Influence of race and neighborhood on the risk for and outcomes of burns in the elderly in North Carolina
Introduction
Older adults are at high risk for burn [1], [2], [3] and experience significant burn-related morbidity and mortality [4]. Burns and other fire-related injuries are currently the second-leading cause of death from home accidents among older adults [5]. Extremes of age are an independent predictor of mortality in burn injury. In the elderly cohort this is due in part, to pre-existing comorbidities complicating surgical management [6].
Individual-level risk factors for mortality and increased hospital length of stay (LOS) in burn patients of all ages are well established. Along with advanced age, percent of total body surface area burned TBSA, comorbid conditions and inhalation injury are the major independent contributors to mortality in the elderly. Risk factors for increased LOS in elderly burn patients include TBSA, inhalation injury, flame injury, and comorbid conditions such as diabetes and cardiovascular disease [7], [8]. The geriatric sequelae that may predispose the elderly to burn injury include decreased physical strength, impaired protective mechanisms, hearing impairment, and poor vision [9]. Older adults may have limited mobility or slower reaction time making escaping house fires difficult [10].
Substandard housing associated with lower socioeconomic status may contribute to burn injury in the elderly population as 20% of the elderly in the United States live below the poverty line [11]. Older adults are less likely to have functional smoke detectors in their homes than younger adults [12]. Additionally, they may live in older houses, which tend to have more fire hazards, or be unable to maintain houses sufficiently to reduce the possibility of fire. Hence, older adults, particularly those with low socioeconomic status, may be at increased risk for house fires. Elderly fire victims are at higher risk for more extensive burn injuries, inhalation injury, and respiratory failure as compared to their younger counterparts [6], increasing the complexity of their care and rehabilitation.
Health disparities among Minorities and the economically disadvantaged in the United States are well recognized and manifested in a wide range of indicators including burn [13], [14]. Compared to this population, African Americans have an elevated mortality rate for eight of the ten leading causes of death [15]. Age-adjusted all-cause mortality rates in African Americans were one and a half times that of European–Americans in 1998, the same as what it was in 1950 [15]. These inequalities may be explained, at least in part, by socioeconomic status [16]. While the relationship between race and socioeconomic status is complex, they are highly interrelated and both are strongly associated with health and mortality [17]. At present, little is known about the influence of race and socioeconomic status on burn injury and mortality in elderly Americans.
Area-based socioeconomic indicators provide a means of characterizing an area's residents, as well as evaluating the contextual effect of characteristics not reducible to the individual level, such as proportion of residents living in poverty. The availability of multiple area level indicators from the United States Census Bureau and the development of geocoding tools have allowed evaluation of the effects of area level social inequality on health outcomes. Numerous studies have shown that living in a deprived neighborhood exerts an effect on the health of residents above and beyond their own economic status [18], [19].
One of the key tenets of injury prevention is to identify high-risk cohorts and environments so that targeted prevention strategies can be deployed. Geographic information systems (GISs) have become important tools for understanding population health. GIS allows the integration of data from a variety of sources and provides a means of analyzing spatial distribution and patterns. A growing body of literature has demonstrated that characteristics of communities where people live, such as family stability, housing conditions, income and wealth, crime, and unemployment influence health outcomes [20], [21]. The use of GIS enables the linkage of individual and neighborhood level data, facilitating the analysis of the geographic dimensions of health at a variety of levels; from state to county to the smallest unit of analysis, the census block group, consisting of a few city blocks.
The aim of this study is to identify demographic and geographic subgroups at increased burn risk, and to examine individual and neighborhood-level determinants of burn and mortality among the elderly population admitted to the Jaycee Burn Center (JBC) at the University of North Carolina at Chapel Hill between 2000 and 2008.
Section snippets
Methods
After approval from the UNC Institutional Review Board, demographic and clinical data was obtained from the JBC registry for patients aged 60 and older admitted between January 2000 and December 2008. Data from patients residing outside of North Carolina was excluded from the analysis.
Individual-level analysis
Between 2000 and 2008, a total of 476 patients aged 60 and older from North Carolina were admitted to the JBC. Of these, there were 406 patients resident within the JBC catchment whose addresses could be successfully geocoded and linked to census data. The characteristics of those excluded from the analysis were not significantly different from those who were included.
The characteristics of this population are shown in Table 1. 36.2% of patients were women and 63.8% were men. The overall median
Discussion
As the elderly population in the United States grows, the number of burn hospitalizations within this cohort is likely to increase. However, the burn burden is not shared equally among this subpopulation, with those in lower socioeconomic groups experiencing a disproportionate burden of injury morbidity and mortality [23]. In this study, there were no significant differences between European–American and Minority burn patients with respect to mortality in any of the models utilized. Minority
Conflict of interest statement
The authors have no financial and personal relationships with other people or organization that could inappropriately influence their work.
Acknowledgement
Funding support for this study was provided by a parent grant of Peggye Dilworth-Anderson (PI), 5KO7 AG023113-4, National Institute on Aging. The study sponsors had no involvement in the study design, data collection, analysis and interpretation of data, writing of the manuscript, or decision to submit the manuscript for publication.
References (40)
- et al.
Fire-fatality study: demographics of fire victims
Burns
(1996) - et al.
Elderly patients discharged home from the emergency department with minor burns
Burns
(2005) - et al.
Burns in patients over 60 years old: epidemiology and mortality
Burns
(1992) - et al.
A three decade analysis of factors affecting burn mortality in the elderly
Burns
(2005) - et al.
Mortality and morbidity among elderly people with burns – evaluation of data on admission
Burns
(2008) - et al.
A population-based study of the epidemiology of acute adult burn injuries in the Calgary Health Region and factors associated with mortality and hospital length of stay from 1995 to 2004
Burns
(2009) - et al.
Clinical factors affecting mortality in elderly burn patients admitted to a burns service
Burns
(2008) Social and economic factors associated with the risk of burn injury
Burns
(2007)- et al.
Association between socioeconomic status and burn injury severity
Burns
(2009) Preventing burns in older patients
Am Fam Physician
(2006)