Mind the gap: A call to integrate equity measures in the Trauma Quality Improvement Program

Equity is the "sixth domain" of health care quality but is not explicitly assessed by the American College of Surgeons Trauma Quality Improvement Program (TQIP). We sought to assess equitable outcomes within hospitals for populations that experience health disparities.

Retrospective analysis of 2018-2020 TQIP data from Level 1/2 trauma centers (TCs). Following TQIP methodology, we applied multivariable logistic regression to calculate hospital-level risk-adjusted mortality and observed versus expected (O/E) in-hospital mortality ratios to identify low- (O/E, 95% confidence interval <1), average-, and high-mortality (O/E, 95% confidence interval >1) TCs. Using stratified analyses, we evaluated within-hospital equity by race (Black vs. Non-Hispanic White), ethnicity (Hispanic vs. Non-Hispanic White), and insurance (uninsured, Medicaid vs. commercial) by assessing concordance with advantaged reference group and presence of low-mortality gap (<5% difference).

We analyzed 892,583 patients at 384 TCs. A total of 192 hospitals (50%) were classified as "low-mortality" (median O/E, 0.85 [0.76-0.93]), 22 (5.7%) as average, and 170 (44.3%) as "high-mortality" (median O/E, 1.13 [1.06-1.22]). Low-mortality TCs treated a higher proportion of White patients (75% vs. 68%) and blunt injuries (95% vs. 93%), with higher Medicaid population (43% vs. 35%) relative to high-mortality hospitals. In stratified analyses among low-mortality TCs, only 4 (2.1%) of hospitals satisfied both equity criteria for their Black patients, 10 (5.2%) for Hispanic patients, 14 (7.3%) for Medicaid patients, and 6 (3.1%) for uninsured patients.

A minority of low-mortality TCs achieve equitable outcomes, with both minoritized and socioeconomically vulnerable populations affected. Such inequities are masked in quality improvement reports of total populations. Equity measures including stratified analyses should be incorporated into standard quality improvement reports to inform hospital-level initiatives and purposefully improve care for populations that experience health disparities.

Prognostic and Epidemiologic; Level III.