Introduction
Traumatic physical injuries are endemic in the USA and are associated with substantial individual suffering and population health burden.1–3 Each year in the USA, over 30 million individuals visit acute care medical settings after incurring traumatic injuries, and between 1.5 and 2.5 million Americans are so severely injured annually that they require inpatient admission.1–3 Between 20% and 40% of injury survivors who have been hospitalized later develop post-traumatic stress disorder (PTSD) symptoms and associated comorbidities.4–8 Following an injury, PTSD and related comorbid conditions are associated with a wide range of functional limitations and significant societal costs.2 3 6 9
The risk of developing PTSD and related comorbidity after an injury accentuates the importance of developing mental health screening, intervention, and referral procedures at trauma centers; the American College of Surgeons Committee on Trauma now mandates trauma centers establish protocols that identify patients at a heightened risk of experiencing psychological sequelae following traumatic injuries and have a referral process in place for patients who receive a positive screening result indicating a high risk.10
Injured patients presenting to trauma care systems after life-threatening exposures are often from racial and ethnic minority groups and are at high risk for not receiving high-quality mental health screening, intervention, and referral; the acute care medical setting can be viewed as a de facto safety net healthcare system serving low-income, multicultural patient populations.11–16 Injured trauma survivors belonging to racial and ethnic minority groups may be at increased risk of developing PTSD and related comorbid conditions.13–15 17 Non-white racial minority patients (ie, African American, American Indian, and Asian American) and ethnically Hispanic patients experience adverse health disparities in acute medical care settings.16 18–20 This includes experiencing reduced administration of pain medication for comparable injuries and exhibiting higher postinjury mortality rates compared with white/non-Hispanic patients.16 18–20 Effectively coordinating acute care with primary care services poses a significant challenge, with racial and ethnic minority patients being particularly susceptible to experiencing disrupted care transitions.12–14 21–24 Patients from ethnic and minority backgrounds are also vulnerable to community violence and associated traumatic injuries.11 25–28 Therefore, efforts to improve the overall quality of mental healthcare delivered at trauma centers could lead to diminished health disparities and markedly improved outcomes for racial and ethnic minority injury survivors.12–15 18 29 30
Emerging research indicates that stepped care collaborative interventions have proven effectiveness in addressing the symptoms of PTSD and related comorbidities among injured trauma survivors.12 23 24 31–33 Stepped collaborative care interventions integrate proactive care management, psychotherapeutic elements, and medications to provide comprehensive postinjury patient support. Preliminary research suggests that stepped collaborative care interventions may be effective when tailored to the needs of racially and ethnically diverse patient populations.12 34–36 The optimal use of stepped screening, intervention, and referral procedures in the delivery of mental health services to diverse patients has the potential to mitigate disparities at trauma centers.
This secondary data analysis examined the impact of a stepped collaborative care intervention for a subgroup of non-white/Hispanic racial and ethnic minority injury survivors recruited from 25 US level I trauma centers. The investigation hypothesized that injury survivors from non-white and Hispanic minority groups would demonstrate greater PTSD symptom improvement when randomized to a collaborative care intervention compared with white, non-Hispanic patients.