Kristan Staudenmayer, MD, MS, FACS
Associate Professor of Surgery (General Surgery)
Surgery - General Surgery
Bio
Dr. Kristan Staudenmayer received her medical degree at the University of Texas at Southwestern Medical School in 1999, and completed her residency in General Surgery at Parkland Hospital in 2006. During her post-graduate training, she conducted NIH T32-funded research at Harborview Hospital evaluating the effects of innate immunity on trauma. She obtained further training in Trauma and Surgical Critical at San Francisco General Hospital, completing her training in 2008. She was subsequently double-boarded in General Surgery and Surgical Critical Care. Dr. Staudenmayer joined Stanford in 2008. She has developed a robust research program and active clinical practice. Her clinical and research interests have contributed to Stanford’s multi-disciplinary approach to the management of surgical trauma. Dr. Staudenmayer’s clinical focus is on trauma, emergency general surgery, and surgical critical care, and her research interests encompass trauma systems of care and vulnerable patient populations such as the elderly. Her efforts have been noteworthy and recognized in her 2013 K08 grant from the National Institute on Aging to study trauma in the elderly population. In 2016, Dr. Staudenmayer was honored by becoming the inaugural Gordon and Betty Moore Endowed Faculty Scholar, which helps to support her ongoing research efforts. Additional research accomplishments include being a co-principal investigator on an NIH CTSA award evaluating trauma systems. Dr. Staudenmayer has published over 50 articles and book chapters and has served on the editorial review board of several academic journals. She contributes nationally towards the academic mission by serving on committees for both the American Association for the Surgery of Trauma and the Eastern Association for the Surgery of Trauma. Dr. Staudenmayer was promoted to Associate Professor of Surgery in 2016, and continues her research, policy and advocacy work to improve the care and outcomes for patients with traumatic injuries and critical surgical illnesses.
Clinical Focus
- Trauma
- Surgical Critical Care
Academic Appointments
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Associate Professor - University Medical Line, Surgery - General Surgery
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Member, Bio-X
Administrative Appointments
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Assistant Professor, Stanford University Medical Center (2010 - 2020)
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Instructor, Instructor Line, Department of Surgery, Stanford University Medical Center (2008 - 2010)
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Instructor and Clinical Fellow in Trauma Surgery, University of San Francisco (2007 - 2008)
Honors & Awards
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ACS Committee on Trauma, American College of Surgeons (2020)
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EAST/ACS Brandeis Health Policy Scholarship, Eastern Association for the Surgery of Trauma & American College of Surgeons (2019)
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Arthur L. Bloomfield Award in Recognition of Excellence in the Teaching of Clinical Medicine, Stanford University School of Medicine (2018)
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Marshall Memorial Fellow, Dallas World Affairs Council (2006)
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NIH T32 National Research Service Award Fellowship, Department of Surgery, University of Washington (2002-2004)
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Trauma Resident and Fellow Competition Winner, Region X American College of Surgeons Committee (2002)
Boards, Advisory Committees, Professional Organizations
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Chair, Surgical Sub-Council, Stanford Health Care (2017 - Present)
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Co-Chair, Healthcare Economics Committee, American Association for the Surgery of Trauma (2017 - Present)
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Unit Based Medical Director, Stanford Health Care (2016 - Present)
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Search Committee, Pediatric Surgery Division Chief, Stanford School of Medicine (2015 - 2015)
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Clinical Competency Committee, PGY2 Subcommittee, Stanford School of Medicine (2014 - Present)
Professional Education
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Board Certification: American Board of Preventive Medicine, Clinical Informatics (2022)
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Fellowship: UCSF Surgery Fellowships (2008) CA
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Residency: University of Texas Southwestern Medical Center (2006) TX
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Medical Education: University of Texas Southwestern Medical Center (1999) TX
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Master's Degree, Stanford University, Health Services Research (2010)
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Board Certification: American Board of Surgery, Surgical Critical Care (2007)
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Board Certification: American Board of Surgery, General Surgery (2006)
Current Research and Scholarly Interests
Defining the Impact of Injuries in the Elderly
2024-25 Courses
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Independent Studies (4)
- Directed Reading in Surgery
SURG 299 (Aut, Win, Spr, Sum) - Graduate Research
SURG 399 (Aut, Win, Spr, Sum) - Medical Scholars Research
SURG 370 (Aut, Win, Spr, Sum) - Undergraduate Research
SURG 199 (Aut, Win, Spr, Sum)
- Directed Reading in Surgery
All Publications
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Trauma care and its financing around the world.
The journal of trauma and acute care surgery
2024
Abstract
ABSTRACT: Worldwide, one billion people sustain trauma, and 5 million people will die every year from their injuries. Countries must build trauma systems to effectively address this high-burden disease, but efforts are often challenged by financial constraints. Understanding mechanisms for trauma funding internationally can help to identify opportunities to address the burden of injuries. Trauma leaders from around the world contributed summaries around how trauma is managed across their respective continents. These were aggregated to create a comparison of worldwide trauma systems of care. The burden of injuries is high across the world's inhabited continents, but trauma systems remain underfunded worldwide and, as a result, are overall underdeveloped and do not rise to the levels required given the burden of disease. Some countries in Africa and Asia have invested in financing mechanisms such as road accident funds or trauma-specific funding. In Latin America, active surgeon involvement in accident prevention advocacy has made meaningful impact. All continents show progress in trauma system maturation. This article describes how different regions of the world organize and commit to trauma care financially. Overall, while trauma tends to be underfunded, there is evidence of change in many regions and good examples of what can happen when a country invests in building trauma systems.LEVEL OF EVIDENCE: Expert Opinions; Level VII.
View details for DOI 10.1097/TA.0000000000004448
View details for PubMedID 39330943
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Emergency General Surgery Process Improvement Review
CURRENT SURGERY REPORTS
2024
View details for DOI 10.1007/s40137-024-00423-x
View details for Web of Science ID 001275421000001
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The importance and benefits of defining full-time equivalence in the field of acute care surgery.
Trauma surgery & acute care open
2024; 9 (1): e001307
Abstract
Acute care surgery (ACS) encompasses five major pillars - trauma, surgical critical care, emergency general surgery, elective general surgery and surgical rescue. The specialty continues to evolve and due to high-acuity, high-volume and around-the-clock care, the workload can be significant leading to workforce challenges such as rightsizing of staff, work-life imbalance, surgeon burnout and more. To address these challenges and ensure a stable workforce, ACS as a specialty must be deliberate and thoughtful about how it manages workload and workforce going forward. In this article, we address the importance, benefits and challenges of defining full-time equivalence for ACS as a method to establish a stable ACS workforce for the future.
View details for DOI 10.1136/tsaco-2023-001307
View details for PubMedID 38974220
View details for PubMedCentralID PMC11227842
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The burden of readmissions after rib fractures among older adults.
Surgery
2024
Abstract
The index hospitalization morbidity and mortality of rib fractures among older adults (aged ≥65 years) is well-known, yet the burden and risks for readmissions after rib fractures in this vulnerable population remain understudied. We aimed to characterize the burdens and etiologies associated with 3-month readmissions among older adults who suffer rib fractures. We hypothesized that readmissions would be common and associated with modifiable etiologies.This survey-weighted retrospective study using the 2017 and 2019 National Readmissions Database evaluated adults aged ≥65 years hospitalized with multiple rib fractures and without major extrathoracic injuries. The main outcome was the proportion of patients experiencing all-cause 3-month readmissions. We assessed the 5 leading principal readmission diagnoses overall and delineated them by index hospitalization discharge disposition (home or facility). Sensitivity analysis using clinical classification categories characterized readmissions that could reasonably represent rib fracture-related sequelae.In 2017, 25,092 patients met the inclusion criteria, with 20% (N = 4,894) experiencing 3-month readmissions. Six percent of patients did not survive their readmission. The 5 leading principal readmission diagnoses were sepsis (many associated with secondary diagnoses of pneumonia [41%] or urinary tract infections [41%]), hypertensive heart/kidney disease, hemothorax, pneumonia, and respiratory failure. In 2019, a comparable 3-month readmission rate of 23% and identical 5 leading diagnoses were found. Principal readmission diagnosis of hemothorax was associated with the shortest time to readmission (median [interquartile range]:9 [5-23] days). Among patients discharged home after index hospitalization, pleural effusion-possibly representing mischaracterized hemothorax-was among the leading principal readmission diagnoses. Some patients readmitted with a principal diagnosis of hemothorax or pleural effusion had these diagnoses at index hospitalization; a lower proportion of these patients underwent pleural fluid intervention during index hospitalization compared with readmission. On sensitivity analysis, 30% of 3-month readmissions were associated with principal diagnoses suggesting rib fracture-related sequelae.Readmissions are not infrequent among older adults who suffer rib fractures, even in the absence of major extrathoracic injuries. Future studies should better characterize how specific complications associated with readmissions, such as pneumonia, urinary tract infections, and delayed hemothoraces, could be mitigated.
View details for DOI 10.1016/j.surg.2024.05.021
View details for PubMedID 38880698
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Craniofacial Assault Against Women: A National Evaluation Defining At-risk Populations and Outcomes.
The Journal of craniofacial surgery
2024
Abstract
Few studies have analyzed epidemiologic factor associated with female patients presenting to the emergency department from facial fractures because of assault. Clearly understanding these factors may assist in developing effective strategies to decrease the incidence and sequelae of these injuries.To determine the epidemiology of facial fractures because of assault in the female population.All female facial fracture visits were queried in the 2019 Nationwide Emergency Department (ED) Sample database. The likelihood of a facial fracture encounter resulting from assault was modeled using logistic regression adjusting for demographics, insurance status, geographic region, location of patient residence, and income. Secondary outcomes analyzed hospitalization costs and adverse events.Of all facial fractures 12.4% of female encounters were due to assault were due to assault. Of assaulted females, 72.8% were between the ages of 20 and 40, and Black women experienced a disproportionate share of assault encounters (odds ratio [OR]=2.55; CI, 2.29-2.84). A large portion (46.4%) of encounters occurred in patients living in the lowest quartile of median household income, and 22.8% of patients were uninsured (OR=1.34; CI, 1.09-1.66). Assaulted patients were more likely to have fractures in nasal bone (58.1% vs. 42.5%), orbit (16.8% vs. 10.9%), zygoma (4.1% vs 3.6%), and mandible (8.7% vs. 4.8%) compared with their nonassaulted counterparts.Facial fractures were especially common in lower income, uninsured, urban, and Black populations. Examining the patterns of injury and presentation are critical to improve prevention strategies and screening tools, identifying critical patients, and develop a more efficient and effective system to treat and support female patients suffering facial fractures secondary to assault.
View details for DOI 10.1097/SCS.0000000000010234
View details for PubMedID 38785427
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Value in Acute Care Surgery, Part 3: Defining Value in Acute Surgical Care - It Depends on the Perspective.
The journal of trauma and acute care surgery
2024
Abstract
The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the healthcare system - the patient, the healthcare organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints.
View details for DOI 10.1097/TA.0000000000004347
View details for PubMedID 38706096
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Financial Toxicity Part II: A Practical Guide to Measuring and Tracking Long-Term Financial Outcomes Among Acute Care Surgery.
The journal of trauma and acute care surgery
2024
Abstract
Acute care surgery (ACS) patients are frequently faced with significant long-term recovery and financial implications that extend far beyond their hospitalization. While major injury and emergency general surgery (EGS) emergencies are often viewed solely as acute moments of crisis, the impact on patients can be lifelong. Financial outcomes after major injury or emergency surgery have only begun to be understood. The Healthcare Economics Committee from the American Association for the Surgery of Trauma (AAST) previously published a conceptual overview of financial toxicity in acute care surgery, highlighting the association between financial outcomes and long-term physical recovery. The aims of second phase financial toxicity review by the Healthcare Economics Committee of the AAST are to (i) understand the unique impact of financial toxicity on acute care surgery patients; (ii) delineate the current limitations surrounding measurement domains of financial toxicity in ACS; (iii) explore the "when, what and how" of optimally capturing financial outcomes in ACS; and (iv) delineate next steps for integration of these financial metrics in our long-term patient outcomes. As acute care surgeons, our patients' recovery is often contingent on equal parts physical, emotional and financial recovery. The ACS community has an opportunity to impact long-term patient outcomes and well-being far beyond clinical recovery.
View details for DOI 10.1097/TA.0000000000004310
View details for PubMedID 38439149
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Angioembolization for splenic injuries: does it help? Retrospective evaluation of grade III–V splenic injuries at two level I trauma centers
Trauma & Acute Care Open
2024; 9
View details for DOI 10.1136/tsaco-2023-001240
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Population need versus trauma center financial sustainability: striking the right balance.
Trauma surgery & acute care open
2024; 9 (1): e001540
View details for DOI 10.1136/tsaco-2024-001540
View details for PubMedID 39252755
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The Interaction Between Geriatric & Neighborhood Vulnerability: Delineating Pre-Hospital Risk Among Older Adult Emergency General Surgery Patients.
The journal of trauma and acute care surgery
2023
Abstract
BACKGROUND: When presenting for EGS care, older adults frequently experience increased risk of adverse outcomes owing to factors related to age ('geriatric vulnerability') and the social determinants of health unique to the places in which they live ('neighborhood vulnerability'). Little is known about how such factors collectively influence adverse outcomes. We sought to explore how the interaction between geriatric and neighborhood vulnerability influences EGS outcomes among older adults.METHODS: Older adults, ≥65 years, hospitalized with an AAST-defined EGS condition were identified in the 2016-2019, 2021 Florida State Inpatient Database. Latent variable models combined the influence of patient age, multimorbidity, and Hospital Frailty Risk Score into a single metric of "geriatric vulnerability." Variations in geriatric vulnerability were then compared across differences in "neighborhood vulnerability" as measured by variations in Area Deprivation Index, Social Vulnerability Index, and their corresponding subthemes (e.g. access to transportation).RESULTS: A total of 448,968 older adults were included. For patients living in the least vulnerable neighborhoods, increasing geriatric vulnerability resulted in up to six-times greater risk of death (30-day risk-adjusted HR[95%CI]: 6.32[4.49-8.89]). The effect was more than doubled among patients living in the most vulnerable neighborhoods, where increasing geriatric vulnerability resulted in up to fifteen-times greater risk of death (30-day risk-adjusted HR[95%CI]: 15.12[12.57-18.19]). When restricted to racial/ethnic minority patients, the multiplicative effect was four-times as high, resulting in corresponding 30-day hazard ratios for mortality of 11.53(4.51-29.44) versus 40.67(22.73-72.78). Similar patterns were seen for death within 365 days.CONCLUSION: Both geriatric and neighborhood vulnerability have been shown to affect pre-hospital risk among older patients. The results of this study build on that work, presenting the first in-depth look at the powerful multiplicative interaction between these two factors. The results show that where a patient resides can fundamentally alter expected outcomes for EGS care such that otherwise less vulnerable patients become functionally equivalent to those who are, at baseline, more aged, more frail, and more sick.LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.
View details for DOI 10.1097/TA.0000000000004191
View details for PubMedID 37962136
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The Interaction Between Geriatric and Neighborhood Vulnerability: Delineating Pre-Hospital Risk among Older Trauma Patients
LIPPINCOTT WILLIAMS & WILKINS. 2023: S264-S265
View details for Web of Science ID 001094086300556
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Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality.
JAMA surgery
2023: e234856
Abstract
Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used.To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors.This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022.Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI.Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression.A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05).The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.
View details for DOI 10.1001/jamasurg.2023.4856
View details for PubMedID 37792354
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Financial Toxicity after Trauma & Acute Care Surgery: From Understanding to Action.
The journal of trauma and acute care surgery
2023
Abstract
Gains in inpatient survival over the last five decades have shifted the burden of major injuries and surgical emergencies from the acute phase to their long-term sequalae. More attention has been placed on evaluation and optimization of long-term physical and mental health; however, the impact of major injuries and surgical emergencies on long-term financial wellbeing remains a critical blind spot for clinicians and researchers. The concept of financial toxicity encompasses both the objective financial consequences of illness and medical care as well as patients' subjective financial concerns. In this review, representatives of the Healthcare Economics Committee from the American Association for the Surgery of Trauma (i) provide a conceptual overview of financial toxicity after trauma or emergency surgery, (ii) outline what is known regarding long-term economic outcomes among trauma and emergency surgery patients, (iii) explore the bidirectional relationship between financial toxicity and long-term physical and mental health outcomes, (iv) highlight policies and programs that may mitigate financial toxicity, and (v) identify the current knowledge gaps and critical next steps for clinicians and researchers engaged in this work.
View details for DOI 10.1097/TA.0000000000003979
View details for PubMedID 37125781
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Contemporary Management and Outcomes of Penetrating Colon Injuries: Validation of the 2020 AAST Colon Organ Injury Scale: Validation of 2020 AAST Colon Organ Injury Scale.
The journal of trauma and acute care surgery
2023
Abstract
This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and AIS < 3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with chi-square, ANOVA, and Kruskal Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion.We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade-V destructive injury, 19% required ≥6 units of transfusion, 24% had an ISS > 15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra- and extra-abdominal infections. Pre-operative imaging in 152 (27%) cases had a low correlation with operative findings (Kappa coefficient 0.13).This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative AAST OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice.III.
View details for DOI 10.1097/TA.0000000000003969
View details for PubMedID 37072893
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Developing a National Trauma Research Action Plan: Results from the trauma systems and informatics panel Delphi survey.
The journal of trauma and acute care surgery
2023; 94 (4): 584-591
Abstract
The National Academies of Sciences, Engineering, and Medicine 2016 report on the trauma care system recommended establishing a National Trauma Research Action Plan to strengthen and guide future trauma research. To address this recommendation, the Department of Defense funded a study to generate a comprehensive research agenda spanning the trauma and burn care continuum. Panels were created to conduct a gap analysis and identify high-priority research questions. The National Trauma Research Action Plan panel reported here addressed trauma systems and informatics.Experts were recruited to identify current gaps in trauma systems research, generate research questions, and establish the priorities using an iterative Delphi survey approach from November 2019 through August 2020. Panelists were identified to ensure heterogeneity and generalizability, including military and civilian representation. Panelists were encouraged to use a PICO format to generate research questions: patient/population, intervention, compare/control, and outcome. In subsequent surveys, panelists prioritized each research question on a 9-point Likert scale, categorized as low-, medium-, and high-priority items. Consensus was defined as ≥60% agreement.Twenty-seven subject matter experts generated 570 research questions, of which 427 (75%) achieved the consensus threshold. Of the consensus reaching questions, 209 (49%) were rated high priority, 213 (50%) medium priority, and 5 (1%) low priority. Gaps in understanding the broad array of interventions were identified, including those related to health care infrastructure, technology products, education/training, resuscitation, and operative intervention. The prehospital phase of care was highlighted as an area needing focused research.This Delphi gap analysis of trauma systems and informatics research identified high-priority research questions that will help guide investigators and funding agencies in setting research priorities to continue to work toward Zero Preventable Deaths after trauma.Therapeutic/Care Management; Level IV.
View details for DOI 10.1097/TA.0000000000003867
View details for PubMedID 36623269
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"Next Gen" Operative Notes - Synoptic Operative Reporting for Cancer Surgery
SPRINGER. 2023: S77-S78
View details for Web of Science ID 001046841200160
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Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development.
Trauma surgery & acute care open
2023; 8 (1): e001049
Abstract
Across disciplines, mentorship has been recognized as a key to success. Acute care surgeons, focused on the care of trauma surgery, emergency general surgery and surgical critical care, practice in a wide variety of settings and have unique mentorship needs across all phases of their career. Recognizing the need for robust mentorship and professional development, the American Association for the Surgery of Trauma (AAST) convened an expert panel entitled 'The Power of Mentorship' at the 81st annual meeting in September 2022 (Chicago, Illinois). This was a collaboration between the AAST Associate Member Council (consisting of surgical resident, fellow and junior faculty members), the AAST Military Liaison Committee, and the AAST Healthcare Economics Committee. Led by two moderators, the panel consisted of five real-life mentor-mentee pairs. They addressed the following realms of mentorship: clinical, research, executive leadership and career development, mentorship through professional societies, and mentorship for military-trained surgeons. Recommendations, as well as pearls and pitfalls, are summarized below.
View details for DOI 10.1136/tsaco-2022-001049
View details for PubMedID 36866105
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Non-Surgical Management and Analgesia Strategies for Older Adults with Multiple Rib Fractures: a Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.
The journal of trauma and acute care surgery
2022
Abstract
BACKGROUND: Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry, noninvasive positive pressure ventilation, and the use of ketamine, epidural and other locoregional approaches to analgesia.METHODS: Relevant questions regarding older patients with significant chest wall injury with patient Population(s), Intervention(s), Comparison(s), and appropriate selected Outcomes (PICO) were chosen. These focused on ICU admission, incentive spirometry, noninvasive positive pressure ventilation, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review was conducted, and our data were analyzed qualitatively and quantitatively and the quality of evidence assessed per the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. No funding was utilized.RESULTS: Our literature review (PROSPERO 2020-CRD42020201241,MEDLINE,EMBASE, Cochrane,Web of Science,1/15/2020) resulted in 151 studies. ICU admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor incentive spirometry performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia (p < 0.0001) and 81% reduction in odds of mortality (p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay or mortality.CONCLUSION: We do not recommend for or against routine ICU admission. We recommend use of incentive spirometry to inform ICU status and conditionally recommend use of noninvasive positive pressure ventilation in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural or other locoregional analgesia.LEVEL OF EVIDENCE: Guideline; systematic review/meta-analysis, level IV.
View details for DOI 10.1097/TA.0000000000003830
View details for PubMedID 36730672
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Reconceptualizing High-Quality Emergency General Surgery Care: Non-Mortality-Based Quality-Metrics Enable Meaningful and Consistent Assessment.
The journal of trauma and acute care surgery
2022
Abstract
BACKGROUND: Ongoing efforts to promote quality-improvement in emergency general surgery (EGS) have made substantial strides but lack clear definitions of what constitutes "high-quality" EGS care. To address this concern, we developed a novel set of five non-mortality-based quality-metrics broadly applicable to the care of all EGS patients and sought to discern whether: (1) they can be used to identify groups of best-performing EGS hospitals, (2) results are similar for simple versus complex EGS severity in both adult (18-64 years) and older adult (≥65 years) populations, and (3) best performance is associated with differences in hospital-level factors.METHODS: Patients hospitalized with 1-of-16 AAST-defined EGS conditions were identified in the 2019 Nationwide Readmissions Database. They were stratified by age/severity into four cohorts: simple adults, complex adults, simple older adults, complex older adults. Within each cohort, risk-adjusted hierarchical models were used to calculate condition-specific risk-standardized quality-metrics. K-means cluster analysis identified hospitals with similar performance, and multinomial regression identified predictors of resultant "best/average/worst" EGS care.RESULTS: 1,130,496 admissions from 984 hospitals were included (40.6% simple adults, 13.5% complex adults, 39.5% simple older adults, 6.4% complex older adults). Within each cohort, K-means cluster analysis identified three groups ("best/average/worst"). Cluster assignment was highly conserved with 95.3% of hospitals assigned to the same cluster in each cohort. It was associated with consistently best/average/worst performance across differences in outcomes (5x) and EGS conditions (16x). When examined for associations with hospital-level factors, best-performing hospitals were those with the largest EGS volume, greatest extent of patient frailty, and most complicated underlying patient case-mix.CONCLUSION: Use of non-mortality-based quality-metrics appears to offer a needed, promising means of evaluating high-quality EGS care. The results underscore the importance of accounting for outcomes applicable to all EGS patients when designing quality-improvement initiatives and suggest that, given the consistency of best-performing hospitals, natural EGS centers-of-excellence could exist.LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level III.
View details for DOI 10.1097/TA.0000000000003818
View details for PubMedID 36245079
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Implementation of a Geriatric Trauma Clinical Pathway-Reply.
JAMA surgery
2022
View details for DOI 10.1001/jamasurg.2022.4823
View details for PubMedID 36197679
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Comment for article "Predictors of Hospital Bypass for Rural Residents Seeking Common Elective Surgery": Surgical bypass: A problem or a symptom?
Surgery
2022
View details for DOI 10.1016/j.surg.2022.08.023
View details for PubMedID 36163087
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Value in acute care surgery, part 2: Defining and measuring quality outcomes.
The journal of trauma and acute care surgery
2022; 93 (1): e30-e39
Abstract
The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.
View details for DOI 10.1097/TA.0000000000003638
View details for PubMedID 35393377
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Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury.
JAMA surgery
2022
Abstract
Importance: Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored.Objective: To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury.Design, Setting, and Participants: A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation.Intervention: The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team.Main Outcomes and Measures: The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed.Results: Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P=.43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P=.87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P<.001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P<.001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P=.03).Conclusions and Relevance: In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.
View details for DOI 10.1001/jamasurg.2022.1556
View details for PubMedID 35675065
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Falls in Older Adults Requiring Emergency Services: Mortality, Use of Healthcare Resources, and Prognostication to One Year.
The western journal of emergency medicine
2022; 23 (3): 375-385
Abstract
INTRODUCTION: Older adults who fall commonly require emergency services, but research on long-term outcomes and prognostication is sparse. We evaluated older adults transported by ambulance after a fall in the Northwestern United States (US) and longitudinally tracked subsequent healthcare use, transitions to skilled nursing, hospice, mortality, and prognostication to one year.METHODS: This was a planned secondary analysis of a cohort study of community-dwelling older adults enrolled from January 1-December 31, 2011, with follow-up through December 31, 2012. We included all adults ≥ 65 years transported by 44 emergency medical services agencies in seven Northwest counties to 51 hospitals after a fall. We matched Medicare claims, state inpatient data, state trauma registry data, and death records. Outcomes included mortality, healthcare use, and new claims for skilled nursing and hospice to one year.RESULTS: There were 3,159 older adults, with 147 (4.7%) deaths within 30 days and 665 (21.1%) deaths within one year. There was an initial spike in inpatient days, followed by increases in skilled nursing and hospice. We identified four predictors of mortality: respiratory diagnosis; serious brain injury; baseline disability; and Charlson Comorbidity Index ≥ 2. Having any of these predictors was 96.6% sensitive (95% confidence interval [CI]: 95.7, 97.5%) and 21.4% specific (95% CI: 19.9, 22.9%) for 30-day mortality, and 91.6% sensitive (95% CI: 89.5, 93.8%). and 23.8% specific (95% CI: 22.1, 25.5%) for one-year mortality.CONCLUSION: Community-dwelling older adults requiring ambulance transport after a fall have marked increases in healthcare use, institutionalized living, and mortality over the subsequent year. Most deaths occur following the acute care period and can be identified with high sensitivity at the time of the index visit, yet with low specificity.
View details for DOI 10.5811/westjem.2021.11.54327
View details for PubMedID 35679504
- Data Resources for Evaluating the Economic and Financial Consequences of Surgical Care in the United States. The journal of trauma and acute care surgery 2022
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Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues.
Journal of the American College of Surgeons
2022; 234 (2): 214-225
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
View details for DOI 10.1097/XCS.0000000000000044
View details for PubMedID 35213443
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Developing a National Trauma Research Action Plan (NTRAP): Results from the Prehospital & Mass Casualty Research Delphi Survey.
The journal of trauma and acute care surgery
2021
Abstract
BACKGROUND: The National Academies of Sciences, Engineering, and Medicine 2016 trauma system report recommended a National Trauma Research Action Plan (NTRAP) to strengthen and guide future trauma research. To address this recommendation, 11 expert panels completed a Delphi survey process to create a comprehensive research agenda, spanning the continuum of trauma care. We describe the gap analysis and high priority research questions generated from the NTRAP panel on prehospital and mass casualty trauma care.METHODS: We recruited interdisciplinary national experts to identify gaps in the prehospital and mass casualty trauma evidence base and generate prioritized research questions using a consensus-driven Delphi survey approach. We included military and civilian representatives. Panelists were encouraged to use the PICO (Patient/Population, Intervention, Compare/Control, and Outcome) format to generate research questions. We conducted four Delphi rounds in which participants generated key research questions and then prioritized the questions on a 9-point Likert scale to low, medium, and high priority items. We defined consensus as ≥60% agreement on the priority category and coded research questions using a taxonomy of 118 research concepts in 9 categories.RESULTS: 31 interdisciplinary subject matter experts generated 490 research questions, of which 433 (88%) reached consensus on priority. The rankings of the 433 questions were: 81 (19%) high priority, 339 (78%) medium priority, and 13 (3%) low priority. Among the 81 high priority questions, there were 46 taxonomy concepts, including: health systems of care (36 questions), interventional clinical trials and comparative effectiveness (32 questions), mortality as an outcome (30 questions); prehospital time/transport mode/level of responder (24 questions), system benchmarks (17 questions), and fluid/blood product resuscitation (17 questions).Conclusions This Delphi gap analysis of prehospital and mass casualty care identified 81 high priority research questions to guide investigators and funding agencies for future trauma research.LEVEL OF EVIDENCE: not applicable.
View details for DOI 10.1097/TA.0000000000003469
View details for PubMedID 34789701
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Outcome-specific Injury Scores (OSIS): Development and Validation of Tailored Prediction Tools for Injured Older Adults
ELSEVIER SCIENCE INC. 2021: E74
View details for Web of Science ID 000718306700179
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MOTIVATIONS AND BARRIERS TOWARD IMPLEMENTATION OF A RECTAL CANCER SYNOPTIC OPERATIVE REPORT: A PROCESS EVALUATION.
Diseases of the colon and rectum
2021
Abstract
BACKGROUND: Use of synoptic reporting has been shown to improve documentation of critical information and provide added value related to data access and extraction, data reliability, relevant detail, and completeness of information. Surgeon acceptance and adoption of synoptic reports has lagged behind other specialties.OBJECTIVE: To evaluate the process of implementing a synoptic operative report.DESIGN: Mixed methods process evaluation including surveys and qualitative interviews.SETTINGS: Colorectal Surgery practices across the United States.PATIENTS: Twenty-eight board-certified colorectal surgeons.INTERVENTIONS: Implementation of the synoptic operative report for rectal cancer.MAIN OUTCOME MEASURES: Acceptability, feasibility, and usability measured by Likert-type survey questions and followed up with individual interviews to elicit experiences with implementation as well as motivations and barriers to use.RESULTS: Among all study participants, 28 surgeons completed the electronic survey (76% response rate) and 21 (57%) completed the telephone interview. Mean usability was 4.14 (range=1-5, standard error (SE)=0.15), mean feasibility was 3.90 (SE=0.15), and acceptability was 3.98 (SE=0.18). Participants indicated substantial administrative and technical support were necessary but not always available for implementation and many were frustrated by the need to change their workflow.LIMITATIONS: Most surgeon participants were male, white, had >12 years in practice, and used Epic electronic medical record systems. Therefore, they may not represent the perspectives of all U.S. colon and rectal surgeons. Additionally, as the synoptic operative report is implemented more broadly across the U.S., it will be important to consider variations in the process by EMR system.CONCLUSIONS: The synoptic operative report for rectal cancer was generally easy to implement and incorporate into workflow but surgeons remained concerned about additional burden without immediate and tangible value. In spite of recognizing benefits, many participants indicated they only implemented the synoptic operative report because it was mandated by the National Accreditation Program for Rectal Cancer. See Video Abstract at http://links.lww.com/DCR/B735.
View details for DOI 10.1097/DCR.0000000000002202
View details for PubMedID 34711713
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Value in Acute Care Surgery, Part 1: Methods of Quantifying Cost.
The journal of trauma and acute care surgery
2021
Abstract
ABSTRACT: With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.Study TypeRegular Review.
View details for DOI 10.1097/TA.0000000000003419
View details for PubMedID 34570063
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General surgeon involvement in the care of patients designated with an American Association for the Surgery of Trauma-endorsed ICD-10-CM emergency general surgery diagnosis code in Wisconsin.
The journal of trauma and acute care surgery
2021
Abstract
BACKGROUND: The current national burden of emergency general surgery (EGS) illnesses and the extent of surgeon involvement in the care of these patients remain largely unknown. To inform needs assessments, research, and education, we sought to: (1) translate previously developed International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes representing EGS conditions to ICD-10-CM codes and (2) determine the national burden of and assess surgeon involvement across EGS conditions.METHODS: We converted ICD-9-CM codes to candidate ICD-10-CM codes using General Equivalence Mappings then iteratively refined the code list. We used National Inpatient Sample 2016-2017 data to develop a national estimate of the burden of EGS disease. To evaluate surgeon involvement, using Wisconsin Hospital Association (WHA) discharge data (1/1/16-6/30/18), we selected adult urgent/emergent encounters with an EGS condition as the principal diagnosis. Surgeon involvement was defined as a surgeon being either the attending provider or procedural physician.RESULTS: 485 ICD-9-CM codes mapped to 1,696 ICD-10-CM codes. The final list contained 985 ICD-10-CM codes. Nationally, there were 2,977,843 adult patient encounters with an ICD-10-CM EGS diagnosis. Of 94,903 EGS patients in the WHA dataset, most encounters were inpatient as compared to observation (75,878 [80.0%] vs 19,025 [20.0%]). 57,780 patients (60.9%) underwent any procedure. Among all Wisconsin EGS patients, most had no surgeon involvement (64.9% [n = 61,616]). Of the seven most common EGS diagnoses, surgeon involvement was highest for appendicitis (96.0%) and biliary tract disease (77.1%). For the other five most common conditions (skin/soft tissue infections, gastrointestinal hemorrhage, intestinal obstruction/ileus, pancreatitis, diverticular disease), surgeons were involved in roughly 20% of patient care episodes.CONCLUSION: Surgeon involvement for EGS conditions ranges from highly likely (appendicitis) to relatively unlikely (skin/soft tissue infections). The wide range in surgeon involvement underscores the importance of multidisciplinary collaboration in the care of EGS patients.LEVEL OF EVIDENCE: Prognostic/epidemiological, Level III.
View details for DOI 10.1097/TA.0000000000003387
View details for PubMedID 34446657
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Complication to consider: delayed traumatic hemothorax in older adults
Trauma Surgery Acute Care Open
2021
View details for DOI 10.1136/tsaco-2020-000626
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The Cost of a Fall Among Older Adults Requiring Emergency Services.
Journal of the American Geriatrics Society
2020
Abstract
BACKGROUND/OBJECTIVE: The cost of a fall among older adults requiring emergency services is unclear, especially beyond the acute care period. We evaluated medical expenditures (costs) to 1 year among community-dwelling older adults who fell and required ambulance transport, including acute versus post-acute periods, the primary drivers of cost, and comparison to baseline expenditures.DESIGN: Retrospective cohort analysis.SETTING: Forty-four emergency medical services agencies transporting to 51 emergency department in seven northwest counties from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012.PARTICIPANTS: We included 2,494 community-dwelling adults, 65years and older, transported by ambulance after a fall with continuous fee-for-service Medicare coverage.MEASUREMENTS: The primary outcome was total Medicare expenditures to 1year (2019U.S. dollars), with separation by acute versus post-acute periods and by cost category. We included 48 variables in a standardized risk-adjustment model to generate adjusted cost estimates.RESULTS: The median age was 83years, with 74% female, and 41.9% requiring admission during the index visit. The median total cost of a fall to 1 year was $26,143 (interquartile range (IQR) = $9,634-$68,086), including acute care median $1,957 (IQR = $1,298-$12,924) and post-acute median $20,560 (IQR = $5,673-$58,074). Baseline costs for the previous year were median $8,642 (IQR = $479-$10,948). Costs increased across all categories except outpatient, with the largest increase for inpatient costs (baseline median $0 vs postfall median $9,477). In multivariable analysis, the following were associated with higher costs: high baseline costs, older age, comorbidities, extremity fractures (lower extremity, pelvis, and humerus), noninjury diagnoses, and surgical interventions. Compared with baseline, costs increased for 74.6% of patients, with a median increase of $12,682 (IQR = -$185 to $51,189).CONCLUSION: Older adults who fall and require emergency services have increased healthcare expenditures compared with baseline, particularly during the post-acute period. Comorbidities, noninjury medical conditions, fracture type, and surgical interventions were independently associated with increased costs.
View details for DOI 10.1111/jgs.16863
View details for PubMedID 33047305
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Emergency General Surgery Quality Improvement Efforts for the Elderly: Are Needs Different from the Young?
ELSEVIER SCIENCE INC. 2020: E16
View details for Web of Science ID 000582798100031
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The Economic Footprint of Interventional Radiology in the United States: Implications for Systems Development.
Journal of the American College of Radiology : JACR
2020
Abstract
PURPOSE: Despite the growing presence of interventional radiology (IR) in inpatient care, its global impact on the health care system remains uncharacterized. The aim of this study was to quantitate the use of IR services rendered to hospitalized patients in the United States and the impact on cost.METHODS: The National Inpatient Sample 2016 was queried. Using the International Classification of Diseases, tenth rev, Clinical Modification/Procedure Classification System, adult inpatients who underwent routine IR procedures were identified. Unadjusted and adjusted analyses were performed. Weighted patient data are presented to provide national estimates.RESULTS: Of the 29.7 million inpatient admissions in 2016, 2.3 million (7.8%) had at least one IR procedure. Patients who needed IR were older (62.8 vs 57.1 years, P < .001), were sicker on the basis of the All Patient Refined Diagnosis Related Groups (27% major or extreme vs 14% for non-IR, P < .001), and had higher inpatient mortality (8.2% vs 1.7%, P < .001). While representing 7.8% of all admissions, this cohort accounted for 18.4% ($68.4 billion) of adult inpatient health care costs and about 3 times higher mean hospitalization cost compared with other inpatients ($29,402 vs $11,062, P < .001), which remained significant even after controlling for age and All Patient Refined Diagnosis Related Group.CONCLUSIONS: Approximately 1 in 10 US inpatients are treated with IR during their hospitalizations. These patients are sicker, with about 4 times higher mortality and 2.5 times greater length of stay, accounting for almost one-fifth of all health care costs. These findings suggest that IR should have a voice in discussions of means to save costs and improve patient outcomes in the United States.
View details for DOI 10.1016/j.jacr.2020.07.038
View details for PubMedID 32918863
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Benchmarking the Value of Care: Variability in Hospital Costs for Common Operations and Its Association with Procedure Volume.
The journal of trauma and acute care surgery
2020
Abstract
BACKGROUND: Efforts to improve healthcare value (quality/cost) have become a priority in the US. While many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the AAST Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and cholecystectomy (LC).METHODS: Nationally-weighted data for adults ≥18y was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 USD and corresponding annual procedure volumes. Cost variation was assessed using caterpillar-plots and risk-standardized observed/expected cost-ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume.RESULTS: In 2016, 1563 hospitals representing 86,170 LA and 2276 hospitals representing 230,120 LC met inclusion criteria. In 2014, the numbers were similar (1602, 2259 hospitals). Compared to a mean of $10,202, LA median costs ranged from $2,850 to $33,381. LC median costs ranged from $4,406 to $40,585 with a mean of $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2%, 5.0%) and patient (6.3%, 3.7%) characteristics and in-hospital complications (0.8%, 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings >$301.9 million/year (95%CI: $280.6 to $325.5 million).CONCLUSIONS: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in EGS and a need to address large discrepancies in an often-overlooked aspect of value.LEVEL OF EVIDENCE: Epidemiological, III.
View details for DOI 10.1097/TA.0000000000002611
View details for PubMedID 32039972
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Evaluating the Association between AAST Emergency General Surgery Anatomic Severity Grades and Clinical Outcomes Using National Claims Data.
The journal of trauma and acute care surgery
2020
Abstract
Emergency General Surgery (EGS) encompasses a heterogenous population of acutely ill patients, and standardized methods for determining disease severity are essential for comparative effectiveness research and quality improvement initiatives. The AAST has developed a grading system for the anatomic severity of 16 EGS conditions; however, little is known regarding how well these AAST EGS grades can be approximated by diagnosis codes in administrative databases.We identified adults admitted for 16 common EGS conditions in the 2012-2017q3 Nationwide Inpatient Sample. Disease severity strata were assigned using ICD-9-CM and ICD-10-CM diagnosis codes based on AAST EGS anatomic severity grades. We evaluated whether assigned EGS severity (multiple strata or dichotomized into less versus more complex) were associated with in-hospital mortality, complications, length of stay, discharge disposition, and costs. Analyses were adjusted for age, sex, comorbidities, hospital traits, geography, and year.We identified 10,886,822 EGS admissions. The number of anatomic severity strata derived from ICD-9/10-CM codes varied by EGS condition and by year. Four conditions mapped to four strata across all years. Two conditions mapped to four strata with ICD-9-CM codes, but only two or three strata with ICD-10-CM codes. Others mapped to three or fewer strata. When dichotomized into less versus more complex disease, patients with more complex disease had worse outcomes across all 16 conditions. The addition of multiple strata beyond a binary measure of complex disease, however, showed inconsistent results.Classification of common EGS conditions according to anatomic severity is feasible with ICD codes. No condition mapped to five distinct severity grades, and the relationship between increasing grade and outcomes was not consistent across conditions. However, a standardized measure of severity-even if just dichotomized into less versus more complex-can inform ongoing efforts aimed at optimizing outcomes for EGS patients across the nation.Level III.
View details for DOI 10.1097/TA.0000000000003030
View details for PubMedID 33214490
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Developing an Inpatient Relationship-Centered Communication Curriculum for Surgical Teams: Pilot Study
ELSEVIER SCIENCE INC. 2019: E48
View details for Web of Science ID 000492749600102
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Tuberculosis and the Acute Abdomen: An Evaluation of the National Inpatient Sample.
Surgical infections
2019
Abstract
Background: Tuberculosis can cause acute abdominal pathology requiring operation. While most cases of tuberculosis resolve with appropriate anti-mycobacterial therapy, a surgical procedure still may be required. We sought to describe the modern epidemiology of acute abdominal pathology associated with tuberculosis in the United States. Methods: We retrospectively analyzed the 2010-2014 National Inpatient Sample for admissions associated with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for both tuberculosis and acute abdominal pain. Cases of acute abdominal tuberculosis were defined as inpatient admissions with a diagnosis of tuberculosis and a diagnosis of acute abdominal pain. Outcomes of interest included need for abdominal operation and death after operation. Adjusted analyses accounting for survey methodology were performed. Results: There were 66,034 inpatient admissions associated with tuberculosis of which 3638 (6%) included a diagnosis of acute abdominal pain. Among cases, 1578 (43%) were 45-64 years old and 2344 (64%) were male. Most patients were Hispanic (n=1090, 30%) or black (n=924, 25%) and were in the lowest quartile of income by zip code (n=1367, 38%). A total of 347 (0.5% of total) patients underwent an operation. Procedures included peritoneal biopsy (n=136, 39%), repair or resection of a hollow viscus (n=122, 35%), and abdominal exploration (n=111, 32%). In adjusted analysis, undergoing a surgical procedure was found to depend on the type of tuberculosis infection (odds ratio [OR]=1.17 for intestinal, peritoneal, or genitourinary tuberculosis versus other types, 95% confidence interval [CI]=[1.12-1.22]) and whether the patient was white or Asian race versus black and Hispanic (OR=1.11, 95% CI [1.02-1.21]). Thirty-nine (11%) of the 347 patients who underwent a surgical procedure died during hospitalization. Conclusions: An operation still may be required for patients with tuberculosis presenting with acute abdominal pain. Black and Hispanic patients are less likely to receive surgical intervention than whites or Asians. The inhospital deaths from acute abdominal pain necessitating operation among patients with tuberculosis are high.
View details for DOI 10.1089/sur.2019.174
View details for PubMedID 31464571
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Firearm Legislation Stringency and Firearm-Related Fatalities among Children in the US
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2019; 229 (2): 150–57
View details for DOI 10.1016/j.jamcollsurg.2019.02.055
View details for Web of Science ID 000476888100003
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The current and future economic state of acute care surgery
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
2019; 87 (2): 413–19
View details for DOI 10.1097/TA.0000000000002334
View details for Web of Science ID 000478606400021
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Questioning the Higher Abscess Rate and Overall Cost of Care Associated With Nonoperative Management of Uncomplicated Acute Appendicitis Reply
JAMA SURGERY
2019; 154 (8): 784–85
View details for DOI 10.1001/jamasurg.2019.1162
View details for Web of Science ID 000484369400029
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Derivation and Validation of a Model to Predict 30-Day Readmission in Surgical Patients Discharged to Skilled Nursing Facility.
Journal of the American Medical Directors Association
2019
Abstract
OBJECTIVES: To identify factors associated with 30-day all-cause readmission rates in surgical patients discharged to skilled nursing facilities (SNFs), and derive and validate a risk score.DESIGN: Retrospective cohort.SETTING AND PARTICIPANTS: Patients admitted to 1 tertiary hospital's surgical services between January 1, 2011, and December 31, 2014 and subsequently discharged to 110 SNFs within a 25-mile radius of the hospital. The first 2years were used for the derivation set and the last 2 for validation.METHODS: Data were collected on 30-day all cause readmissions, patient demographics, procedure and surgical service, comorbidities, laboratory tests, and prior health care utilization. Multivariate regression was used to identify risk factors for readmission.RESULTS: During the study period, 2405 surgical patients were discharged to 110 SNFs, and 519 (21.6%) of these patients experienced readmission within 30days. In a multivariable regression model, hospital length of stay [odds ratio (OR) per day: 1.03, 95% confidence interval (CI) 1.02-1.04], number of hospitalizations in past year (OR 1.24 per hospitalization, 95% CI 1.18-1.31), nonelective surgery (OR 1.33, 95% CI 1.18-1.65), low-risk service (orthopedic/spine service) (OR 0.32, 95% CI 0.25-0.42), and intermediate-risk service (cardiothoracic surgery/urology/gynecology/ear, nose, throat) (OR 0.69, 95% CI 0.53-0.88) were associated with all-cause readmissions. The model had a C index of 0.71 in the validation set. Using the following risk score [0.8*(hospital length of stay)+7*(number of hospitalizations in past year)+10 for nonelective surgery,+36 for high-risk surgery, and+20 for intermediate-risk surgery], a score of >40 identified patients at high risk of 30-day readmission (35.8% vs 12.6%, P<.001).CONCLUSIONS/IMPLICATIONS: Among surgical patients discharged to an SNF, a simple risk score with 4 parameters can accurately predict the risk of 30-day readmission.
View details for DOI 10.1016/j.jamda.2019.04.016
View details for PubMedID 31176675
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BASE Jumping Injuries Presenting to Emergency Departments in the United States: an Assessment of Morbidity, Emergency Department, and Inpatient Costs
WILDERNESS & ENVIRONMENTAL MEDICINE
2019; 30 (2): 150–54
View details for DOI 10.1016/j.wem.2019.02.002
View details for Web of Science ID 000472986100007
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Questioning the Higher Abscess Rate and Overall Cost of Care Associated With Nonoperative Management of Uncomplicated Acute Appendicitis-Reply.
JAMA surgery
2019
View details for PubMedID 31090887
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The Current and Future Economic State of Acute Care Surgery.
The journal of trauma and acute care surgery
2019
View details for PubMedID 31033894
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BASE Jumping Injuries Presenting to Emergency Departments in the United States: an Assessment of Morbidity, Emergency Department, and Inpatient Costs.
Wilderness & environmental medicine
2019
Abstract
BACKGROUND: BASE (building, antenna, span, earth) jumping involves jumping from fixed objects with specialized parachutes. BASE jumping is associated with less aerodynamic control and flight stability than skydiving because of the lower altitude of jumps. Injuries and fatalities are often attributed to bad landings and object collision.METHODS: We performed a retrospective analysis of the 2010-2014 National Emergency Department Sample database, a nationally representative sample of all visits to US emergency departments (EDs). BASE jumping-associated injuries were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes [E004.0]. Outcomes evaluated included morbidity, mortality, inpatient admission, and costs. Adjusted analyses accounting for survey methodology were performed.RESULTS: After weighting, 1790 BASE-associated ED presentations were identified with 358±28 injuries annually. A total of 1313 patients (73%) were aged 18 to 44 y, and 1277 (71%) were male. Nine hundred seventy-six (55%) multiple body system injuries and 677 (38%) isolated extremity injuries were reported. There were 1588 (89%) patients discharged home from the ED; only 144 (7%) were admitted as inpatients. On multivariate logistic regression, only anatomic site of injury was associated with inpatient admission (odds ratio=0.6, P<0.001, 95% CI 0.5-0.8). Including ED and inpatient costs, BASE injuries cost the US healthcare system approximately $1.7 million annually. No deaths were identified within the limitations of the survey design.CONCLUSIONS: Although deemed one of the most dangerous extreme sports, many patients with BASE injuries surviving to arrival at definitive medical care do not require inpatient admission.
View details for PubMedID 31003883
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Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; A collaboration from the American Association for the Surgery of Trauma Patient Assessment Committee, the American Association for the Surgery of Trauma Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
2019; 86 (4): 737–43
View details for DOI 10.1097/TA.0000000000002155
View details for Web of Science ID 000463201000022
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The economic footprint of acute care surgery in the United States: Implications for systems development
LIPPINCOTT WILLIAMS & WILKINS. 2019: 609–16
View details for DOI 10.1097/TA.0000000000002181
View details for Web of Science ID 000463201000007
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Firearm Legislation Stringency and Firearm-Related Fatalities among Children in the United States.
Journal of the American College of Surgeons
2019
Abstract
BACKGROUND: Firearm-related injuries are the second leading cause of pediatric death in the U.S. We sought to evaluate the effectiveness of both state child access prevention (CAP) laws and gun regulations on pediatric firearm mortality. We hypothesized that states with more stringent firearm legislation had lower pediatric firearm mortality.STUDY DESIGN: We used 2014-2015 firearm mortality data from the Web-Based Injury Statistics Query and Reporting System, 2014 Brady scores (used to quantify stringency of state gun regulations) and CAP laws. State-level covariates were obtained from government sources including the Bureau of Labor Statistics and the Department of Education. Spearman rank correlations and linear regression were used to determine the relationship between overall pediatric firearm mortality and gun regulations. We also examined the relationship between gun regulations and firearm related homicides and suicides.RESULTS: Annually, there were approximately 2,715 pediatric firearm fatalities among children; 62.1% were homicides and 31.4% suicides. There was a moderate negative correlation between states' firearm legislation stringency and overall pediatric firearm mortality (rho=-0.66, p<0.001), and between CAP laws and firearm suicide rates (rho=-0.56, p<0.001). After controlling for poverty, unemployment, substance abuse, and the number of registered firearms, the association between firearm legislation stringency and overall pediatric firearm mortality remained significant (p=0.04). The association between CAP laws and firearm suicide rate remained significant after controlling for socioeconomic factors, registered firearms, and other firearm legislation (p=0.04).CONCLUSIONS: Strict gun legislation and CAP laws are associated with fewer pediatric firearm fatalities and firearm suicides, respectively, though no such association was identified with pediatric firearm homicides. While more studies are needed to determine causality, state-level legislation could play an important role in reducing pediatric firearm-related deaths.
View details for PubMedID 30928667
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The Applied Mathematics of the Geriatric Trauma Evaluation.
Annals of emergency medicine
2019; 73 (3): 291–93
View details for PubMedID 30797294
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Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients
JAMA SURGERY
2019; 154 (2): 141–49
View details for DOI 10.1001/jamasurg.2018.4282
View details for Web of Science ID 000459484600012
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Impact of licensed federal firearm suppliers on firearm-related mortality
LIPPINCOTT WILLIAMS & WILKINS. 2019: 123–27
View details for DOI 10.1097/TA.0000000000002067
View details for Web of Science ID 000454937100017
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Necrotizing Soft Tissue Infections.
JAMA
2019; 321 (17): 1738
View details for PubMedID 31063576
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Macroeconomic trends and practice models impacting acute care surgery.
Trauma surgery & acute care open
2019; 4 (1): e000295
Abstract
Acute care surgery (ACS) diagnoses are responsible for approximately a quarter of the costs of inpatient care in the US government, and individuals will be responsible for a larger share of the costs of this healthcare as the population ages. ACS as a specialty thus has the opportunity to meet a significant healthcare need, and by optimizing care delivery models do so in a way that improves both quality and value. ACS practice models that have maintained or added emergency general surgery (EGS) and even elective surgery have realized more operative case volume and surgeon satisfaction. However, vulnerabilities exist in the ACS model. Payer mix in a practice varies by geography and distribution of EGS, trauma, critical care, and elective surgery. Critical care codes constitute approximately 25% of all billing by acute care surgeons, so even small changes in reimbursement in critical care can have significant impact on professional revenue. Staffing an ACS practice can be challenging depending on reimbursement and due to uneven geographic distribution of available surgeons. Empowered by an understanding of economics, using team-oriented leadership inherent to trauma surgeons, and in partnership with healthcare organizations and regulatory bodies, ACS surgeons are positioned to significantly influence the future of healthcare in the USA.
View details for PubMedID 31058241
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The Economic Footprint of Acute Care Surgery in the United States: Implications for Systems Development.
The journal of trauma and acute care surgery
2018
Abstract
BACKGROUND: Acute Care Surgery (ACS) comprises Trauma, Surgical Critical Care, and Emergency General Surgery (EGS), encompassing both operative and non-operative conditions. While the burden of EGS and trauma have been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the U.S. inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics METHODS: We queried the National Inpatient Sample (NIS) 2014, a nationally representative database for inpatient hospitalizations. In order to capture all adult ACS patients, we included adult admissions with any ICD-9-CM diagnosis of trauma or an ICD-9-CM diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates.RESULTS: Of the 29.2 million adult patients admitted to U.S. hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for $85.8 billion dollars, or 25% of total U.S. inpatient costs ($341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of healthcare utilization with longer lengths of stay (5.9 vs. 4.5 days, p<0.001), and higher mean costs ($14,466 vs. $10,951, p<0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of U.S. hospitals cared for both trauma and EGS patients.CONCLUSION: Acute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the U.S. In addition to being costly, they overall have higher healthcare utilization and worse outcomes. This suggests there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall U.S. healthcare costs.Epidemiologic, level III.
View details for PubMedID 30589750
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Evidence-based review of trauma center care and routine palliative care processes for geriatric trauma patients; a collaboration from the American Association for the Surgery of Trauma (AAST) Patient Assessment Committee, the AAST Geriatric Trauma Committee, and the Eastern Association for the Surgery of Trauma Guidelines Committee.
The journal of trauma and acute care surgery
2018
Abstract
BACKGROUND: Despite an aging population and increasing number of geriatric trauma patients annually, gaps in our understanding of best practices for geriatric trauma patients persist. We know that trauma center care improves outcomes for injured patients generally, and palliative care processes can improve outcomes for disease-specific conditions, and our goal was to determine effectiveness of these interventions on outcomes for geriatric trauma patients.METHODS: A priori questions were created regarding outcomes for patients age 65+ with respect to care at trauma centers versus non trauma centers and use of routine palliative care processes. A query of MEDLINE, PubMed, Cochrane Library, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded. GRADE methodology was used to perform a systematic review and create recommendations.RESULTS: We reviewed 7 articles relevant to trauma center care and 9 articles reporting results on palliative care processes as they related to geriatric trauma patients. Given data quality and limitations, we conditionally recommend trauma center care for the severely injured geriatric trauma patients, but are unable to make a recommendation on the question of routine palliative care processes for geriatric trauma patients.CONCLUSION: As our older adult population increases, injured geriatric patients will continue to pose challenges for care, such as comorbidities or frailty. We found that trauma center care was associated with improved outcomes for geriatric trauma patients in most studies, and that utilization of early palliative care consultations was generally associated with improved secondary outcomes, such as length of stay, however inconsistency and imprecision prevented us from making a clear recommendation for this question. As caregivers, we should ensure adequate support for trauma systems and palliative care processes in our institutions and communities and continue to support robust research to study these and other aspects of geriatric trauma.LEVEL OF EVIDENCE: Systematic review/guideline, Level III.
View details for PubMedID 30531333
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INTER-HOSPITAL VARIABILITY IN TIME TO DISCHARGE TO REHABILITATION AMONG INSURED TRAUMA PATIENTS.
The journal of trauma and acute care surgery
2018
Abstract
BACKGROUND: Hospital costs are partly a function of length of stay (LOS), which can be impacted by the local availability of post-acute care (PAC) resources (inpatient rehabilitation and skilled nursing facilities), particularly for injured patients. We hypothesized that LOS for trauma patients destined for PAC would be variable based on insurance type and hospitals from which they are discharged.METHODS: We used the 2014-2015 National Inpatient Sample from the Healthcare Cost and Utilization Project (HCUP). We included all adult admissions with a primary diagnosis of trauma (ICD-9CM codes), who were insured and discharged to PAC. We then ranked hospitals based upon mean LOS and divided them into quartiles to determine differences. The primary outcome was inpatient LOS; secondary outcome was cost.RESULTS: 958,005 trauma patients met inclusion criteria. Mean LOS varied based upon insurance type (Medicaid vs. Private vs. Medicare: 12.7 days vs. 8.8 and 5.7: p<0.001). Shortest LOS hospitals had a marginal variation in LOS (Medicaid vs. Private vs. Medicare: 5.5 days vs. 4.8 vs. 4.2, p<0.001). Longest LOS hospitals had mean LOS that varied substantially (16.4 vs. 11.0 vs. 6.7 days, p<0.001). Multivariate regression controlling for patient and hospital characteristics revealed that Medicaid patients spent Medicaid patients spent an additional 0.4 days in shortest LOS hospitals and an additional 2.6 days in longest LOS hospitals (p<0.001). The average daily cost of inpatient care was $3,500 (SD $132). Even with conservative estimates, Medicaid patients at hospitals without easy access to rehabilitation incur significant additional inpatient costs over $10,000 in some hospitals.CONCLUSION: Prolonged LOS is likely a function of access to post-acute facilities, which is largely out of the hands of trauma centers. Efficiencies in care are magnified by access to post-acute beds, suggesting that increased availability of rehabilitation facilities, particularly for Medicaid patients, might help to reduce length of stay.LEVEL OF EVIDENCE: Epidemiologic, level III.
View details for PubMedID 30531207
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Climbing-Related Injury Among Adults in the United States: 5-Year Analysis of the National Emergency Department Sample
WILDERNESS & ENVIRONMENTAL MEDICINE
2018; 29 (4): 425–30
View details for Web of Science ID 000452686900002
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Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients.
JAMA surgery
2018
Abstract
Importance: Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking.Objective: To compare the outcomes of nonoperatively managed appendicitis against appendectomy.Design, Setting, and Participants: This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018.Exposures: Appendectomy (control arm) or nonoperative management (treatment arm).Main Outcomes and Measures: Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index.Results: Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P<.001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P=.02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P<.001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P<.001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P=.003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days.Conclusions and Relevance: According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.
View details for PubMedID 30427983
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Nonoperative Management of Appendicitis in Privately Insured Patients
ELSEVIER SCIENCE INC. 2018: S156–S157
View details for DOI 10.1016/j.jamcollsurg.2018.07.332
View details for Web of Science ID 000447760600303
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Climbing-Related Injury Among Adults in the United States: 5-Year Analysis of the National Emergency Department Sample.
Wilderness & environmental medicine
2018
Abstract
BACKGROUND: Rock climbing and mountaineering are popular outdoor recreational activities. More recently, indoor climbing has become popular, which has increased the number of persons at risk for climbing-related injuries.OBJECTIVE: To assess the morbidity, mortality, and healthcare cost due to climbing-related injury among persons presenting to US emergency departments (ED).METHODS: We performed a retrospective analysis of the 2010 to 2014 National Emergency Department Sample database, a nationally representative sample of all visits to US EDs. Rock climbing, mountain climbing, and wall climbing injuries were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes (E004.0). Outcomes evaluated included morbidity, mortality, inpatient admission, and costs. Adjusted analyses accounting for survey methodology were performed.RESULTS: A weighted-estimate 15,116 adult ED visits were associated with climbing-related injury. Patient age was 32.8±14.7 (mean±SD) (95% CI: 32.1-33.5) y, and 62% of patients were male. The majority of the injuries occurred in the Western census region (9593; 63%). Less than 1% of all climbing-related visits resulted in death. Only of injury severity score >15 was associated with death (P=0.005). A total of 1610 (11%) of patients were admitted as inpatients. Accounting for ED and inpatient costs, climbing-related injuries cost the US healthcare system approximately $102 (95% CI: $75-130) million USD for the 5-y period, averaging $20±9.5million USD per y.CONCLUSIONS: Most persons with climbing-related injuries presenting to EDs do not require inpatient admission. Although death is rare among patients with climbing-related injuries, the costs of injuries in survivors remain high.
View details for PubMedID 30241931
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Impact of Licensed Federal Firearm Suppliers on Firearm-Related Mortality.
The journal of trauma and acute care surgery
2018
Abstract
BACKGROUND: Legal firearm sales occur largely through suppliers that have Federal Firearm Licensees (FFLs). Since FFL density might reflect ease-of-access to firearm purchases, we hypothesized that the number of FFL dealers would be associated with firearm-related deaths. We further hypothesized that licensee-type subsets would be associated with differential risks for gun-related deaths.METHODS: We used data from the National Center for Health Statistics National Vital Statistics System (2008-2014) and national data on Federal Firearms Licensees for 2014. Correlation analysis and linear regression analysis were performed to determine the relationship between different licensee types and firearm-related deaths. We controlled for population, number of statewide registered firearms, and the density of other types of FFLs.RESULTS: We identified a total of 65,297 FFLs. There was a moderate correlation (R = 0.53, rho = 0.48) between total FFL density and firearm-related death rates. Further analysis by type of firearm-related death showed a strong correlation (R = 0.81, rho = 0.76) between total FFL density and firearm-related suicide rates. No correlation was found between total FFL density and firearm-related homicide rate. Among individual FFL types, FFL02 (firearm dealing pawnshop) density was the only FFL-type found to be correlated with firearm-related death rates. We found a strong correlation between FFL02 density and overall firearm-related death rate (R = 0.69, rho = 0.78) and firearm-related suicide rate (R = 0.72, rho = 0.78). Linear regression analysis showed that even while controlling for number of registered firearms and population, the number of firearm-dealing pawnshops remained significantly associated with overall firearm-related deaths and firearm-related suicides.CONCLUSION: Access to legally-distributed firearms is associated with firearm-related death rates, particularly firearm-related suicides. Specifically, firearm-dealing pawnshops were associated with suicide-related deaths. These findings suggest that deeper exploration of legal firearm access and firearm-related injuries would benefit discussion of preventative measures.LEVEL OF EVIDENCE: IV TYPE OF STUDY: Prognostic and Epidemiological.
View details for PubMedID 30212424
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The association between angioembolization and splenic salvage for isolated splenic injuries.
The Journal of surgical research
2018; 229: 150–55
Abstract
BACKGROUND: Recent data suggest improved splenic salvage rates when angioembolization (AE) is routinely employed for high-grade splenic injuries; however, protocols and salvage rates vary among centers.MATERIALS/METHODS: Adult patients with isolated splenic injuries were identified using the National Trauma Data Bank, 2013-2014. Patients were excluded if they underwent immediate splenectomy or died in the emergency department. To characterize patterns of AE, trauma centers were grouped into quartiles based on frequency of AE use. Unadjusted analyses and mixed-effects logistical regression controlling for center effects were performed.RESULTS: Five thousand and ninety three adult patients were identified. Overall, 705 (13.8%) underwent AE and 290 (5.7%) required a splenectomy. In unadjusted comparisons, splenectomy rates were lower for patients with severe spleen injuries who underwent AE (7% versus 11%, P=0.02). In mixed-effect logistical regression patients with severe splenic injuries undergoing AE had a lower odds ratio (OR) for splenectomy (OR = 0.67, P=0.04). Patients treated at centers in the highest quartile of AE use had a lower OR for splenectomy (OR = 0.58, P=0.02).CONCLUSIONS: The use of AE in patients with isolated severe splenic injuries is associated with decreased splenectomy rates. There is an association between centers that perform AE frequently and reduced splenectomy rates.
View details for PubMedID 29936983
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Variations in institutional review board processes and consent requirements for trauma research: an EAST multicenter survey.
Trauma surgery & acute care open
2018; 3 (1): e000176
Abstract
Oversight of human subject research has evolved considerably since its inception. However, previous studies identified a lack of consistency of institutional review board (IRB) determination for the type of review required and whether informed consent is necessary, especially for prospective observational studies, which pose minimal risk of harm. We hypothesized that there is significant inter-institution variation in IRB requirements for the type of review and necessity of informed consent, especially for prospective observational trials without blood/tissue utilization. We also sought to describe investigators' and IRB members' attitudes toward the type of review and need for consent. Eastern Association for the Surgery of Trauma (EAST) and IRB members were sent an electronic survey on IRB review and informed consent requirement. We performed descriptive analyses as well as Fisher's exact test to determine differences between EAST and IRB members' responses. The response rate for EAST members from 113 institutions was 13.5%, whereas a convenience sample of IRB members from 14 institutions had a response rate of 64.4%. Requirement for full IRB review for retrospective studies using patient identifiers was reported by zero IRB member compared with 13.1% of EAST members (p=0.05). Regarding prospective observational trials without blood/tissue collection, 48.1% of EAST members reported their institutions required a full IRB review compared with 9.5% of IRB members (p=0.01). For prospective observational trials with blood/tissue collection, 80% of EAST members indicated requirement to submit a full IRB review compared with only 13.6% of IRB members (p<0.001). Most EAST members (78.6%) stated that informed consent is not ethically necessary in prospective observational trials without blood/tissue collection, whereas most IRB members thought that informed consent was ethically necessary (63.6%, p<0.001). There is significant variation in perception and practice regarding the level of review for prospective observational studies and whether informed consent is necessary. We recommend future interdisciplinary efforts between researchers and IRBs should occur to better standardize local IRB efforts.IV.
View details for DOI 10.1136/tsaco-2018-000176
View details for PubMedID 29862323
View details for PubMedCentralID PMC5976138
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Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals.
Journal of the American College of Surgeons
2018
Abstract
BACKGROUND: Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability.STUDY DESIGN: We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin.RESULTS: California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n= 4) and nonprofit-owned SNHs (64%, n= 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p<0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively.CONCLUSIONS: The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system.
View details for PubMedID 29680414
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The Hospital Readmission Reduction Program for Surgical Conditions: Impactful or Harmful?
Annals of surgery
2018; 267 (4): 606–7
View details for PubMedID 28953553
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Surgical deserts in California: an analysis of access to surgical care
JOURNAL OF SURGICAL RESEARCH
2018; 223: 102–8
Abstract
Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties.We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis.There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty.Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.
View details for PubMedID 29433860
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Self-inflicted gunshot wounds: readmission patterns
JOURNAL OF SURGICAL RESEARCH
2018; 223: 22–28
Abstract
Self-inflicted gunshot wounds (SI-GSWs) are often fatal, but roughly 20% of individuals survive. What happens to survivors after the initial hospitalization is unknown. We hypothesized that the SI-GSW survivors are frequently readmitted and that the pattern of readmission is different from that of the survivors of non-GSW self-harm (SH).We conducted a retrospective cohort analysis using the 2013 and 2014 Nationwide Readmission Database. Patients with any diagnosis indicating deliberate SH in the first 6 months of the year were included. This group was divided into those who had SI-GSW as their mechanism and those who did not. Weighted numbers are reported.A total of 1987 patients were admitted for SI-GSW in the study period. Many (n = 506, 26%) experienced at least one readmission in 6 months. When compared with non-GSW SH patients, readmission rates were not statistically different (26% versus 26%, P = 0.60). However, readmissions for repeat SH were lower for the SI-GSW cohort (3% versus 7%, P = 0.004). Readmission for the SI-GSW cohort less frequently had a primary diagnosis of psychiatric illness (28% versus 57%, P < 0.001). In multivariate analysis, there was no difference in odds ratios (OR) of all-cause readmission between the two groups. SI-GSW was associated with a lower OR of repeat SH readmission compared with non-GSW SH (OR 0.65, P = 0.039).Readmissions after an SI-GSW are frequent, highlighting the burden of this injury beyond the index hospitalization. There are differences in readmission patterns for SI-GSW patients versus non-GSW SH patients, and this suggests that prevention and follow-up strategies may differ between the two groups.
View details for PubMedID 29433877
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Trauma-induced insurance instability: Variation in insurance coverage for patients who experience readmission after injury.
The journal of trauma and acute care surgery
2018; 84 (6): 876–84
Abstract
Traumatic injuries result in a significant disruption to patients' lives, including their ability to work, which may place patients at risk of losing insurance coverage. Our objective was to evaluate the impact of injury on insurance status. We hypothesized that trauma patients with ongoing health needs experience changes in coverage.We used the Nationwide Readmission Database (2013-2014), a nationally representative sample of readmissions in the United States. We included patients aged 27 years to 64 years admitted with any diagnosis of trauma with at least one readmission within 6 months. Patients on Medicare and with missing payer information were excluded. The primary outcome was payer status.57,281 patients met inclusion criteria, 11,006 (19%) changed insurance payer at readmission. Of these, 21% (n = 2,288) became uninsured, 25% (n = 2,773) gained coverage, and 54% (n = 5,945) switched insurance. Medicaid and Medicare gained the largest fraction of patients (from 16% to 30% and 0% to 18%, respectively), with a decrease in private payer coverage (37% to 17%). In multivariate analysis, patients who were younger (27-35 years vs. 56-64 years; odds ratio [OR], 1.30; p < 0.001); lived in a zip code with average income in the lowest quartile (vs. the highest quartile; OR, 1.37; p < 0.001); and had three or more comorbidities (vs. none; OR, 1.61; p < 0.001) were more likely to experience a change in insurance.Approximately one fifth of trauma patients who are readmitted within 6 months of their injury experience a change in insurance coverage. Most switch between insurers, but nearly a quarter lose their insurance. The government adopts a large fraction of these patients, indicating a growing reliance on government programs like Medicaid. Trauma patients face challenges after injury, and a change in insurance may add to this burden. Future policy and quality improvement initiatives should consider addressing this challenge.Epidemiologic, level III.
View details for PubMedID 29443863
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Mortality, hospital admission, and healthcare cost due to injury from venomous and non-venomous animal encounters in the USA: 5-year analysis of the National Emergency Department Sample.
Trauma surgery & acute care open
2018; 3 (1): e000250
Abstract
Background: Injuries due to encounters with animals can be serious, but are often discussed anecdotally or only for isolated types of encounters. We sought to characterize animal-related injuries presenting to US emergency departments (ED) to determine the impact of these types of injuries.Methods: All ED encounters with diagnosis codes corresponding to animal-related injury were identified using ICD-9-CM codes from the 2010 2014 National Emergency Department Sample (NEDS). Outcomes assessed included inpatient admission, mortality, and healthcare cost. Survey methodology was applied to univariate and multivariate analyses. Weighted numbers are presented.Results: There were 6 457 534 ED visits resulting from animal-related injuries identified. Bites from non-venomous arthropods (n=2 648 880; 41%), dog bites (n=1 658 295; 26%) and envenomation from hornets, wasps or bees (n=812357; 13%) constitute the majority of encounters. There were 210516 patients (3%) admitted as inpatients. Inpatient admission was most common for those suffering from venomous snakes or lizard bites (24%, n=10332). Death was infrequent occurring in 1162 patients (0.02% of all ED presentations). The greatest number of deaths was due to bites from non-venomous arthropods (24% of deaths, n=278) whereas rat bites proved the most lethal (6.5 deaths per 10000 bites). Among persons aged 85 years or greater, odds of hospital admission for any animal-related injury was 6.42 (95% CI 5.57 to 7.40) and the OR for death was 27.71 (95% CI 10.38 to 73.99). Female sex was associated with improved survival (OR 0.55, 95% CI 0.41 to 0.73) and lower rates of hospital admission (OR 0.77, 95%CI 0.75 to 0.79). The total healthcare cost for these animal encounters during the observed time period was $5.96 billion (95%CI $5.43 to $6.50 billion).Conclusion: The morbidity, mortality, and healthcare cost due to animal encounters in the USA is considerable. Often overlooked, this particular mechanism of injury warrants further public health prevention efforts.Level of Evidence: Level IV.
View details for PubMedID 30623028
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A Potential Mechanism for Immune Suppression by Beta-Adrenergic Receptor Stimulation following Traumatic Injury
JOURNAL OF INNATE IMMUNITY
2018; 10 (3): 202–14
Abstract
β-Adrenergic agents suppress inflammation and may play an important role in posttraumatic infections. Mechanisms may include inhibition of MAP kinase signaling. We sought to determine whether MKP-1 contributed to catecholamine suppression of innate immunity and also wanted to know whether early catecholamine treatment after traumatic injury increases the risk of later nosocomial infection.We performed experiments using THP-1 cells and peripheral blood mononuclear cells from healthy individuals. We exposed cells to epinephrine and/or LPS and measured inflammatory gene transcription and MAP kinase activation. We inhibited MKP-1 activity to determine its role in catecholamine-induced immune suppression. Finally, we studied injured subjects to determine whether early catecholamine treatment was associated with nosocomial infection.Epinephrine increases MKP-1 transcripts and protein and decreases LPS-induced p38 and JNK phosphorylation and TNF-α gene transcription. RNAi inhibition of MKP-1 at least partially restores LPS-induced TNF-α gene expression (p = 0.024). In the clinical cohort, subjects treated with β-adrenergic agents had an increased risk of ventilator-associated pneumonia (aOR = 1.9; 95% CI = 1.3-2.6) and bacteremia (aOR = 1.5; 95% CI = 1.1-2.3).MKP-1 may have a role in catecholamine-induced suppression of innate immunity, and exogenous catecholamines might contribute to nosocomial infection risk.
View details for PubMedID 29455206
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Expanding the scope of quality measurement in surgery to include nonoperative care: Results from the American College of Surgeons National Surgical Quality Improvement Program emergency general surgery pilot
LIPPINCOTT WILLIAMS & WILKINS. 2017: 837–45
Abstract
Patients managed nonoperatively have been excluded from risk-adjusted benchmarking programs, including the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Consequently, optimal performance evaluation is not possible for specialties like emergency general surgery (EGS) where nonoperative management is common. We developed a multi-institutional EGS clinical data registry within ACS NSQIP that includes patients managed nonoperatively to evaluate variability in nonoperative care across hospitals and identify gaps in performance assessment that occur when only operative cases are considered.Using ACS NSQIP infrastructure and methodology, surgical consultations for acute appendicitis, acute cholecystitis, and small bowel obstruction (SBO) were sampled at 13 hospitals that volunteered to participate in the EGS clinical data registry. Standard NSQIP variables and 16 EGS-specific variables were abstracted with 30-day follow-up. To determine the influence of complications in nonoperative patients, rates of adverse outcomes were identified, and hospitals were ranked by performance with and then without including nonoperative cases.Two thousand ninety-one patients with EGS diagnoses were included, 46.6% with appendicitis, 24.3% with cholecystitis, and 29.1% with SBO. The overall rate of nonoperative management was 27.4%, 6.6% for appendicitis, 16.5% for cholecystitis, and 69.9% for SBO. Despite comprising only 27.4% of patients in the EGS pilot, nonoperative management accounted for 67.7% of deaths, 34.3% of serious morbidities, and 41.8% of hospital readmissions. After adjusting for patient characteristics and hospital diagnosis mix, addition of nonoperative management to hospital performance assessment resulted in 12 of 13 hospitals changing performance rank, with four hospitals changing by three or more positions.This study identifies a gap in performance evaluation when nonoperative patients are excluded from surgical quality assessment and demonstrates the feasibility of incorporating nonoperative care into existing surgical quality initiatives. Broadening the scope of hospital performance assessment to include nonoperative management creates an opportunity to improve the care of all surgical patients, not just those who have an operation.Care management, level IV; Epidemiologic, level III.
View details for PubMedID 29068873
View details for PubMedCentralID PMC5755591
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SERIOUS, NONLETHAL FIREARM-RELATED INJURIES IN THE UNITED STATES: COMPILING THE EVIDENCE RESPONSE
AMERICAN JOURNAL OF PUBLIC HEALTH
2017; 107 (8): E25
View details for PubMedID 28700309
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Clinical phenotypes of US level I trauma centers: use of clustering methodology
ACADEMIC PRESS INC ELSEVIER SCIENCE. 2017: 146–52
Abstract
American College of Surgeons Level I Trauma Centers (ACSL1TCs) meet the same personnel and structural requirements but serve different populations. We hypothesized that these nuanced differences may amenable to description through mathematical clustering methodology.The National Trauma Data Bank 2014 was used to derive information on ACSL1TCs. Explorative cluster hypothesis generation was performed using Ward's linkage to determine expected number of clusters based on patient and injury characteristics. Subsequent k-means clustering was applied for analysis. Comparison between clusters was performed using the Kruskal-Wallis or chi-square test.In 2014, 113 ACSL1TCs admitted 267,808 patients (median = 2220 patients, range: 928-6643 patients). Three clusters emerged. Cluster I centers (n = 53, 47%) were more likely to admit older, Caucasian patients who suffered from falls (P < 0.05) and had higher proportions of private (31%) and Medicare payers (29%) (P = 0.001). Cluster II centers (n = 18, 16%) were more likely to admit younger, minority males who suffered from penetrating trauma (P < 0.05) and had higher proportions of Medicaid (24%) or self-pay patients (19%) (P = 0.001). Cluster III centers (n = 42, 37%) were similar to cluster I with respect to racial demographic and payer status but resembled cluster II centers with respect to injury patterns (P < 0.05).Our analysis identified three unique, mathematically definable clusters of ACSL1TCs serving three broadly different patient populations. Understanding these mathematically definable clusters should have utility when assessing an institution's financial risk profile, directing prevention and outreach programs, and performing needs and resource assessments. Ultimately, clustering allows for more meaningful direct comparisons between phenotypically similar trauma centers.
View details for PubMedID 28688640
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The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system.
journal of trauma and acute care surgery
2017; 82 (6): 1014-1022
Abstract
Florida serves as a model for the study of trauma system performance. Between 2010 and 2104, 5 new trauma centers were opened alongside 20 existing centers. The purpose of this study was to explore the impact of trauma system expansion on system triage performance and trauma center patients' profiles.A statewide data set was queried for all injury-related discharges from adult acute care hospitals using International Classification of Diseases, Ninth Revision (ICD-9) codes for 2010 and 2014. The data set, inclusion criteria, and definitions of high-risk injury were chosen to match those used by the Florida Department of Health in its trauma registry. Hospitals were classified as existing Level I (E1) or Level II (E2) trauma centers and new E2 (N2) centers.Five N2 centers were established 11.6 to 85.3 miles from existing centers. Field and overall trauma system triage of high-risk patients was less accurate with increased overtriage and no change in undertriage. Annual volume at N2 centers increased but did not change at E1 and E2 centers. In 2014, Patients at E1 and E2 centers were slightly older and less severely injured, while those at N2 centers were substantially younger and more severely injured than in 2010. The injured patient-payer mix changed with a decrease in self-pay and commercial patients and an increase in government-sponsored patients at E1 and E2 centers and an increase in self-pay and commercial patients with a decrease in government-sponsored patients at N2 centers.Designation of new trauma centers in a mature system was associated with a change in established trauma center demographics and economics without an improvement in trauma system triage performance. These findings suggest that the health of an entire trauma system network must be considered in the design and implementation of a regional trauma system.Therapeutic/care management study, level IV; epidemiological, level IV.
View details for DOI 10.1097/TA.0000000000001442
View details for PubMedID 28328670
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The prevalence of psychiatric diagnoses and associated mortality in hospitalized US trauma patients
JOURNAL OF SURGICAL RESEARCH
2017; 213: 171–76
Abstract
We hypothesized that psychiatric diagnoses would be common in hospitalized trauma patients in the United States and when present, would be associated with worse outcomes.The Nationwide Inpatient Sample (NIS, 2012) was used to determine national estimates for the number of patients admitted with an injury. Psychiatric diagnoses were identified using diagnosis codes according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.A total of 36.5 million patients were admitted to hospitals in the United States in 2012. Of these, 1.3 million (4%) were due to trauma. Psychiatric conditions were more common in patients admitted for trauma versus those admitted for other reasons (44% versus 34%, P < 0.001). Trauma patients who had a psychiatric diagnosis compared to trauma patients without a psychiatric diagnosis were older (mean age: 61 versus 56 y, P < 0.001), more often female (52% versus 50%, P < 0.001), and more often white (73% versus 68%, P < 0.001). For ages 18-64, drug and alcohol abuse predominated (41%), whereas dementia and related disorders (48%) were the most common in adults ≥65 y. Mortality was lower for trauma patients with a psychiatric diagnosis compared to those who did not in both unadjusted and adjusted analysis (1.9% versus 2.8%; odds ratio: 0.56, P < 0.001).Psychiatric conditions are present in almost half of all hospitalized trauma patients in the United States; however, the types of conditions varied with age. The frequency of psychiatric conditions in the trauma population suggests efforts should be made to address this component of patient health.
View details for PubMedID 28601311
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Costs and Financial Burden of Initial Hospitalizations for Firearm Injuries in the United States, 2006-2014.
American journal of public health
2017; 107 (5): 770-774
Abstract
To quantify the inflation-adjusted costs associated with initial hospitalizations for firearm-related injuries in the United States.We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2006 to 2014. We converted charges from hospitalization to costs, which we inflation-adjusted to 2014 dollars. We used survey weights to create national estimates.Costs for the initial inpatient hospitalization totaled $6.61 billion. The largest proportion was for patients with governmental insurance coverage, totaling $2.70 billion (40.8%) and was divided between Medicaid ($2.30 billion) and Medicare ($0.40 billion). Self-pay individuals accounted for $1.56 billion (23.6%) in costs.From 2006 to 2014, the cost of initial hospitalizations for firearm-related injuries averaged $734.6 million per year. Medicaid paid one third and self-pay patients one quarter of the financial burden. These figures substantially underestimate true health care costs. Public health implications. Firearm-related injuries are costly to the US health care system and are particularly burdensome to government insurance and the self-paying poor.
View details for DOI 10.2105/AJPH.2017.303684
View details for PubMedID 28323465
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Population-based estimate of trauma-related deaths for law enforcement personnel: Risks for death are higher and increasing over time.
journal of trauma and acute care surgery
2017
Abstract
Trauma-related deaths remain an important public health problem. One group susceptible to death due to traumatic mechanisms is U.S. Law Enforcement (LE). We hypothesized that LE officers experienced a higher chance of violent death compared to the general U.S. population and that risks have increased over time.The National Institute on Occupational Safety and Health (NIOSH) National Occupational Mortality Surveillance (NOMS) is a population-based survey of occupational deaths. It includes data for workers who died during 1985-1998 in one of 30 U.S states (EARLY period). Additional deaths were added from 23 U.S. states in 1999, 2003-2004, 2007-2010 (LATE period). Mortality rates are estimated by calculating proportionate mortality ratios (PMR). A PMR above 100 is considered to exceed the average background risk for all occupations. All adults >18 years of age whose primary occupation was listed as "Law Enforcement Worker" were included in the analysis.Law enforcement personnel were more likely to die from an injury compared to the general population (Figure 1). The overall PMR for injury in EARLY was 111 (95% Confidence Interval [CI] 108-114, p<0.01), and for LATE was 118 (95% CI 110-127, p<0.01). Four mechanisms of death reached statistical significance: motor vehicle traffic (MVT)-driver, MVT-other, intentional self-harm, and assault/homicide. The highest PMR in EARLY was associated with firearms (PMR 272, 95% CI 207-350, p<0.01). The highest PMR in LATE was associated with death due to being a driver in an MVT (PMR 194, 95% CI 169-222, p<0.01). There were differences in risk of death by race and gender. White females had the highest PMR due to Assault and Homicide (PMR 317, 95% CI 164-554, p<0.01). All groups had similar risks of death due to Intentional Self-Harm (PMR 130-171).The risk of death for US LEOs is high and increasing over time, suggesting an at-risk population that requires further interventions. Targeted efforts based on risk factors, such as gender and race, may assist with the development of prevention programs for this population.
View details for DOI 10.1097/TA.0000000000001528
View details for PubMedID 28422921
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The American College of Surgeons (ACS) Needs-Based Assessment of Trauma Systems (NBATS): Estimates for the State of California.
journal of trauma and acute care surgery
2017
Abstract
In 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California.Trauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers.A total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results.Estimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool.Economic, level V.
View details for DOI 10.1097/TA.0000000000001408
View details for PubMedID 28248801
View details for PubMedCentralID PMC5400714
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National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy.
JAMA surgery
2017; 152 (12): 1119–25
Abstract
Options for managing splenic injuries have evolved with a focus on nonoperative management. Long-term outcomes, such as readmissions and delayed splenectomy rate, are not well understood.To describe the natural history of isolated splenic injuries in the United States and determine whether patterns of readmission were influenced by management strategy.The Healthcare Cost and Utilization Project's Nationwide Readmission Database is an all-payer, all-ages, longitudinal administrative database that provides data on more than 35 million weighted US discharges yearly. The database was used to identify patients with isolated splenic injuries and the procedures that they received. Adult patients with isolated splenic injuries admitted from January 1 through June 30, 2013, and from January 1 through June 30, 2014, were included. Those who died during the index hospitalization or who had an additional nonsplenic injury with an Abbreviated Injury Score of 2 or greater were excluded. Univariate and mixed-effects logistic regression analysis controlling for center effect were used. Weighted numbers are reported.Initial management strategy at the time of index hospitalization, including nonprocedural management, angioembolization, and splenectomy.All-cause 6-month readmission rate. Secondary outcome was delayed splenectomy rate.A weighted sample of 3792 patients (2146 men [56.6%] and 1646 women [43.4%]; mean [SE] age, 48.5 [0.7] years) with 5155 admission events was included. During the index hospitalization, 825 (21.8%) underwent splenectomy, 293 (7.7%) underwent angioembolization, and 2673 (70.5%) had no procedure. The overall readmission rate was 21.1% (799 patients). Readmission rates did not differ based on initial management strategy (195 patients undergoing splenectomy [23.6%], 70 undergoing angioembolism [23.9%], and 534 undergoing no procedure [20%]; P = .33). Splenectomy was performed in 36 of 799 readmitted patients (4.5%) who did not have a splenectomy at their index hospitalization, leading to an overall delayed splenectomy rate of 1.2% (36 of 2967 patients). In mixed-effects logistic regression analysis controlling for patient, injury, clinical, and hospital characteristics, the choice of splenectomy (odds ratio, 0.93; 95% CI, 0.66-1.31) vs angioembolization (odds ratio, 1.19; 95% CI, 0.72-1.97) as initial management strategy was not associated with readmission.This national evaluation of the natural history of isolated splenic injuries from index admission through 6 months found that approximately 1 in 5 patients are readmitted within 6 months of discharge after an isolated splenic injury. However, the chance of readmission for splenectomy after initial nonoperative management was 1.2%. This finding suggests that the current management strategies used for isolated splenic injuries in the United States are well matched to patient need.
View details for PubMedID 28768329
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Effects of mechanism of injury and patient age on outcomes in geriatric rib fracture patients.
Trauma surgery & acute care open
2017; 2 (1): e000074
Abstract
Background: Patients older than 65 years have 2-5 times higher mortality if they sustain ≥2 rib fractures compared to younger adults. As a result, our level I trauma center guidelines suggest that older adults with rib fractures be admitted to the intensive care unit for the first 24 hours. In this study, we evaluated the outcomes associated with these guidelines.Methods: We retrospectively reviewed all patients aged ≥65 years in our Trauma Registry who sustained rib fractures from January 2008 to March 2015. Data included demographics, comorbidities, injuries, length of intensive care and hospital stay (LOS), ventilator days, analgesic used, morbidity, mortality, and disposition.Results: 97 patients aged ≥65 years with at least one rib fracture and an Abbreviated Injury Score of ≤2 for other regions were admitted. Falls caused 58% of the injuries, while motor vehicle collisions (MVC) accounted for 33%. Overall mortality was 4%. Patients who fell had a median hospital LOS that was 0.5 to 1 day longer than in those who suffered other mechanisms of injury or were involved in an MVC respectively. Patients aged ≥70 years had a median LOS of 4 days, twice that of those aged 65 to 69 years. Of the 87 patients with more than one rib fracture, 59 (68%) were not admitted directly to the intensive care unit (ICU) from the emergency department as recommended by our guidelines. 6 of these 59 patients (9%) were later transferred to the ICU and 2 of these patients expired.Conclusions: Although overall compliance with the geriatric rib fracture guideline was low, both mortality and hospital LOS were low in this group. This suggests that the guideline could be modified to reduce ICU resource usage without compromising patient outcomes.Level of evidence: Level III, retrospective cohort study.
View details for PubMedID 29766084
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Hospitalized Patients with Heart Failure and Common Bacterial Infections: A Nationwide Analysis of Concomitant Clostridium Difficile Infection Rates and In-Hospital Mortality.
Journal of cardiac failure
2016; 22 (11): 891-900
Abstract
Patients with heart failure (HF) are frequently hospitalized with common bacterial infections. It is unknown whether they experience concomitant Clostridium difficile infection (CDI) more frequently than patients without HF, and whether CDI affects their mortality.We used 2012 National Inpatient Sample data to determine the rate of CDI and associated in-hospital mortality for hospitalized patients with comorbid HF and urinary tract infection (UTI), pneumonia (PNA), or sepsis. Univariate and multivariate analyses were performed. Weighted data are presented.There were an estimated 5,851,582 patient hospitalizations with discharge diagnosis of UTI, PNA, or sepsis in 2012 in the United States. Of these, 23.4% had discharge diagnosis of HF. Patients with HF were on average older and had more comorbidities. CDI rates were higher in hospitalizations with discharge diagnosis of HF compared with those without HF (odds ratio 1.13, 95% confidence interval 1.10-1.16) after controlling for patient demographics and comorbidities and hospital characteristics. Among HF hospitalizations with UTI, PNA, or sepsis, those with concomitant CDI had a higher in-hospital mortality than those without concomitant CDI (odds ratio 1.81, 95% confidence interval 1.71-1.92) after controlling for the covariates outlined previously.HF is associated with higher CDI rates among hospitalized patients with other common bacterial infections, even when adjusting for other known risk factors for CDI. Among these patients with comorbid HF, CDI is associated with markedly higher in-hospital mortality. These findings may suggest an opportunity to improve outcomes for hospitalized patients with HF and common bacterial infections, possibly through improved Clostridium difficile screening and prophylaxis protocols.
View details for DOI 10.1016/j.cardfail.2016.06.005
View details for PubMedID 27317844
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The American Association for the Surgery of Trauma grading scale for 16 emergency general surgery conditions: Disease-specific criteria characterizing anatomic severity grading.
journal of trauma and acute care surgery
2016; 81 (3): 593-602
View details for DOI 10.1097/TA.0000000000001127
View details for PubMedID 27257696
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Trends in open vascular surgery for trauma: implications for the future of acute care surgery.
journal of surgical research
2016; 205 (1): 208-212
Abstract
Trauma patients with vascular injuries have historically been within a general surgeon's operative ability. Changes in training and decline in operative trauma have decreased trainees' exposure to these injuries. We sought to determine how frequently vascular procedures are performed at US trauma centers to quantify the need for general surgeons trained to manage vascular injuries.We conducted a retrospective analysis of the National Trauma Data Base (NTDB) from 2012 compared with 2002. Patients with general surgical and vascular procedures were identified using International Classification of Diseases, Ninth Revision, procedure codes 38.0-39.99, excluding 38.9-38.99.General surgery or vascular operations were performed on 12,099 (24%) of 50,248 severely injured adult patients in 2002 and 21,854 (16%) of 138,009 injured patients in 2012. Nineteen percent to 26% of all patients underwent vascular procedures. Patients with combined general surgery and vascular procedures were less likely to be discharged home and more likely to die. In 2002, 6% of severely injured adult trauma patients underwent open vascular procedures at level III/IV trauma centers; by 2012, only 1% of vascular surgery procedures were performed at level III/IV centers (P < 0.001).Need for emergent vascular surgery remains common for severely injured patients. Future trauma systems and surgical training programs will need to account for the need for open vascular skills. The findings suggest that there is already a trend away from open vascular procedures at level III/IV trauma centers, which may be a sign of system compensation for changes in the workforce.
View details for DOI 10.1016/j.jss.2016.06.032
View details for PubMedID 27621021
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Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2016; 222 (6): 1125-1137
Abstract
The American College of Surgeons Committee on Trauma sets national targets for the accuracy of field trauma triage at ≥95% sensitivity and ≥65% specificity, yet the cost-effectiveness of realizing these goals is unknown. We evaluated the cost-effectiveness of current field trauma triage practices compared with triage strategies consistent with the national targets.This was a cost-effectiveness analysis using data from 79,937 injured adults transported by 48 emergency medical services agencies to 105 trauma and nontrauma hospitals in 6 regions of the western United States from 2006 through 2008. Incremental differences in survival, quality-adjusted life years (QALYs), costs, and the incremental cost-effectiveness ratio (costs per QALY gained) were estimated for each triage strategy during a 1-year and lifetime horizon using a decision analytic Markov model. We considered an incremental cost-effectiveness ratio threshold of <$100,000 to be cost-effective.For these 6 regions, a high-sensitivity triage strategy consistent with national trauma policy (sensitivity 98.6%, specificity 17.1%) would cost $1,317,333 per QALY gained, and current triage practices (sensitivity 87.2%, specificity 64.0%) cost $88,000 per QALY gained, compared with a moderate sensitivity strategy (sensitivity 71.2%, specificity 66.5%). Refining emergency medical services transport patterns by triage status improved cost-effectiveness. At the trauma-system level, a high-sensitivity triage strategy would save 3.7 additional lives per year at a 1-year cost of $8.78 million, and a moderate sensitivity approach would cost 5.2 additional lives and save $781,616 each year.A high-sensitivity approach to field triage consistent with national trauma policy is not cost-effective. The most cost-effective approach to field triage appears closely tied to triage specificity and adherence to triage-based emergency medical services transport practices.
View details for DOI 10.1016/j.jamcollsurg.2016.02.014
View details for PubMedID 27178369
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Use of emergency department imaging in patients with minor trauma
JOURNAL OF SURGICAL RESEARCH
2016; 203 (1): 238-245
Abstract
Advanced radiographic studies have detrimental risks, yet the prevalence of CT utilization in patients with minor trauma presenting to the emergency department (ED) has never been fully evaluated. Our objective was to evaluate the frequency of CT imaging in patients presenting to the ED for minor trauma.A retrospective analysis of the California Office of Statewide Health Planning and Development Emergency Department and Ambulatory Surgery Data from 2005 to 2013 was performed. A total of 8,535,831 patients were identified using the following inclusion criteria: adult patients (age ≥18 y); with a traumatic ECODE diagnosis and injury severity score <9; and discharge to home. The primary study outcome measurement was the prevalence of CT imaging for each year in the study period. We performed univariate and multivariate analysis to evaluate clinical and hospital-level factors related to CT use in this population. We also performed a trend analysis using Poisson logistic regression to assess the trend of imaging scans over the study period.Of the study population, 5.9% received at least one CT study during their ED visit. The proportion of patients with at least one CT scan increased from 3.51% in 2005 to 7.17% in 2013 (P < 0.005). Adjusted predictors for CT included age 18-24 y or >45 y (P < 0.005), Medicare and self-pay patients (P < 0.005), fall injuries (P < 0.005), motor vehicle collision injuries (P < 0.005), and patients seen at level I/II trauma centers (P = 0.005).Even after clinical and demographic predictors were adjusted for, there was a 1.97-fold increase in CT among minor trauma patients from 2005-2013.
View details for DOI 10.1016/j.jss.2015.11.046
View details for Web of Science ID 000378170200029
View details for PubMedID 26732499
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Trends in the management of pelvic fractures, 2008-2010
JOURNAL OF SURGICAL RESEARCH
2016; 202 (2): 335-340
Abstract
Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time.The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality.A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001).AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.
View details for DOI 10.1016/j.jss.2015.12.052
View details for PubMedID 27229108
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The Triage of Injured Patients: Mechanism of Injury, Regardless of Injury Severity, Determines Hospital Destination
AMERICAN SURGEON
2016; 82 (4): 356-361
Abstract
The target rate for trauma undertriage is <5 per cent, but rates are as high as 30 to 40 per cent in many trauma systems. We hypothesized that high undertriage rates were due to the tendency to undertriage injured elderly patients and a growing elderly population. We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database over a 5-year period. All hospital admissions and emergency department visits associated with injury were longitudinally linked. The primary outcome was triage pattern. Triage patterns were stratified across three dimensions: age, mechanism of injury, and access to care. A total of 60,182 severely injured patients were included in the analysis. Fall-related injuries were frequently undertriaged compared with injuries from motor vehicle collisions (MVCs) and penetrating trauma (52% vs 12% and 10%, respectively). This pattern was true for all age groups. Conversely, MVCs and penetrating traumas were associated with high rates of overtriage (>70% for both). In conclusion, in contrast to our hypothesis, we found that triage is largely determined by mechanism of injury regardless of injury severity. High rates of undertriage are largely due to the undertriage of fall-related injuries, which occurs in both younger and older adults. Patients injured after MVCs and penetrating trauma victims are brought to trauma centers regardless of injury severity, resulting in high rates of overtriage. These findings suggest an opportunity to improve trauma system performance.
View details for Web of Science ID 000377853800022
View details for PubMedID 27097630
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Trauma center care is associated with reduced readmissions after injury.
journal of trauma and acute care surgery
2016; 80 (3): 412-418
Abstract
Trauma center care has been associated with improved mortality. It is not known if access to trauma center care is also associated with reduced readmissions. We hypothesized that receiving treatment at a trauma center would be associated with improved care and therefore would be associated with reduced readmission rates.We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from 2007-2008. All hospital admissions and emergency department visits associated with injury were longitudinally linked. Regions were categorized by whether or not they had trauma centers. We excluded all patients younger than 18 years of age. We performed univariate and multivariate regression analyses to determine if readmissions were associated with patient characteristics, length of stay for initial hospitalization, trauma center access, and triage patterns.A total of 211,504 patients were included in the analysis. Of these, 5,094 (2%) died during the index hospitalization. Of those who survived their initial hospitalization, 79,123 (38%) experienced one or more readmissions to any hospital within one year. The majority of these were one-time readmissions (62%) but 38% experienced multiple readmissions. Over 67% of readmissions were unplanned and 8% of readmissions were for a trauma. After controlling for patient variables known to be associated with readmissions, primary triage to a trauma center was associated with a lower odds of readmission (OR 0.89, p<0.001). The effect of transport to a trauma center remained significantly associated with decreased odds of readmission at one year (OR 0.96, p<0.001).Readmissions after injury are common and are often unscheduled. While patient factors play a role in this, care at a trauma center is also associated with decreased odds for re-admission, even when controlling for severity of injury. This suggests that the benefits of trauma center care extend beyond improvements in mortality to improved long-term outcomes.Economic/Decision LEVEL OF EVIDENCE: Level IV.
View details for DOI 10.1097/TA.0000000000000956
View details for PubMedID 26713975
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Uninsured status may be more predictive of outcomes among the severely injured than minority race
INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED
2016; 47 (1): 197-202
Abstract
Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.We performed a retrospective analysis of the 2010-2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18-64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29-1.98, p<0.001) and black race (OR 1.24, 1.04-1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36-0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29-2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32-0.63, p<0.001).Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.
View details for DOI 10.1016/j.injury.2015.09.003
View details for Web of Science ID 000367339900036
View details for PubMedCentralID PMC4698055
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Improving early identification of the high-risk elderly trauma patient by emergency medical services.
Injury
2016; 47 (1): 19-25
Abstract
We sought to (1) define the high-risk elderly trauma patient based on prognostic differences associated with different injury patterns and (2) derive alternative field trauma triage guidelines that mesh with national field triage guidelines to improve identification of high-risk elderly patients.This was a retrospective cohort study of injured adults ≥65 years transported by 94 EMS agencies to 122 hospitals in 7 regions from 1/1/2006 through 12/31/2008. We tracked current field triage practices by EMS, patient demographics, out-of-hospital physiology, procedures and mechanism of injury. Outcomes included Injury Severity Score≥16 and specific anatomic patterns of serious injury using abbreviated injury scale score ≥3 and surgical interventions. In-hospital mortality was used as a measure of prognosis for different injury patterns.33,298 injured elderly patients were transported by EMS, including 4.5% with ISS≥16, 4.8% with serious brain injury, 3.4% with serious chest injury, 1.6% with serious abdominal-pelvic injury and 29.2% with serious extremity injury. In-hospital mortality ranged from 18.7% (95% CI 16.7-20.7) for ISS≥16 to 2.9% (95% CI 2.6-3.3) for serious extremity injury. The alternative triage guidelines (any positive criterion from the current guidelines, GCS≤14 or abnormal vital signs) outperformed current field triage practices for identifying patients with ISS≥16: sensitivity (92.1% [95% CI 89.6-94.1%] vs. 75.9% [95% CI 72.3-79.2%]), specificity (41.5% [95% CI 40.6-42.4%] vs. 77.8% [95% CI 77.1-78.5%]). Sensitivity decreased for individual injury patterns, but was higher than current triage practices.High-risk elderly trauma patients can be defined by ISS≥16 or specific non-extremity injury patterns. The field triage guidelines could be improved to better identify high-risk elderly trauma patients by EMS, with a reduction in triage specificity.
View details for DOI 10.1016/j.injury.2015.09.010
View details for PubMedID 26477345
View details for PubMedCentralID PMC4698024
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Uninsured status may be more predictive of outcomes among the severely injured than minority race.
Injury
2016; 47 (1): 197-202
Abstract
Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.We performed a retrospective analysis of the 2010-2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18-64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29-1.98, p<0.001) and black race (OR 1.24, 1.04-1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36-0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29-2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32-0.63, p<0.001).Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.
View details for DOI 10.1016/j.injury.2015.09.003
View details for PubMedID 26396045
View details for PubMedCentralID PMC4698055
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Improving early identification of the high-risk elderly trauma patient by emergency medical services
INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED
2016; 47 (1): 19-25
View details for DOI 10.1016/j.injury.2015.09.010
View details for Web of Science ID 000367339900005
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Adding insult to injury: discontinuous insurance following spine trauma.
journal of bone and joint surgery. American volume
2015; 97 (2): 141-146
Abstract
Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.
View details for DOI 10.2106/JBJS.N.00148
View details for PubMedID 25609441
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Adding Insult to Injury: Discontinuous Insurance Following Spine Trauma
JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME
2015; 97A (2): 141-146
Abstract
Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.
View details for DOI 10.2106/JBJS.N.00148
View details for Web of Science ID 000348217200012
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Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank.
World journal of emergency surgery
2015; 10: 23-?
Abstract
Patients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14-15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI.The National Trauma Databank (2007-2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14-15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables.The study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention.We found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.
View details for DOI 10.1186/s13017-015-0017-6
View details for PubMedID 26060506
View details for PubMedCentralID PMC4460849
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Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank.
World journal of emergency surgery
2015; 10: 23-?
Abstract
Patients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14-15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI.The National Trauma Databank (2007-2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14-15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables.The study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention.We found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.
View details for DOI 10.1186/s13017-015-0017-6
View details for PubMedID 26060506
View details for PubMedCentralID PMC4460849
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Patient and Trauma Center Characteristics Associated With Helicopter Emergency Medical Services Transport for Patients With Minor Injuries in the United States
ACADEMIC EMERGENCY MEDICINE
2014; 21 (11): 1232-1239
View details for DOI 10.1111/acem.12512
View details for Web of Science ID 000345237300007
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Patient and trauma center characteristics associated with helicopter emergency medical services transport for patients with minor injuries in the United States.
Academic emergency medicine
2014; 21 (11): 1232-1239
Abstract
Helicopter emergency medical services (EMS) transport is expensive, and previous work has shown that cost-effective use of this resource is dependent on the proportion of minor injuries flown. To understand how overtriage to helicopter EMS versus ground EMS can be reduced, it is important to understand factors associated with helicopter transport of patients with minor injuries.The aim was to characterize patient and hospital characteristics associated with helicopter transport of patients with minor injuries.This was a retrospective analysis of adults ≥18 years who were transported by helicopter to Level I/II trauma centers from 2009 through 2010 as identified in the National Trauma Data Bank. Minor injuries were defined as all injuries scored at an Abbreviated Injury Scale (AIS) score of <3. Patient and hospital characteristics associated of being flown with only minor injuries were compared in an unadjusted and adjusted fashion. Hierarchical, multivariate logistic regression was used to adjust for patient demographics, mechanism of injury, presenting physiology, injury severity, urban-rural location of injury, total EMS time, hospital characteristics, and region.A total of 24,812 records were identified, corresponding to 76,090 helicopter transports. The proportion of helicopter transports with only minor injuries was 36% (95% confidence interval [CI] = 34% to 39%). Patient characteristics associated with being flown with minor injuries included being uninsured (odds ratio [OR] = 1.36, 95% CI = 1.26 to 1.47), injury by a fall (OR = 1.32, 95% CI = 1.20 to 1.45), or other penetrating trauma (OR = 2.52, 95% CI = 2.12 to 3.00). Being flown with minor injuries was more likely if the patient was transported to a trauma center that also received a high proportion of patients with minor injuries by ground EMS (OR = 1.89, 95% CI = 1.58 to 2.26) or a high proportion of EMS traffic by helicopter (OR = 1.35, 95% CI = 1.02 to 1.78). No significant association with urban-rural scene location or EMS transport time was found.Better recognizing which patients with falls and penetrating trauma have serious injuries that could benefit from being flown may lead to the more cost-effective use of helicopter EMS. More research is needed to determine why patients without insurance, who are most at risk for high out-of-pocket expenses from helicopter EMS, are at higher risk for being flown when only having minor injuries. This suggests that interventions to optimize cost-effectiveness of helicopter transport will likely require an evaluation of helicopter triage guidelines in the context of regional and patient needs.
View details for DOI 10.1111/acem.12512
View details for PubMedID 25377400
View details for PubMedCentralID PMC4329240
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Ground-level Falls Are a Marker of Poor Outcome in the Injured Elderly
AMERICAN SURGEON
2014; 80 (11): 1171-1173
View details for Web of Science ID 000346142300037
View details for PubMedID 25347512
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Environmental Sampling for Clostridium difficile on Alcohol-Based Hand Rub Dispensers in an Academic Medical Center
SURGICAL INFECTIONS
2014; 15 (5): 581-584
Abstract
Clostridum difficile is a gram-positive, spore-forming anaerobic bacillus that has substantial associated morbidity, mortality, and associated healthcare burdens. Clostridium difficile spores are not destroyed by alcohol. Alcohol gel dispensers are used commonly as the hand sanitization method of choice in hospitals. It is possible that gel dispensers are fomites for C. difficile.Thirty alcohol-based gel dispenser handles outside of rooms of patients with active C. difficile infection were sampled. The samples were assessed for C. difficile by both culture and polymerase chain reaction (PCR). The samples were also assessed for other organisms by culture.No C. difficile was cultured or detected by PCR on any of the gel dispensers. Coagulase-negative Staphyloccus spp., diptheroids, and Bacillus spp. were the organisms detected most commonly.At our institution, C. difficile is not present on alcohol-based gel dispensers, but other potentially pathogenis are.
View details for DOI 10.1089/sur.2013.102
View details for Web of Science ID 000343224800018
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Environmental sampling for Clostridium difficile on alcohol-based hand rub dispensers in an academic medical center.
Surgical infections
2014; 15 (5): 581-584
Abstract
Clostridum difficile is a gram-positive, spore-forming anaerobic bacillus that has substantial associated morbidity, mortality, and associated healthcare burdens. Clostridium difficile spores are not destroyed by alcohol. Alcohol gel dispensers are used commonly as the hand sanitization method of choice in hospitals. It is possible that gel dispensers are fomites for C. difficile.Thirty alcohol-based gel dispenser handles outside of rooms of patients with active C. difficile infection were sampled. The samples were assessed for C. difficile by both culture and polymerase chain reaction (PCR). The samples were also assessed for other organisms by culture.No C. difficile was cultured or detected by PCR on any of the gel dispensers. Coagulase-negative Staphyloccus spp., diptheroids, and Bacillus spp. were the organisms detected most commonly.At our institution, C. difficile is not present on alcohol-based gel dispensers, but other potentially pathogenis are.
View details for DOI 10.1089/sur.2013.102
View details for PubMedID 25126976
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PHYSIOLOGIC FIELD TRIAGE CRITERIA FOR IDENTIFYING SERIOUSLY INJURED OLDER ADULTS
PREHOSPITAL EMERGENCY CARE
2014; 18 (4): 461-470
View details for DOI 10.3109/10903127.2014.912707
View details for Web of Science ID 000342230400001
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Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non-Trauma Center Emergency Departments Disparities by Insurance Status
JAMA SURGERY
2014; 149 (5): 422-430
Abstract
IMPORTANCE Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non-trauma center emergency departments (EDs). OBJECTIVES To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non-trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non-trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region. MAIN OUTCOMES AND MEASURES Inpatient admission vs transfer to another acute care facility. RESULTS In 2009, a total of 4513 observations from 636 non-trauma center EDs were available for analysis, representing a nationally weighted population of 19 312 non-trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non-trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non-teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10 000 annual ED visits). CONCLUSIONS AND RELEVANCE Patients with severe injuries initially evaluated at non-trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.
View details for DOI 10.1001/jamasurg.2013.4398
View details for Web of Science ID 000337908600005
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Variability in California triage from 2005 to 2009: A population-based longitudinal study of severely injured patients.
journal of trauma and acute care surgery
2014; 76 (4): 1041-1047
Abstract
Timely access to trauma care requires that severely injured patients are ultimately triaged to trauma centers. We sought to determine triage patterns for the injured population within the state of California to determine those factors associated with undertriage.We conducted a retrospective analysis of all hospital visits in California using the Office of Statewide Health Planning and Development Database from January 1, 2005, and December 31, 2009. All visits associated with injury were linked longitudinally. Sixty-day and one-year mortality was determined using vital statistics data. Primary field triage was defined as field triage to a Level I/II trauma center; retriage was defined as initial triage to a non-Level I/II center followed by transfer to a Level I/II. Regions were organized by local emergency medical services agencies. The primary outcomes were triage patterns and mortality.The undertriage rate was 35% (n = 20,988) but was variable across regions (12-87%). Primary field triage ranged from 7% to 77%. Retriage rates not only were overall low (6% of all severely injured patients) but also varied by region (1-38%). In adjusted analysis, factors associated with a lower odds ratio (OR) of primary field triage included the following: age of 55 years or greater (OR, 0.78; p = 0.001), female sex (OR, 0.88; p = 0.014), greater number of comorbidities (OR, 0.92; p < 0.001), and fall mechanism versus motor vehicle collision (OR, 0.54; p < 0.001). One-year mortality was higher for undertriaged patients (25% vs. 16% and 18% for primary field and retriage, respectively, p < 0.001).This is the first study to create a longitudinal database of all emergency department visits, hospitalizations, and long-term mortality for every severely injured patient within an entire state during a 5-year period. Undertriage varied substantially by region and was associated with multiple factors including access to care and patient factors.Epidemiologic study, level III.
View details for DOI 10.1097/TA.0000000000000197
View details for PubMedID 24662870
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The epidemiology of trauma-related mortality in the United States from 2002 to 2010.
journal of trauma and acute care surgery
2014; 76 (4): 913-920
Abstract
Epidemiologic trends in trauma-related mortality in the United States require updating and characterization. We hypothesized that during the past decade, there have been changing trends in mortality that are associated with multiple public health and health care-related factors.Multiple sources were queried for the period of 2002 to 2010: the National Trauma Data Bank, the National Centers for Disease Control, the National Highway Traffic Safety Administration, the Nationwide Emergency Department Sample, and the US Census Bureau. The incidence of injury and mortality for motor vehicle traffic (MVT) collisions, firearms, and falls were determined using National Centers for Disease Control data. National Highway Traffic Safety Administration data were used to determine motor vehicle collision information. Injury severity data were derived from the Nationwide Emergency Department Sample and National Trauma Data Bank. Analysis of mortality trends by year was performed using the Cochran-Armitage test for trend. Time-trend multivariable Poisson regression was used to determine risk-adjusted mortality over time.From 2002 to 2010, the total trauma-related mortality decreased by 6% (p < 0.01). However, mortality trends differed by mechanism. There was a 27% decrease in the MVT death rate associated with a 20% decrease in motor vehicle collisions, 19% decrease in the number of occupant injuries per collision, lower injury severity, and improved outcomes at trauma centers. While firearm-related mortality remained relatively unchanged, mortality caused by firearm suicides increased, whereas homicide-associated mortality decreased (p < 0.001 for both). In contrast, fall-related mortality increased by 46% (5.95-8.70, p < 0.01).MVT mortality rates have decreased during the last decade, owing in part to decreases in the number and severity of injuries. Conversely, fall-related mortality is increasing and is projected to exceed both MVT and firearm mortality rates should current trends continue. Trauma systems and injury prevention programs will need to take into account these changing trends to best accommodate the needs of the injured population.Epidemiologic study, level III.
View details for DOI 10.1097/TA.0000000000000169
View details for PubMedID 24662852
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Gunshot Injuries in Children Served by Emergency Services
PEDIATRICS
2013; 132 (5): 862-870
Abstract
To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms.This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age ≤ 19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥ 16, major surgery, blood transfusion, mortality, and average per-patient acute care costs.A total of 49,983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100,000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28,510 per patient, 95% CI 22,193-34,827).Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.
View details for DOI 10.1542/peds.2013-1350
View details for PubMedID 24127481
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Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States.
Annals of emergency medicine
2013; 62 (4): 351-364 e19
Abstract
STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.
View details for DOI 10.1016/j.annemergmed.2013.02.025
View details for PubMedID 23582619
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Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States.
Annals of emergency medicine
2013; 62 (4): 351-364 e19
Abstract
STUDY OBJECTIVE: We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS: We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS: Helicopter EMS must provide a minimum of a 17% relative risk reduction in mortality (1.6 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 33% (3.7 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION: Helicopter EMS needs to provide at least a 17% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.
View details for DOI 10.1016/j.annemergmed.2013.02.025
View details for PubMedID 23582619
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Triage of elderly trauma patients: a population-based perspective.
Journal of the American College of Surgeons
2013; 217 (4): 569-576
Abstract
Elderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes.This is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center.There were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers.This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.
View details for DOI 10.1016/j.jamcollsurg.2013.06.017
View details for PubMedID 24054408
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The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers
HEALTH AFFAIRS
2013; 32 (9): 1591-1599
Abstract
Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.
View details for DOI 10.1377/hlthaff.2012.1142
View details for Web of Science ID 000324681500012
View details for PubMedID 24019364
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Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems
ACADEMIC EMERGENCY MEDICINE
2013; 20 (9): 911-919
Abstract
Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis.This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. "Serious injury" was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings.A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols.Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis.
View details for DOI 10.1111/acem.12213
View details for PubMedID 24050797
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Variability of ICU use in adult patients with minor traumatic intracranial hemorrhage.
Annals of emergency medicine
2013; 61 (5): 509-517 e4
Abstract
Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P<.001).Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.
View details for DOI 10.1016/j.annemergmed.2012.08.024
View details for PubMedID 23021347
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The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
2013; 74 (5): 1298-1306
Abstract
BACKGROUND: National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. METHODS: This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. RESULTS: A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). CONCLUSION: Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm. LEVEL OF EVIDENCE: Diagnostic test, level II.
View details for DOI 10.1097/TA.0b013e31828b7848
View details for PubMedID 23609282
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Predictors of emergency department death for patients presenting with ruptured abdominal aortic aneurysms
JOURNAL OF VASCULAR SURGERY
2012; 56 (3): 651-655
Abstract
Ruptured abdominal aortic aneurysm (rAAA) is a critically time-sensitive condition with outcomes dependent on rapid diagnosis and definitive treatment. Emergency department (ED) death reflects the hemodynamic stability of the patient upon arrival and the ability to mobilize resources before hemodynamic stability is lost. The goals of this study were to determine the incidence and predictors of ED death for patients presenting to EDs with rAAAs.Data for patients presenting with International Classification of Disease, 9th Revision, Clinical Modification codes for rAAA from 2006 to 2008 were extracted from discharge data using the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. The NEDS is the largest stratified weighted sample of US hospital-based ED visits with links to inpatient files. We compared those transferred to those admitted and treated. Sample weights were applied to produce nationally representative estimates. Patient and hospital factors associated with transfer were identified using multivariate logistic regression. These factors were then analyzed for a relationship with ED deaths.A total of 18,363 patients were evaluated for rAAAs. Of these, 7% (1201) died in the ED, 6% (1160) were admitted and died without a procedure, 42% (7731) were admitted and died after repair, and 41% (7479) were admitted, treated, and survived. Transfers accounted for 4% (793) of all ED visits for rAAAs. ED death was more likely for patients seen in nonmetropolitan hospitals (12.7%) vs metropolitan nonteaching (7.0%) or metropolitan teaching hospitals (4.5%; P < .0001). Compared with other regions, the West had a higher ED mortality rate (9.6% vs 5.1%-6.9%; P = .0038). On multivariate analysis, ED death was associated with hospital groups exhibiting both high and low transfer rates.ED death remains a significant cause for mortality for rAAAs and varies by hospital type, rural/urban location, and geographic region. Both delays in ED arrival and delays in providing definitive care may contribute to increased ED death rates, suggesting that improved regional systems of care may improve survival after rAAA.
View details for DOI 10.1016/j.jvs.2012.02.025
View details for Web of Science ID 000308085500010
View details for PubMedID 22560234
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Evaluating Age in the Field Triage of Injured Persons
ANNALS OF EMERGENCY MEDICINE
2012; 60 (3): 335-345
Abstract
We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.
View details for DOI 10.1016/j.annemergmed.2012.04.006
View details for PubMedID 22633339
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Payer status is associated with the use of prophylactic inferior vena cava filter in high-risk trauma patients
SURGERY
2012; 152 (2): 232-237
Abstract
It is controversial whether patients at high risk for pulmonary embolism (PE) should receive prophylactic inferior vena cava filters (IVC) filters. This lack of clarity creates the potential for variability and disparities in care. We hypothesized there would be differential use of prophylactic IVC filters for patients at high risk for PE on the basis of insurance status.We performed a retrospective analysis using the National Trauma Databank (2002-2007). We included adult patients at high risk for PE (traumatic brain injury or spinal cord injury) and excluded patients with a diagnosis of deep venous thrombosis (DVT) or PE. Logistic regression was performed to control for confounders and a hierarchical mixed effects model was used to control for center.A prophylactic filter was placed in 3,331 (4.3%) patients in the study cohort. Patients without insurance had an IVC filter placed less often compared with those with any form of insurance (2.7% vs 4.9%, respectively). After adjusting for confounders, we found that patients without insurance were less likely to receive a prophylactic IVC filter, even when we controlled for center (OR 5.3, P < .001).When guidelines lack clarity, unconscious bias has the potential to create a system with different levels of care based on socioeconomic disparities.
View details for DOI 10.1016/j.surg.2012.05.041
View details for Web of Science ID 000307157500013
View details for PubMedID 22828145
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Evaluating the Use of Existing Data Sources, Probabilistic Linkage, and Multiple Imputation to Build Population-based Injury Databases Across Phases of Trauma Care
ACADEMIC EMERGENCY MEDICINE
2012; 19 (4): 469-480
Abstract
The objective was to evaluate the process of using existing data sources, probabilistic linkage, and multiple imputation to create large population-based injury databases matched to outcomes.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical systems (EMS) agencies to 122 hospitals in seven regions of the western United States over a 36-month period (2006 to 2008). All injured patients evaluated by EMS personnel within specific geographic catchment areas were included, regardless of field disposition or outcome. The authors performed probabilistic linkage of EMS records to four hospital and postdischarge data sources (emergency department [ED] data, patient discharge data, trauma registries, and vital statistics files) and then handled missing values using multiple imputation. The authors compare and evaluate matched records, match rates (proportion of matches among eligible patients), and injury outcomes within and across sites.There were 381,719 injured patients evaluated by EMS personnel in the seven regions. Among transported patients, match rates ranged from 14.9% to 87.5% and were directly affected by the availability of hospital data sources and proportion of missing values for key linkage variables. For vital statistics records (1-year mortality), estimated match rates ranged from 88.0% to 98.7%. Use of multiple imputation (compared to complete case analysis) reduced bias for injury outcomes, although sample size, percentage missing, type of variable, and combined-site versus single-site imputation models all affected the resulting estimates and variance.This project demonstrates the feasibility and describes the process of constructing population-based injury databases across multiple phases of care using existing data sources and commonly available analytic methods. Attention to key linkage variables and decisions for handling missing values can be used to increase match rates between data sources, minimize bias, and preserve sampling design.
View details for DOI 10.1111/j.1553-2712.2012.01324.x
View details for PubMedID 22506952
View details for PubMedCentralID PMC3334286
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The forgotten trauma patient: Outcomes for injured patients evaluated by emergency medical services but not transported to the hospital
JOURNAL OF TRAUMA AND ACUTE CARE SURGERY
2012; 72 (3): 594-599
Abstract
Injured patients who are not transported by an ambulance to the hospital are often not included in trauma registries. The outcomes of these patients have until now been unknown. Understanding what happens to nontransports is necessary to better understand triage validity, patient outcomes, and costs associated with injury. We hypothesized that a subset of patients who were not transported from the scene would later present for evaluation and that these patients would have a nonzero mortality rate.This is a population-based, retrospective cohort study of injured adults and children for three counties in California from 2006 to 2008. Prehospital data for injured patients for whom an ambulance was dispatched were probabilistically linked to trauma registry data from four trauma centers, state-level discharge data, emergency department records, and death files (1-year mortality).A total of 69,413 injured persons who were evaluated at the scene by emergency medical services were included in the analysis. Of them, 5,865 (8.5%) were not transported. Of those not transported, 1,616 (28%) were later seen in an emergency department and discharged and 92 (2%) were admitted. Seven (0.2%) patients later died.Patients evaluated by emergency medical services, but not initially transported from the field after injury, often present later to the hospital. The mortality rate in this population was not zero, and these patients may represent preventable deaths.III, therapeutic study.
View details for DOI 10.1097/TA.0b013e31824764ef
View details for Web of Science ID 000301371100016
View details for PubMedID 22491541
View details for PubMedCentralID PMC3489913
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A Multisite Assessment of the American College of Surgeons Committee on Trauma Field Triage Decision Scheme for Identifying Seriously Injured Children and Adults
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2011; 213 (6): 709-721
Abstract
The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort.This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16.There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings.The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
View details for DOI 10.1016/j.jamcollsurg.2011.09.012
View details for PubMedID 22107917
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Ruptured Biliary Cystadenoma Managed by Angiographic Embolization and Interval Partial Hepatectomy
DIGESTIVE DISEASES AND SCIENCES
2011; 56 (7): 1949-1953
View details for DOI 10.1007/s10620-011-1677-z
View details for PubMedID 21445579
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Systematic Review: Benefits and Harms of In-Hospital Use of Recombinant Factor VIIa for Off-Label Indications
ANNALS OF INTERNAL MEDICINE
2011; 154 (8): 529-W190
Abstract
Recombinant factor VIIa (rFVIIa), a hemostatic agent approved for hemophilia, is increasingly used for off-label indications.To evaluate the benefits and harms of rFVIIa use for 5 off-label, in-hospital indications: intracranial hemorrhage, cardiac surgery, trauma, liver transplantation, and prostatectomy.Ten databases (including PubMed, EMBASE, and the Cochrane Library) queried from inception through December 2010. Articles published in English were analyzed.Two reviewers independently screened titles and abstracts to identify clinical use of rFVIIa for the selected indications and identified all randomized, controlled trials (RCTs) and observational studies for full-text review.Two reviewers independently assessed study characteristics and rated study quality and indication-wide strength of evidence.16 RCTs, 26 comparative observational studies, and 22 noncomparative observational studies met inclusion criteria. Identified comparators were limited to placebo (RCTs) or usual care (observational studies). For intracranial hemorrhage, mortality was not improved with rFVIIa use across a range of doses. Arterial thromboembolism was increased with medium-dose rFVIIa use (risk difference [RD], 0.03 [95% CI, 0.01 to 0.06]) and high-dose rFVIIa use (RD, 0.06 [CI, 0.01 to 0.11]). For adult cardiac surgery, there was no mortality difference, but there was an increased risk for thromboembolism (RD, 0.05 [CI, 0.01 to 0.10]) with rFVIIa. For body trauma, there were no differences in mortality or thromboembolism, but there was a reduced risk for the acute respiratory distress syndrome (RD, -0.05 [CI, -0.02 to -0.08]). Mortality was higher in observational studies than in RCTs.The amount and strength of evidence were low for most outcomes and indications. Publication bias could not be excluded.Limited available evidence for 5 off-label indications suggests no mortality reduction with rFVIIa use. For some indications, it increases thromboembolism.
View details for PubMedID 21502651
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Matching Trauma Triage Criteria to Adult Age: Development of Field Triage Guidelines for Identifying High-Risk Young and Older Adults
LIPPINCOTT WILLIAMS & WILKINS. 2010
View details for Web of Science ID 000208231600147
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Outcomes and complications of open abdomen technique for managing non-trauma patients.
Journal of emergencies, trauma, and shock
2010; 3 (2): 118-122
Abstract
Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate.Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay.One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n = 19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1-3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25-31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%.Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.
View details for DOI 10.4103/0974-2700.62106
View details for PubMedID 20606786
View details for PubMedCentralID PMC2884440
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Comparison of Thromboembolic Event Rates in Randomized Controlled Trials and Observational Studies of Recombinant Factor VIIa for Off-Label Indications.
51st Annual Meeting and Exposition of the American-Society-of-Hematology
AMER SOC HEMATOLOGY. 2009: 571–72
View details for Web of Science ID 000272725801583
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Trauma training in simulation: Translating skills from SIM time to real time
66th Annual Meeting of the American-Association-for-the-Surgery-of-Trauma
LIPPINCOTT WILLIAMS & WILKINS. 2008: 255–63
Abstract
: Training surgical residents to manage critically injured patients in a timely fashion presents a significant challenge. Simulation may have a role in this educational process, but only if it can be demonstrated that skills learned in a simulated environment translate into enhanced performance in real-life trauma situations.: A five-part, scenario-based trauma curriculum was developed specifically for this study. Midlevel surgical residents were randomized to receiving this curriculum in didactic lecture (LEC) fashion or with the use of a human performance simulator (HPS). A written learning objectives test was administered at the completion of the training. The first four major trauma resuscitations performed by each participating resident were captured on videotape in the emergency department and graded by two experienced judges blinded to the method of training. The assessment tool used by the judges included an evaluation of both initial trauma evaluation or treatment skills (part I) and crisis management skills (part II) as well as an overall score (poor/fail, adequate, or excellent).: The two groups of residents received almost identical scores on the posttraining written test. Average SIM and LEC scores for part I were also similar between the two groups. However, SIM-trained residents received higher overall scores and higher scores for part II crisis management skills compared with the LEC group, which was most evident in the scores received for the teamwork category (p = 0.04).: A trauma curriculum incorporating simulation shows promise in developing crisis management skills that are essential for evaluation of critically injured patients.
View details for DOI 10.1097/TA.0b013e31816275b0
View details for Web of Science ID 000253287100001
View details for PubMedID 18301184
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Angiopoietin-2, marker and mediator of endothelial activation with prognostic significance early after trauma?
ANNALS OF SURGERY
2008; 247 (2): 320-326
Abstract
To measure plasma levels of angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), and vascular endothelial growth factor (VEGF) early after trauma and to determine their clinical significance.Angiopoietins and VEGF play a central role in the physiology and pathophysiology of endothelial cells. Ang-2 has recently been shown to have pathogenetic significance in sepsis and acute lung injury. Little is known about the role of angiopoietins and VEGF early after trauma.Blood specimens from consecutive major trauma patients were obtained immediately upon arrival in the emergency department and plasma samples assayed for Ang-1, Ang-2, VEGF, markers of endothelial activation, protein C pathway, fibrinolytic system, and complement. Base deficit was used as a measure of tissue hypoperfusion. Data were collected prospectively.Blood samples were obtained from 208 adult trauma patients within 30 minutes after injury before any significant fluid resuscitation. Plasma levels of Ang-2, but not Ang-1 and VEGF were increased and correlated independently with severity of injury and tissue hypoperfusion. Furthermore, plasma levels of Ang-2 correlated with markers of endothelial activation, coagulation abnormalities, and activation of the complement cascade and were associated with worse clinical outcome.Ang-2 is released early after trauma with the degree proportional to both injury severity and systemic hypoperfusion. High levels of Ang-2 were associated with an activated endothelium, coagulation abnormalities, complement activation, and worse clinical outcome. These data indicate that Ang-2 is a marker and possibly a direct mediator of endothelial activation and dysfunction after severe trauma.
View details for DOI 10.1097/SLA.0b013e318162d616
View details for Web of Science ID 000252758500018
View details for PubMedID 18216540
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Ethnic disparities in long-term function outcomes after traumatic brain injury
20th Annual Meeting of the Eastern-Association-for-the-Surgery-of-Trauma
LIPPINCOTT WILLIAMS & WILKINS. 2007: 1364–69
Abstract
Ethnic disparities in access to acute rehabilitation and in long-term global neurologic outcomes after traumatic brain injury (TBI) have been previously documented. The current study was undertaken to determine whether there are specific types of functional deficits that disproportionately affect ethnic minorities after TBI.The TBI Clinical Trials Network is a National Institutes of Health-funded multicenter prospective study. Local data from trauma centers in a single ethnically diverse major metropolitan study site were analyzed. Functional outcomes were measured in 211 patients with blunt TBI (head Abbreviated Injury Scale score 3-5) who were alive >/=6 months after discharge using the Functional Status Examination (FSE), which measures outcome in 10 functional domains and compares current functional status to preinjury status. For each domain, patients were classified as functionally independent (FSE score 1, 2) or dependent upon others (FSE score 3, 4). Ethnic minorities (n = 66) were compared with non-Hispanic whites (n = 145), with p < 0.05 considered significant.The two groups had similar injury severity (head Abbreviated Injury Scale score, initial Glasgow Coma Scale score, Injury Severity Score) and were equally likely to be placed in rehabilitation after trauma center discharge (minorities 51%, whites 46%, p = 0.28). Minority patients experienced worse long-term functional outcomes in all domains, which reached statistical significance in post-TBI standard of living, engagement in leisure activities, and return to work or school.Ethnic minorities with TBI suffer worse long-term deficits in three specific functional domains. TBI rehabilitation programs should target these specific areas to reduce disparities in functional outcomes in ethnic minorities.
View details for DOI 10.1097/TA.0b013e31815b897b
View details for Web of Science ID 000251768100031
View details for PubMedID 18212662
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Civilian hospital response to mass casualty events: basic principles.
Bulletin of the American College of Surgeons
2007; 92 (8): 16-20
View details for PubMedID 17715580
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Hypertonic saline modulates innate immunity in a model of systemic inflammation
SHOCK
2005; 23 (5): 459-463
Abstract
We sought to determine if hypertonic saline (HTS) impacted alveolar macrophage (AM) activation and intracellular inflammatory gene signaling in a model of systemic inflammation. Rats received an intravenous administration of 4 mL/kg of 7.5% HTS or L-lactate lactated Ringer's (L-LR). They were simultaneously treated with an intraperitoneal injection of zymosan, which induces noninfectious systemic inflammation. AM were harvested by bronchoalveolar lavage 24 h after treatment. AM activation was analyzed by measurement of baseline and lipopolysaccharide (LPS)-induced TNF-alpha production. Intracellular signaling was analyzed for activation of the mitogen-activated protein kinases (MAPKs): ERK1/2, JNK, and p38. AM from HTS-treated rats produced less TNF-alpha than from L-LR-treated rats (927 +/- 335 pg/mL [SEM] vs. 3628 +/- 783 pg/mL [SEM], P = 0.001) and were also less responsive to LPS (4444 +/- 86 pg/mL [SEM] vs. 6666 +/- 91 pg/mL [SEM], P = 0.058). However, there was no difference in MAPK activation. In vivo HTS prevents excessive AM activation during systemic inflammation. This suppression is mediated through alternate pathways and does not induce the classic MAPK signaling cascade.
View details for DOI 10.1097/01.shk.0000160523.37106.33
View details for Web of Science ID 000228913500011
View details for PubMedID 15834313