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Safety concerns for rescue providers using sternal intraosseous infusion systems.

nearly linear. We therefore believe that our risk adjustment was at least as reliable as those of other studies in this arena. Dr. Zafar is concerned that we chose not to use weights provided by the NIS in our analysis. As we explained in our article, we made this decision because we were forced to exclude from our analysis the four states that chose not to report race to the NIS, an exclusion that invalidated the weights provided by the NIS. We, too, were concerned about performing an unweighted analysis, but as we mentioned in our article, including the weights changed our results minimally. Dr. Zafar disputes our claim to be ‘‘the first population-based national study with comprehensive risk adjustment to examine the association between race and mortality in injured patients’’ using the NIS, citing an article by Hicks et al. We agree that the article by Hicks et al. preceded ours (and cited the article by Hicks et al. in our article), but we believe our risk adjustment was more comprehensive because we included shock as a covariate and excluded insurance coverage. Interestingly, Hicks et al. found that black patients older than 64 years had a lower risk of mortality than did white patients, a finding that our study confirmed and that puzzles both Hicks’ group and ours. Dr. Zafar disputes our claim that ‘‘studies examining black-white disparities in trauma mortality are nearly all based on the NTDB,’’ citing the meta-analysis of this topic conducted by Haider et al. We relied heavily on the excellent article of Haider et al. in our review of the race/insurance/trauma literature. While it is true that the meta-analysis of Haider et al. considers a total of 35 studies, only 7 are deemed adequate to be included in a meta-analysis of black-white disparities (all of which we cited in our article), 4 of which were conducted using the NTDB. Thus, we agree that we overstated our point in the introduction to our article. A more felicitous phrasing would have been ‘‘most of these studies were based on the NTDB.’’ As it happens, this is actually the phrasing that we use in the Discussion section of our article. We apologize for the hyperbole of our introduction. Overall, Dr. Zafar’s concern about our use of the NIS suggests that he believes we would have reached a different conclusion about the importance of race had we used the NTDB as our research data set instead of the NIS. However, as we noted in our manuscript, using a model similar to ours that carefully controlled for mechanism of injury and shock, Millham and Jain found, as we did, that race is not associated with survival in the NTDB. Thus, we believe that our finding that black race is not associated with higher mortality rates is the result of carefully modeling injury mechanism and shock and should not be attributed to the choice of the research data set used in our analysis. That ‘‘the devil is in the details’’ is as true of statistical modeling as any other enterprise, and unfortunately, there are many more incorrect ways than correct ways to conduct any analysis (e.g., in our work, the importance of excluding insurance coverage from our final model was not initially apparent). We believe that by carefully modeling two critically important predictors (mechanism of injury and shock), Millham and Jain and our group have independently refuted using two different data sets the long-standing narrative that our system of trauma care discriminates against the black race by providing inferior care to this group, which has been claimed to result in unnecessary deaths of black patients. We have tried hard to get this analysis right, but we would encourage other researchers to examine the effect of race on survival in the NTDB for themselves. We believe our results in the NIS will be replicated by others in the NTDB; we would be happy to assist any researcher(s) interested in pursuing this question in any way we can.