Racial and Ethnic Disparities in Helicopter Transport Utilization in Severely Injury Children

Abstract

Introduction

In the United States, trauma is a leading cause of pediatric mortality. In severe injury, every second counts towards maximizing survival, an urgency encapsulated in the concept of the 'Golden Hour.' In this context, helicopter air ambulances is as a vital component of the emergency medical services system, reducing the time to definitive care for severely injured patients. However, persisting racial and ethnic disparities in trauma outcomes in the US raise questions about whether non-clinical factors, such as race or ethnicity, influence the deployment of life saving interventions, such as air transport for severely injured children. In this study, we evaluated whether there is a racial or ethnic disparity in the risk-adjusted use of helicopter ambulance following severe pediatric trauma. We also evaluated whether the gaps in helicopter utilization between children of different races and ethnicity have begun to narrow or widen over time.

Methods

We conducted a population-based, 1:1 propensity-score matched, retrospective cohort study using data from the National Trauma Data Bank (NTDB) between 2017 and 2022. Our cohort included 42,812children (15) and had and emergency department disposition to the operating room or the ICU at level I or II trauma centers. Our primary outcome was the risk-adjusted transport mode comparing racial/ethnic groups (helicopter ambulance vs. ground ambulance). We used linear risk and log-binomial regression models and summarized the results as adjusted relative risk (RRadj), absolute risk difference (RDadj) along with their 95% confidence intervals (CIs). To account for clinical characteristics that could influence the decision to use helicopter transport, the propensity score models controlled for age, sex, hospital teaching status, American College of Surgeons verification level, state designation, hospital bed size, patient's primary insurance, injury intentionality, injury mechanism, chronic complex condition, body region, injury severity score, EMS reported Glasgow coma scale, heart rate and systolic blood pressure, and a distance indicator between injury site and receiving hospital.

Result

Helicopter transport was associated with a lower mortality risk compared to ground transport (RRadj: 0.86, 95%CI: 0.79 to 0.93, P-value < 0.001). Despite the mortality benefits of helicopter utilization, non-Hispanic Black children were 50% relative less likely to be air transported, compared to Non-Hispanic White children (20.0% vs. 33.6%, RDadj: -20.0%, 95% CI: -22.0 to -18.0, P-value < 0.001). Similarly, Non-Hispanic Others (24.7% vs. 33.6%, RDadj: -11.0%, 95% CI: -14.0 to -8.0%, P-value < 0.001), and Hispanics (24.0% vs. 33.6%, RDadj: -11.0%, 95% CI: -13.0 to -10.0%, P-value < 0.001) were both less likely to be air transported compared to Non-Hispanic White children—Figure 1. We found no statistical evidence of narrowing of the disparity gap during the study period (likelihood ratio test for the interaction between race/ethnicity and year, P-value = 0.180)

Conclusion

Despite the clear survival benefits of helicopter transport in severe trauma situations, minority populations are less likely to be airlifted compared to White children. These disparities have not narrowed over time, challenging the effectiveness of current efforts to expand helicopter ambulance programs. As pediatric trauma care continues to evolve, it is our collective responsibility to ensure that access to rapid and life-saving care is not – advertently or inadvertently – affected by non-clinical needs such as race and ethnicity.