outcomes in two
studies, but education was not reported for any of the seven
studies.
Disparities Reported
Mortality from injury was positively associated with mi-
nority race in two of the seven studies. In the first study,
Gannon and colleagues (2002) prospectively sought to in-
vestigate gender in relation to trauma mortality with more
than 22,000 trauma registry records. Besides gender, the in-
vestigators linked age, Caucasian and non-Caucasian race,
and comorbidity variables to mortality in patients with mild
(ISS<15), moderate (ISS 15–29), and severe (ISS>30) in-
jury. Although associations between age and gender to in-
jury mortality were analyzed by individual ISS groups, the
association between race and mortality was analyzed for the
full sample, without differentiation between injury sever-
ity groups. Results showed that non-Caucasian patients had
nearly twice the chance of dying from injury as did their
White counterparts (Gannon et al., 2002).
Similarly, in another study of mortality, investigators
conducted a retrospective analysis of nearly 34,000 records
of patients with mild (ISS<15), moderate (ISS 15–29), and
severe (ISS>30) injuries (Grossman, Miller, Scaff, & Arcona,
2002). Again, variables such as injury mechanism and age
were analyzed and reported by injury severity group, the ef-
fect of race on mortality in geriatric patients was reported
for the full sample. The conditional odds ratio for the effect
of race on mortality was comparable, and slightly higher
(1.09) than that of age (1.068) or gender (0.656). Race had
nearly the same effect on mortality as did the severity of in-
jury (OR 1.098). Because the aim of this study was to define
the significance of comorbidities and clinical variables on
mortality rates in injured elderly, and not to identify dispar-
ities in vulnerable populations, results were not reported for
racial subcategories.
Acute complications of life-threatening injury have been
positively associated with race. In one study of injured pa-
tients (ISS>16), specific differences in genetic morphology
that have implications for the development of sepsis were
found to occur significantly more frequently in AA patients
than in other groups of patients, including White and His-
panic patients (Barber & O’Keefe, 2003). This genetic differ-
ence was also found in a control group sample of noninjured
AAs. The identification of racial disparities in outcomes was
not the primary aim of this prospective study. The purpose
was to examine genetic differences in severely injured pa-
tients (n=151) who developed and survived complicated
sepsis, but investigators also correlated minority racial sta-
tus with genetic polymorphisms.
In another study in which race was correlated with in-
jury complications, investigators found racial differences in
a sample of injured patients who were at risk for developing
delirium tremens (DT) during their hospital stay (Lukan,
Reed, Looney, Spain, & Blondell, 2002). The trauma reg-
istry database at a Level 1 trauma center was retrospectively
reviewed in this study for patients who either had a positive
blood alcohol concentration on admission or who had de-
veloped DT while in the ICU or hospital (n=1,751). Data
for race were collected as an independent variable and cor-
related to subsequent development of DT, although racial
subcategories other than “White” were not reported. In a
group of patients with similar severity of injury (mean ISS
of 13.3), White race was found to be a significant predictor
for the development of DT, a complication that can increase
hospital length of stay and place injury victims as risk for
increased acute care complications (Lukan et al., 2002).
No Disparities Reported
In the three remaining studies, no correlations between
race and acute injury outcomes were reported. Two of these
studies were focused on acute injury morbidity and mortality
outcomes. No differences were found in mortality rates for
people of Caucasian, AA, or Hispanic race when investiga-
tors sought to identify relationships between demographic
characteristics and outcomes in people who suffered trau-
matic brain injury (TBI) from intentional acts of violence
and who were admitted to the ICU or hospital for more
than 24 hours (Wagner, Sasser, Hammond, Wiercisiewski,
& Alexander, 2000). In this prospective study of more than
2600 patients with TBI from causes such as gunshot wounds
and assault with a blunt object, the investigators evaluated
characteristics of vulnerability such as age, race, (Caucasian,
AA, or Hispanic) income, and substance abuse in connec-
tion with incidence of intentional TBI and mortality. Re-
sults regarding income showed that, although more than
60% of patients in the sample had mean incomes of less
than $39,000, no association was found between income
and death from TBI before acute care discharge.
Bochicchio and colleagues (2002) reported no signifi-
cant differences in the incidence or absence of systemic in-
flammatory response syndrome (SIRS) as a complication of
severe injury for people of Caucasian, AA, Hispanic, Asian,
or “Other” race. Injury severity was defined by requirement
of admission to the ICU for more than 24 hours. This finding
was one component of a prospective analysis of 702 records
to evaluate the utility of using SIRS scores in predicting the
incidence of nosocomial infection and outcome (Bochicchio
et al., 2002).
Administrative outcomes were the focus of the final
study of injured patients. In this research conducted by
Legoretta and colleagues (1993), the sample included pa-
tients from the hospital trauma registry database who had
injuries severe enough to require admission to the hospital
or ICU, including “major significant trauma” as defined by
New York State Major Diagnostic Category 25. The inves-
tigators sought to identify potential relationships between
Journal of Nursing Scholarship Third Quarter 2006 3

4. Racial Disparities in Injury Outcomes
AA, Hispanic, White, or “Other” race and health-insurance
payer to costs, through their evaluation of reimbursement
characteristics for injury care in an urban New York hospital
(Legorreta, Mikos, Sullivan, & Delany, 1993). Retrospective
chart reviews of 209 records showed no association between
payer status or race with hospital costs or injury severity.
Discussion
Study findings for racial disparities in acute outcomes of
life-threatening injury are mixed, and analyses often do not
include other variables known to be associated with health
disparities, such as income and education. In four of the
seven studies racial disparities were reported in trauma mor-
bidity and mortality. Conversely, three studies showed no
correlations between race and acute trauma morbidity and
mortality. These results lead to the conclusion that more
research is needed to investigate the potential for racial dis-
parities in life-threatening injury. This research should also
include other variables known to be associated with health
disparities, such as income and education.
Findings from the four studies that showed racial dis-
parities in injury morbidity and mortality are consistent with
much of the health disparities literature. Although few in
number, these studies mirror results reported in the IOM
(2003) report on racial disparities in health care, as well as
study findings in the nonacute injury and critical care liter-
ature. This consistency indicates evidence to support future
research specifically aimed at searching for racial disparities
in acute outcomes of injury.
Many investigators focus their research on improving
acute outcomes of injury. However, the majority of injury
outcome studies were excluded from this review because,
although investigators collected race or ethnicity data as
independent variables, these variables were not linked to
outcomes in the final results. Small adjustments in current
research designs, including the linkage of already collected
race data to acute injury outcomes, and the collection of
other variables associated with health disparities, such as
income and education, would help bring injury research
closer to meeting U.S. national priorities for the elimination
of health disparities.
One of the studies included in this analysis indicated
significant evidence that disparities might exist in the bio-
logic response to life-threatening injury that may affect acute
outcomes. Barber and O’Keefe (2003) found genetic poly-
morphisms with implications for sepsis survival from injury
among people from minority groups. Results such as these
are significant for several reasons. First, these findings are
consistent with research in related fields of science that sup-
port emerging theories of physiologic changes resulting from
the cumulative effects of chronic stress, or “allostatic load”
(Korte, Koolhaas, Wingfield, & McEwen, 2005; McEwen
& Seeman, 1999). Chronic stress is disproportionately ex-
perienced in vulnerable populations, including ethnic mi-
norities, and places them at risk for increased susceptibil-
ity to disease (Kristenson, Erikson, Sluiter, Starke, & Ursin,
2004; Seeman et al., 2004; Steptoe, Owen, Kunz-Ebrecht, &
Mohamed-Ali, 2002). Second, such differences are being re-
ported with increasing frequency to influence the symptoms,
mechanisms of, and responses to complications of injury
(Korte et al., 2005; Zehnbauer, 2000). Finally, these findings
have specific implications for a provider’s choice of tailored
interventions for life-threatening injury, and more research
is required to validate these findings (Bevan et al., 2003;
Exner, Dries, Domanski, & Cohn, 2001; Wood, 2001). Con-
sequently, investigators urge injury researchers to explore
racial differences as independent variables in injury out-
comes (Barber & O’Keefe, 2003).
One explanation for the unexplored status of disparities
in the area of injury outcomes might be that many Ameri-
cans believe that race is irrelevant in health care (IOM, 2003;
Lillie-Blanton, Martinez, & Salganicoff, 2001). Classic in-
jury outcome studies that did not correlate factors of race
or ethnicity as independent variables to outcomes are con-
sistent with this belief (Brenneman, Boulanger, McLellan,
Culhane, & Redelmeier, 1995; Champion et al., 1990; Hol-
brook & Hoyt, 2004). Research that excludes these vari-
ables perpetuates this ideology and contributes to the gap
in knowledge about possible racial health disparities in life-
threatening injury.
Another explanation for the deficit of research in this
area might be that some research environments do not ex-
plicitly promote scholarly inquiry on racial and ethnic differ-
ences in health outcomes. Ninety-eight percent (345 out of
352) of the studies abstracted for this review did not include
variables of race in their analysis, and none of the findings
reported are the result of testing the investigators’ primary
hypotheses. Results about race as independent variables in
injury outcomes were significant, yet unexpected findings.
Although no evidence was found to indicate that these re-
sults were the reason most injury researchers ignored race
in their analyses, innovative research designs are needed to
study race in relation to acute injury outcomes.
Implications
Evidence from this analysis indicates that more re-
search is needed to identify racial disparities in outcomes
from acute injury. Theoretical frameworks exist for devel-
oping research questions aimed at this purpose and include
the psychoneuroimmunology framework (DeKeyser, 2003),
the human response model (Heitkemper & Bond, 2003),
and the vulnerable populations conceptual framework
(Flaskerud & Winslow, 1998). All of these frameworks in-
dicate that health outcomes are dependent on vulnerability,
risk, and resources.
Mitigation of the effects of illness and injury in
vulnerable populations requires research on sociological,
environmental, and biological determinants of health and
health disparities, including assessments of how race,
income, and education might differentially affect health
4 Third Quarter 2006 Journal of Nursing Scholarship

5. Racial Disparities in Injury Outcomes
outcomes (Flaskerud & Nyamathi, 2002; IOM, 2003).
Questions for future research based on this analysis include:
(a) Do people in minority groups and of low socioeconomic
status have worse acute outcomes of life-threatening injury?
(b) If disparities exist, what are their characteristics, and how
do they compare to disparities found in other areas of health
and illness? (c) What specific psychological and biological
factors explain disparities in outcomes from life-threatening
injury?
Conclusions
The results of this analysis indicate important but in-
sufficient and inconclusive evidence of racial disparities in
acute outcomes of life-threatening injury. Achieving posi-
tive outcomes of care is difficult without an understanding
of the effects of patient risk factors on outcomes (MacKen-
zie, Shapiro, Moody, Siegel, & Pitt, 1987). More research is
needed with a focus on acute outcomes of life-threatening in-
jury in people from racial and ethnic minorities, and people
of different income and education levels. The effects of co-
morbidities commonly associated with factors such as race
or ethnicity on influencing acute outcomes of injury must be
recognized when analyzing complications of injury (Maier
& Rhodes, 2001). These facts serve as an excellent foun-
dation upon which to develop future research in acute out-
comes of life-threatening injury to answer the national call
to discover and eliminate health disparities in all leading
causes of death for racial and ethnic minorities.
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6 Third Quarter 2006 Journal of Nursing Scholarship

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