"Addressing Systemic Inequities in Alcohol Testing for Burn Victims: An Analysis through the Lens of Critical Race Theory"

Objective: Burn injuries are associated as well as complicated by alcohol misuse. Medical social workers will likely first encounter burn patients in the emergency department or direct admission to a burn centre. This study investigated if there were associations between race and decisions to test for alcohol upon burn admissions, controlling for demographics, burn severity, and other circumstances associated with burn injuries. We use critical race theory (CRT) to conceptualize the relationship between race/ethnicity and practitioner decision-making. Knowledge of pre-morbid alcohol consumption is important when treating burn patients due to the increased risk of mortality, morbidity, medical and psychiatric complications, and poor outcomes that are known to be associated with alcohol misuse. Yet, there has been little research on how admitting providers determine which burn trauma patients to test for alcohol intoxication on admission.

Methodology: This study was a longitudinal secondary analysis of 32,258 cases from the National Burn Data Repository from 2008 to 2017. The dependent variable was whether a burn victim was screened for alcohol use, and independent variables were age, gender, whether physical abuse was reported, mental health comorbidities, marital status, the severity of burns, whether the injury was work-related, injury circumstances, and etiology of injury. Race and ethnicity were independent variables of focus. used. There were 45,917 White, 16,129 Black, 1,923 Asian, 665 Indigenous, 188 Hawaiian /Pacific Islander, and 6,822 “other” race burn victims. The focus of the current study was on Black and White burn victims. In order to avoid possible issues with large differences in sample size between Black and White victims, a random sample of 16,129 White victims were selected, so the study sample included 16,129 Black and 16,129 White burn victims, for a total of 32,258 burn victims. Missing data were handled with full information maximum likelihood. Binary logistic regression was used to test for the relationship between race and selection for alcohol testing, controlling for other independent variables.

Results: The overall Chi-square for the logistic regression model based on robust maximum likelihood estimation was, χ 2 (50) = 3126.5, p < .00001. The estimated overall R-square was .18 (SE = .005, z = 32.5, p < .001, 95% CI: .168, .188). The test of all interaction terms was χ 2 (24) = 120.5, p < .0001. These results imply that determinations of who will be screened for alcohol use during admission depend on race. While this does not indicate any forms of implicit or explicit race bias, it does suggest that implicit and/or explicit race bias may be a factor is these determinations.

Conclusion and Implications: Using Critical Race Theory as a framework, our study results suggest racial bias may have influenced decisions to screen for alcohol misuse in reported burn cases. Social workers are uniquely qualified advocates for social justice and equitable medical care. Given the social justice orientation of the profession, medical social workers can be integral in the process of supporting more equitable and just protocols for alcohol screening upon burn centre admission.