Lisa Marie Knowlton, MD, MPH, FACS, FRCSC

All Publications

• Taking action to achieve health equity and eliminate healthcare disparities within acute care surgery. Trauma surgery & acute care open McCrum, M. L., Zakrison, T. L., Knowlton, L. M., Bruns, B., Kao, L. S., Joseph, K. A., Berry, C. 2024; 9 (1): e001494

  Abstract

  Addressing disparities is crucial for enhancing population health, ensuring health security, and fostering resilient health systems. Disparities in acute care surgery (trauma, emergency general surgery, and surgical critical care) have been well documented and the magnitude of inequities demand an intentional, organized, and effective response. As part of its commitment to achieve high-quality, equitable care in all aspects of acute care surgery, the American Association for the Surgery of Trauma convened an expert panel at its eigty-second annual meeting in September 2023 to discuss how to take action to work towards health equity in acute care surgery practice. The panel discussion framed contemporary disparities in the context of historic and political injustices, then identified targets for interventions and potential action items in health system structure, health policy, the surgical workforce, institutional operations and quality efforts. We offer a four-pronged approach to address health inequities: identify, reduce, eliminate, and heal disparities, with the goal of building a healthcare system that achieves equity and justice for all.

  View details for DOI 10.1136/tsaco-2024-001494

  View details for PubMedID 39416956

  View details for PubMedCentralID PMC11481130

• Emergency Medicaid enrollment after traumatic injury predicts long-term health care utilization. The journal of trauma and acute care surgery Haddad, D. N., Eisinger, E., Hatchimonji, J. S., Chen, A. T., Ramadan, O. I., Morgan, A. U., Lile, D. J., Delgado, M. K., Reese, J., Seamon, M. J., Martin, N. D., Reilly, P. M., Knowlton, L. M., Kaufman, E. J. 2024

  Abstract

  Injured patients have high rates of uninsurance, which is associated with worse outcomes. Insurance linkage programs that connect patients to Medicaid coverage can prevent catastrophic costs for patients. Less is known about the long-term impact of insurance enrollment. We examined health care utilization for previously uninsured patients, hypothesizing that newly insured patients postinjury would use health care more than those remaining uninsured.We linked institutional trauma registry data to the electronic medical record to identify injured patients aged 18 to 64 years from 2017 to 2021. Patients admitted without insurance and then retroactively insured (RI) during hospitalization were compared with patients with preestablished Medicaid (Medicaid insured [MI]) and those remaining uninsured. We compared demographic and injury characteristics and future health care utilization, including hospitalizations, emergency department (ED) visits, and clinic visits, among groups at 30 days and 12 months postinjury. Patient-reported outcomes (PROs) 6 months after injury were compared by group for a subset of patients participating in an ongoing study of long-term PROs.We compared 494 RI patients with 1,706 MI and 148 uninsured patients. Retroactively insured patients were younger, more likely to have penetrating injuries, and longer hospitalization than other groups. There was a significant increase in ED and clinic visits and hospital admissions at 30 days and 12 months between RI and uninsured patients (p < 0.001). Using multivariable logistic regression, RI was associated with higher future ED utilization, hospital admissions, and specialist visits at 30 days and 12 months compared with uninsured patients. Of the 265 patients with 6-month PROs, Medicaid coverage was not associated with any significant difference in physical function or anxiety.Patients enrolled in insurance postinjury are more likely to use health care in the future than patients without insurance, but the downstream effects are less clear. Health insurance is a necessary step but not independently sufficient to optimize care and improve health outcomes.Prognostic and Epidemiological; Level IV.

  View details for DOI 10.1097/TA.0000000000004403

  View details for PubMedID 39225808

• Does preperitoneal packing increase venous thromboembolim risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers. The journal of trauma and acute care surgery Knowlton, L. M., Sauaia, A., Moore, E. E., Knudson, M. M., CLOTT Study Group 2024

  Abstract

  INTRODUCTION: Pelvic fractures are associated with a high risk of venous thromboembolism (VTE). Among treatment options, including pelvic angioembolization (PA), preperitoneal pelvic packing (PPP), and pelvic open reduction internal fixation (ORIF), PPP has been postulated as a VTE risk factor. We aimed to characterize the risk of VTE among pelvic fracture patients receiving PPP, PA or ORIF.METHODS: We used observational data from a 17-site Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group, a US level I trauma center collaborative working to identify factors associated with posttraumatic VTE, deep venous thrombosis, pulmonary embolism, or pulmonary thrombosis. The CLOTT criteria included age 18 to 40 years with at least one independent VTE risk factor. We compared outcomes of PPP, PA, and pelvic ORIF to reference of no pelvic intervention. Our primary outcome was VTE. A competing risk analysis was performed.RESULTS: Among 1,387 pelvic fracture patients, VTE incidence was 5.6%. The ORIF patients were most likely to develop VTE (24.7%), while VTE incidence for PPP was 9.0% and 2.6% for PA. After multivariate, risk-competing analysis, none of the three treatment interventions for pelvic fractures were significantly associated with VTE. Initiation of VTE prophylaxis in the first 24 hours of admission independently halved VTE incidence (hazard ratio, 0.55; confidence interval, 0.33-0.91).CONCLUSION: Pelvic fracture interventions do not appear to be independent risk factors for VTE in our study. Initiation of VTE pharmacoprophylaxis within the first 24 hours of admission remains critical to significantly decreasing VTE formation in this high-risk population.LEVEL OF EVIDENCE: Therapeutic Study; Level III.

  View details for DOI 10.1097/TA.0000000000004416

  View details for PubMedID 39058389

• Hospital Presumptive Eligibility Emergency Medicaid Programs: An Opportunity for Continuous Insurance Coverage? Medical care Knowlton, L. M., Arnow, K., Trickey, A. W., Tran, L. D., Harris, A. H., Morris, A. M., Wagner, T. H. 2024

  Abstract

  Lack of health insurance is a public health crisis, leading to foregone care and financial strain. Hospital Presumptive Eligibility (HPE) is a hospital-based emergency Medicaid program that provides temporary (up to 60 d) coverage, with the goal that hospitals will assist patients in applying for ongoing Medicaid coverage. It is unclear whether HPE is associated with successful longer-term Medicaid enrollment.To characterize Medicaid enrollment 6 months after initiation of HPE and determine sociodemographic, clinical, and geographic factors associated with Medicaid enrollment.This was a cohort study of all HPE approved inpatients in California, using claims data from the California Department of Healthcare Services.The study was conducted across all HPE-participating hospitals within California between January 1, 2016 and December 31, 2017.We studied California adult hospitalized inpatients, who were uninsured at the time of hospitalization and approved for HPE emergency Medicaid. Using multivariable logistic regression models, we compared HPE-approved patients who enrolled in Medicaid by 6 months versus those who did not.HPE emergency Medicaid approval at the time of hospitalization.The primary outcome was full-scope Medicaid enrollment by 6 months after the hospital's presumptive eligibility approval.Among 71,335 inpatient HPE recipients, a total of 45,817 (64.2%) enrolled in Medicaid by 6 months. There was variability in Medicaid enrollment across counties in California (33%-100%). In adjusted analyses, Spanish-preferred-language patients were less likely to enrollin Medicaid (aOR 0.77, P<0.001). Surgical intervention (aOR 1.10, P<0.001) and discharge to another inpatient facility or a long-term care facility increased the odds of Medicaid enrollment (vs. routine discharge home: aOR 2.24 and aOR 1.96, P<0.001).California patients who enroll in HPE often enroll in Medicaid coverage by 6 months, particularly among patients requiring surgical intervention, repeated health care visits, and ongoing access to care. Future opportunities include prospective evaluation of HPE recipients to understand the impact that Medicaid enrollment has on health care utilization and financial solvency.

  View details for DOI 10.1097/MLR.0000000000002026

  View details for PubMedID 38986116

• Small bowel obstruction due to a migrated pyloric stent. Trauma surgery & acute care open Agolia, J. P., Wang, S., Fisher, A., Bryan, J. L., Knowlton, L. M. 2024; 9 (1): e001443

  View details for DOI 10.1136/tsaco-2024-001443

  View details for PubMedID 38756695

  View details for PubMedCentralID PMC11097799

• 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 Ayoung-Chee, P. R., Gore, A. V., Bruns, B., Knowlton, L. M., Nahmias, J., Davis, K. A., Leichtle, S., Ross, S. W., Scherer, L. R., Velopulos, C., Martin, R. S., Staudenmayer, K. L. 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

• Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019. The Journal of surgical research Korah, M., Tennakoon, L., Knowlton, L. M., Tung, J., Spain, D. A., Ko, A. 2024; 298: 307-315

  Abstract

  Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA.The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay.Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001).NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.

  View details for DOI 10.1016/j.jss.2024.03.017

  View details for PubMedID 38640616

• Severe intracranial and intra-abdominal hemorrhage: timing is everything. Trauma surgery & acute care open Farooqi, N. B., Wong, S. Y., Wang, S., Knowlton, L. M. 2024; 9 (1): e001434

  View details for DOI 10.1136/tsaco-2024-001434

  View details for PubMedID 38616787

  View details for PubMedCentralID PMC11015236

• Firearm-Related Injuries and the US Opioid and Other Substance Use Epidemic: A Nationwide Evaluation of Emergency Department Encounters. The Journal of surgical research Tennakoon, L., Ko, A., Knight, A. W., Nassar, A. K., Wu, R., Spain, D. A., Knowlton, L. M. 2024; 298: 128-136

  Abstract

  There has been a sharp climb in the Unites States' death rate among opioid and other substance abuse patients, as well as an increased prevalence in gun violence. We aimed to investigate the association between substance abuse and gun violence in a national sample of patients presenting to US emergency departments (EDs).We queried the 2018-2019 Nationwide Emergency Department Sample for patients ≥18 years with substance abuse disorders (opioid and other) using International Classification of Diseases, 10th Revision, Clinical Modification codes. Within this sample, we analyzed characteristics and outcomes of patients with firearm-related injuries. The primary outcome was mortality; secondary outcomes were ED charges and length of stay.Among the 25.2 million substance use disorder (SUD) patients in our analysis, 35,306 (0.14%) had a firearm-related diagnosis. Compared to other SUD patients, firearm-SUD patients were younger (33.3 versus 44.7 years, P < 0.001), primarily male (88.6% versus 54.2%, P < 0.001), of lower-income status (0-25th percentile income: 56.4% versus 40.5%, P < 0.001), and more likely to be insured by Medicaid or self-pay (71.6% versus 53.2%, P < 0.001). Firearm-SUD patients had higher mortality (1.4% versus 0.4%, P < 0.001), longer lengths of stay (6.5 versus 4.9 days, P < 0.001), and higher ED charges ($9269 versus $5,164, P < 0.001). Firearm-SUD patients had a 60.3% rate of psychiatric diagnoses. Firearm-SUD patients had 5.5 times greater odds of mortality in adjusted analyses (adjusted odds ratio: 5.5, P < 0.001).Opioid-substance abuse patients with firearm injuries have higher mortality rates and costs among these groups, with limited discharge to postacute care resources. All these factors together point to the urgent need for improved screening and treatment for this vulnerable group of patients.

  View details for DOI 10.1016/j.jss.2024.02.007

  View details for PubMedID 38603943

• Managing career transitions in the profession of acute care surgery. Trauma surgery & acute care open Fitzgerald, C. A., Dumas, R. P., Cripps, M. W., Gurney, J. M., Davis, K. A., Knowlton, L. M. 2024; 9 (1): e001334

  Abstract

  Career shifts are a naturally occurring part of the trauma and acute care surgeon's profession. These transitions may occur at various timepoints throughout a surgeon's career and each has their own specific challenges. Finding a good fit for your first job is critical for ensuring success as an early career surgeon. Equally, understanding how to navigate promotions or a change in job location mid-career can be fraught with uncertainty. As one progresses in their career, knowing when to take on a leadership position is oftentimes difficult as it may mean a change in priorities. Finally, navigating your path towards a fulfilling retirement is a complex discussion that is different for each surgeon. The American Association for the Surgery of Trauma (AAST) convened an expert panel of acute care surgeons in a virtual grand rounds session in August 2023 to address the aforementioned career transitions and highlight strategies for successfully navigating each shift. 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 early, mid-career and senior surgeons, and recommendations are summarized below and in figure 1.

  View details for DOI 10.1136/tsaco-2023-001334

  View details for PubMedID 38616786

  View details for PubMedCentralID PMC11015232

• Large uterine fibroids causing a closed loop small bowel obstruction following uterine fibroid embolization. Trauma surgery & acute care open Antono, A. C., Najar, J., Wong, S. Y., Junn, J., Knowlton, L. M. 2024; 9 (1): e001425

  View details for DOI 10.1136/tsaco-2024-001425

  View details for PubMedID 38464551

  View details for PubMedCentralID PMC10921493

• 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 Knowlton, L. M., Scott, J. W., Dowzicky, P., Murphy, P., Davis, K. A., Staudenmayer, K., Martin, R. S. 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

• Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry. Trauma surgery & acute care open Lombardo, S., McCrum, M., Knudson, M. M., Moore, E. E., Kornblith, L., Brakenridge, S., Bruns, B., Cipolle, M. D., Costantini, T. W., Crookes, B., Haut, E. R., Kerwin, A. J., Kiraly, L. N., Knowlton, L. M., Martin, M. J., McNutt, M. K., Milia, D. J., Mohr, A., Rogers, F., Scalea, T., Sixta, S., Spain, D., Wade, C. E., Velmahos, G. C., Nirula, R., Nunez, J. 2024; 9 (1): e001230

  Abstract

  Optimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads to lower VTE risk. We hypothesized that WB dosing would decrease VTE risk compared with standard fixed dosing (SFD).Patients from the prospective, observational CLOTT-1 registry receiving prophylactic enoxaparin (n=5539) were categorized as WB (0.45-0.55 mg/kg two times per day) or SFD (30 mg two times per day, 40 mg once a day). Multivariate logistic regression was used to generate a predicted probability of VTE for WB and SFD patients.Of 4360 patients analyzed, 1065 (24.4%) were WB and 3295 (75.6%) were SFD. WB patients were younger, female, more severely injured, and underwent major operation or major venous repair at a higher rate than individuals in the SFD group. Obesity was more common among the SFD group. Unadjusted VTE rates were comparable (WB 3.1% vs. SFD 3.9%; p=0.221). Early prophylaxis was associated with lower VTE rate (1.4% vs. 5.0%; p=0.001) and deep vein thrombosis (0.9% vs. 4.4%; p<0.001), but not pulmonary embolism (0.7% vs. 1.4%; p=0.259). After adjustment, VTE incidence did not differ by dosing strategy (adjusted OR (aOR) 0.75, 95% CI 0.38 to 1.48); however, early administration was associated with a significant reduction in VTE (aOR 0.47, 95% CI 0.30 to 0.74).In young trauma patients, WB prophylaxis is not associated with reduced VTE rate when compared with SFD. The timing of the initiation of chemoprophylaxis may be more important than the dosing strategy. Further studies need to evaluate these findings across a wider age and comorbidity spectrum.Level IV, therapeutic/care management.

  View details for DOI 10.1136/tsaco-2023-001230

  View details for PubMedID 38420604

  View details for PubMedCentralID PMC10900334

• Cholecystocolonic fistula: an unusual presentation of large bowel obstruction. Trauma surgery & acute care open Knight, A. W., Wu, R., Tennakoon, L., Knowlton, L. M. 2024; 9 (Suppl 1): e001242

  View details for DOI 10.1136/tsaco-2023-001242

  View details for PubMedID 38196931

• A Qualitative Study of Emergency Medicaid Programs From the Perspective of Hospital Stakeholders. The Journal of surgical research Boncompagni, A. C., Handley, T. J., Sasnal, M., Morris, A. M., Knowlton, L. M. 2023; 295: 530-539

  Abstract

  Uninsured patients often have poor clinical outcomes associated with lower access to care. Hospital Presumptive Eligibility (HPE) provides up to 60-d emergency Medicaid coverage for uninsured, low-income patients. After obtaining 60-d HPE, patients must file for ongoing Medicaid to sustain coverage; however, navigating HPE approval is complex. We conducted a qualitative study to understand (1) stakeholder perspectives on the application process and workflow and (2) facilitators and barriers to HPE approval to understand process improvement opportunities.We conducted semi-structured interviews between September-December 2021 with key stakeholders (social workers, financial counselors, case managers, and private third-party vendor representatives) involved in HPE coverage determination, screening, approval, and Medicaid sustainment at our institution. We performed a team-based thematic analysis to elicit factors influencing HPE screening and approval, and recommendations for process improvement.Study participants described the HPE application and Medicaid approval processes. Patient-level barriers included information disclosure and immigration status, inability to contact patients or next-of-kin, and knowledge gaps about insurance acquisition and sustainment. System-level barriers included technical challenges with the state HPE application portal, inadequate staffing for patient screening, and short emergency department stays that limited opportunities to initiate HPE. Stakeholders proposed improvements in education, patient outreach, and logistics.This qualitative study reveals the process of HPE approval and outlines barriers within HPE and Medicaid processing from the perspective of direct hospital stakeholders. We identified opportunities at the patient, hospital, and policy levels that could improve successful HPE application and approval rates.

  View details for DOI 10.1016/j.jss.2023.11.038

  View details for PubMedID 38086253

• Delayed hollow viscus injury with an occult seatbelt abrasion presenting as a small bowel obstruction. Trauma case reports Shideler, B. L., Berera, D. C., Knowlton, L. M., Knight, A. W. 2023; 48: 100934

  Abstract

  We present the case of a previously healthy 29-year-old male who presented with a small bowel obstruction in the absence of previous abdominal surgery who was found to have evidence of an occult seatbeltabrasion and ultimately multifocal hollow viscus injury secondary to blunt abdominal trauma at the time of exploratory laparotomy. Hollow viscus injury is a rare, but potentially life-threatening, complication of blunt abdominal trauma. While cross-sectional imaging is an important diagnostic tool, results must be considered within a patient's clinical context as delays in surgical management can lead to significant morbidity and mortality.

  View details for DOI 10.1016/j.tcr.2023.100934

  View details for PubMedID 38098811

  View details for PubMedCentralID PMC10719448

• State-Level Variability in Hospital Presumptive Eligibility Programs. JAMA network open Gibson, A. B., Hendricks, W. D., Arnow, K., Tran, L. D., Wagner, T. H., Knowlton, L. M. 2023; 6 (11): e2345244

  View details for DOI 10.1001/jamanetworkopen.2023.45244

  View details for PubMedID 38015508

• Do Hospital-Based Emergency Medicaid Programs Benefit Trauma Centers? A Mixed-Methods Analysis. The journal of trauma and acute care surgery Knowlton, L. M., Logan, D. S., Arnow, K., Hendricks, W. D., Gibson, A. B., Tran, L. D., Wagner, T. H., Morris, A. M. 2023

  Abstract

  INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization which can offset patient costs of care, increase access to post-discharge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement, as well as characterize incentives for HPE participation among hospitals and TCs. We hypothesized there would be financial, operational, and mission-based incentives.METHODS: We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (HCAI) (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semi-structured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8).RESULTS: Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE 77 (21%) of which are TCs. As of early 2015, 100% of trauma centers had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II trauma centers. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue (b = 6.74, p < 0.001) and decreased uncompensated care costs (b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included: reduction of hospital bad debt, improved patient satisfaction and community benefit in access to care.CONCLUSION: HPE programs are a promising pathway not only for long-term insurance coverage for trauma patients, but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program.LEVEL OF EVIDENCE: Economic/decision study, Level II.

  View details for DOI 10.1097/TA.0000000000004162

  View details for PubMedID 37828656

• An Open-Source Curriculum to Teach Practical Academic Research Skills. Annals of surgery open : perspectives of surgical history, education, and clinical approaches Lee, J. J., Korndorffer, J. R., Knowlton, L. M., Choi, J. 2023; 4 (3): e329

  Abstract

  Academic productivity is important for career advancement, yet not all trainees have access to structured research programs. Without formal teaching, acquiring practical skills for research can be challenging. A comprehensive research course that teaches practical skills to translate ideas into publications could accelerate trainees' productivity and liberate faculty mentors' time. We share our experience designing and teaching "A Practical Introduction to Academic Research", a course that teaches practical skills including building productive habits, recognizing common statistical pitfalls, writing cover letters, succinct manuscripts, responding to reviewers, and delivering effective presentations. We share open-source educational material used during the Winter 2022 iteration to facilitate curriculum adoption at peer institutions.

  View details for DOI 10.1097/AS9.0000000000000329

  View details for PubMedID 37746596

  View details for PubMedCentralID PMC10513130

• Does tranexamic acid increase venous thromboembolism risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers. Injury Knowlton, L. M., Arnow, K., Trickey, A. W., Sauaia, A., Knudson, M. M. 2023: 111008

  Abstract

  IMPORTANCE: The early use of tranexamic acid (TXA) has demonstrated benefit among some trauma patients in hemorrhagic shock. The association between TXA administration and thromboembolic events (including deep vein thrombosis (DVT), pulmonary embolism (PE) and pulmonary thrombosis (PT)) remains unclear. We aimed to characterize the risk of venous thromboembolism (VTE) subtypes among trauma patients receiving TXA and to determine whether TXA is associated with VTE risk and mortality.METHODS: We analyzed a prospective, observational, multicenter cohort data from the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted across 17 US level I trauma centers between January 1, 2018, and December 31,2020. We studied trauma patients ages 18-40 years, admitted for at least 48h with a minimum of 1 VTE risk factor and followed until hospital discharge or 30 days. We compared TXA recipients to non-recipients for VTE and mortality using inverse probability weighted Cox models. The primary outcome was the presence of documented venous thromboembolism (VTE). The secondary outcome was mortality. VTE was defined as DVT, PE, or PT.RESULTS: Among the 7,331 trauma patients analyzed, 466 (6.4%) received TXA. Patients in the TXA group were more severely injured than patients in the non-TXA group (ISS 16+: 69.1%vs. 48.5%, p<0.001) and a higher percentage underwent a major surgical procedure (85.8%vs. 73.6%, p<0.001). Among TXA recipients, 12.5% developed VTE(1.3% PT, 2.4% PE, 8.8% DVT) with 5.6% mortality. In the non-TXA group, 4.6% developed VTE (1.1% PT, 0.5% PE, 3.0% DVT) with 1.7% mortality. In analyses adjusting for patient demographic and clinical characteristics, TXA administration was not significantly associated with VTE (aHR 1.00, 95%CI: 0.69-1.46, p=0.99) but was significantly associated with increased mortality (aHR 2.01, 95%CI: 1.46-2.77, p<0.001).CONCLUSION: TXA was not clearly identified as an independent risk factor for VTE in adjusted analyses, but the risk of VTE among trauma patients receiving TXA remains high (12.5%). This supports the judicious use of TXA in resuscitation, with consideration of early initiation of DVT prophylaxis in this high-risk group.

  View details for DOI 10.1016/j.injury.2023.111008

  View details for PubMedID 37669883

• Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines. The American surgeon Elkbuli, A., Breeding, T., Ngatuvai, M., Patel, H., Andrade, R., Rosander, A., Knowlton, L. M., Liu, H., Ang, D. 2023: 31348231192062

  Abstract

  This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines.We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10.In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score.A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.

  View details for DOI 10.1177/00031348231192062

  View details for PubMedID 37515511

• TRENDS IN DISPARITIES RESEARCH ON TRAUMA AND ACUTE CARE SURGERY OUTCOMES: A 10-YEAR SYSTEMATIC REVIEW OF ARTICLES PUBLISHED IN THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY. The journal of trauma and acute care surgery Breeding, T., Ngatuvai, M., Rosander, A., Maka, P., Davis, J., Knowlton, L. M., Hoops, H., Elkbuli, A. 2023

  Abstract

  Systematic Review; Level IV.

  View details for DOI 10.1097/TA.0000000000004067

  View details for PubMedID 37405809

• Bias in the trauma bay: A multicenter qualitative study on team communication. The journal of trauma and acute care surgery Bankhead, B. K., Bichard, S. L., Seltzer, T., Thompson, L. A., Chambers, B., Davis, B., Knowlton, L. M., Tatebe, L. C., Vella, M. A., Dumas, R. P. 2023; 94 (6): 771-777

  Abstract

  Team communication and bias in and out of the operating room have been shown to impact patient outcomes. Limited data exist regarding the impact of communication bias during trauma resuscitation and multidisciplinary team performance on patient outcomes. We sought to characterize bias in communication among health care clinicians during trauma resuscitations.Participation from multidisciplinary trauma team members (emergency medicine and surgery faculty, residents, nurses, medical students, emergency medical services personnel) was solicited from verified level 1 trauma centers. Comprehensive semistructured interviews were conducted and recorded for analysis; sample size was determined by saturation. Interviews were led by a team of doctorate communications experts. Central themes regarding bias were identified using Leximancer analytic software (Leximancer Pty Ltd., Brisbane, Australia).Interviews with 40 team members (54% female, 82% White) from 5 geographically diverse Level 1 trauma centers were conducted. More than 14,000 words were analyzed. Statements regarding bias were analyzed and revealed a consensus that multiple forms of communication bias are present in the trauma bay. The presence of bias is primarily related to sex but was also influenced by race, experience, and occasionally the leader's age, weight, and height. The most commonly described targets of bias were females and non-White providers unfamiliar to the rest of the trauma team. Most common sources of bias were White male surgeons, female nurses, and nonhospital staff. Participants perceived bias being unconscious but affecting patient care.Bias in the trauma bay is a barrier to effective team communication. Identification of common targets and sources of biases may lead to more effective communication and workflow in the trauma bay.Prognostic and Epidemiological; Level IV.

  View details for DOI 10.1097/TA.0000000000003897

  View details for PubMedID 36880706

• Organ donation in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma surgery & acute care open Seshadri, A., Cuschieri, J., Kaups, K. L., Knowlton, L. M., Kutcher, M. E., Pathak, A., Rappold, J., Rinderknecht, T., Stein, D. M., Young, J., Michetti, C. P. 2023; 8 (1): e001107

  View details for DOI 10.1136/tsaco-2023-001107

  View details for PubMedID 37205276

  View details for PubMedCentralID PMC10186482

• Quality care is equitable care: a call to action to link quality to achieving health equity within acute care surgery. Trauma surgery & acute care open Knowlton, L. M., Zakrison, T., Kao, L. S., McCrum, M. L., Agarwal, S., Bruns, B., Joseph, K. A., Berry, C. 2023; 8 (1): e001098

  Abstract

  Health equity is defined as the sixth domain of healthcare quality. Understanding health disparities in acute care surgery (defined as trauma surgery, emergency general surgery and surgical critical care) is key to identifying targets that will improve outcomes and ensure delivery of high-quality care within healthcare organizations. Implementing a health equity framework within institutions such that local acute care surgeons can ensure equity is a component of quality is imperative. Recognizing this need, the AAST (American Association for the Surgery of Trauma) Diversity, Equity and Inclusion Committee convened an expert panel entitled 'Quality Care is Equitable Care' at the 81st annual meeting in September 2022 (Chicago, Illinois). Recommendations for introducing health equity metrics within health systems include: (1) capturing patient outcome data including patient experience data by race, ethnicity, language, sexual orientation, and gender identity; (2) ensuring cultural competency (eg, availability of language services; identifying sources of bias or inequities); (3) prioritizing health literacy; and (4) measuring disease-specific disparities such that targeted interventions are developed and implemented. A stepwise approach is outlined to include health equity as an organizational quality indicator.

  View details for DOI 10.1136/tsaco-2023-001098

  View details for PubMedID 37205273

  View details for PubMedCentralID PMC10186480

• Financial Toxicity after Trauma & Acute Care Surgery: From Understanding to Action. The journal of trauma and acute care surgery Scott, J. W., Knowlton, L. M., Murphy, P., Neiman, P. U., Martin, R. S., Staudenmayer, K. 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

• Evaluating Emergency Medicaid Program Policy Changes During the COVID-19 Pandemic. The Journal of surgical research Handley, T. J., Boncompagni, A. C., Arnow, K., Sasnal, M., Day, H. S., Trickey, A., Morris, A. M., Knowlton, L. M. 2023; 289: 97-105

  Abstract

  Trauma patients are twice as likely to be uninsured as the general population, which can lead to limited access to postinjury resources and higher mortality. The Hospital Presumptive Eligibility (HPE) program offers emergency Medicaid for eligible patients at presentation. The HPE program underwent several changes during the COVID-19 pandemic; we quantify the program's success during this time and seek to understand features associated with HPE approval.A mixed methods study at a Level I trauma center using explanatory sequential design, including: 1) a retrospective cohort analysis (2015-2021) comparing HPE approval before and after COVID-19 policy changes; and 2) semistructured interviews with key stakeholders.589 patients listed as self-pay or Medicaid presented after March 16, 2020, when COVID-19 policies were first implemented. Of these, 409 (69%) patients were already enrolled in Medicaid at hospitalization. Among those uninsured at arrival, 160 (89%) were screened and 98 (61%) were approved for HPE. This marks a significant improvement in the prepandemic HPE approval rate (48%). In adjusted logistic regression analyses, the COVID-19 period was associated with an increased likelihood of HPE approval (versus prepandemic: aOR, 1.64; P = 0.005). Qualitative interviews suggest that mechanisms include state-based expansion in HPE eligibility and improvements in remote approval such as telephone/video conferencing.The HPE program experienced an overall increased approval rate and adapted to policy changes during the pandemic, enabling more patients' access to health insurance. Ensuring that these beneficial changes remain a part of our health policy is an important aspect of improving access to health insurance for our patients.

  View details for DOI 10.1016/j.jss.2023.03.030

  View details for PubMedID 37086602

  View details for PubMedCentralID PMC10043965

• Developing an Inpatient Relationship Centered Communication Curriculum (I-RCCC) rounding framework for surgical teams. BMC medical education Nassar, A. K., Weimer-Elder, B., Yang, R., Kline, M., Dang, B. K., Spain, D. A., Knowlton, L. M., Valdez, A. B., Korndorffer, J. R., Johnson, T. 2023; 23 (1): 137

  Abstract

  Morning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience.A mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients' expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop.Needs assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. The self-reflected behaviors that demonstrated the most dramatic change between the pre and post-workshop surveys were: I listened without interrupting; I spoke clearly and at a moderate pace; I repeated key points; and I checked that the patient understood. All these changed from being performed by 50% of respondents "about half of the time" to 100% of them "always". Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference of up to 20%.The Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of an increase in LTRs and provider-specific patient satisfaction items. This curriculum will be refined based on the study results and potentially scalable to other surgical specialties.

  View details for DOI 10.1186/s12909-023-04105-7

  View details for PubMedID 36859253

• Trauma Activation Fees-A Fair Approach to Reimburse Trauma Readiness Costs or a Pathway to Profitability? JAMA network open Knowlton, L. M., Haut, E. R. 2023; 6 (1): e2252526

  View details for DOI 10.1001/jamanetworkopen.2022.52526

  View details for PubMedID 36692886

• Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development. Trauma surgery & acute care open Knowlton, L. M., Butler, W. J., Dumas, R. P., Bankhead, B. K., Meizoso, J. P., Bruns, B., Van Gent, J., Kaafarani, H. M., Martin, M. J., Namias, N., Stein, D. M., Tadlock, M. D., Martin, R. S., Staudenmayer, K. L., Gurney, J. M. 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

• Insurance churn after adult traumatic injury: a national evaluation among a large private insurance database. The journal of trauma and acute care surgery Fu, S. J., Arnow, K., Barreto, N. B., Aouad, M., Trickey, A. W., Spain, D. A., Morris, A., Knowlton, L. 2022

  Abstract

  Traumatic injury leads to significant disability, with injured patients often requiring substantial healthcare resources to return to work and baseline health. Temporary disability or inability to work can result in changes or loss of employer-based private insurance coverage, which may significantly impact healthcare access and outcomes. Among privately insured patients, we hypothesized increased instability in insurance coverage for patients with higher severity of injury.Adults 18 years and older presenting to a hospital with traumatic injury were evaluated for insurance churn using Clinformatics® Data Mart private-payer claims. Insurance churn was defined as cessation of enrollment in the patient's private health insurance plan. Using injury severity score (ISS), we compared insurance churn over the year following injury between patients with mild (ISS <9), moderate (ISS 9-15), severe (ISS 16-24), and very severe (ISS > 24) injuries. Kaplan-Meier analysis was used to compare time to insurance churn by ISS category. Flexible parametric regression was used to estimate hazard ratios for insurance churn.Among 750,862 privately insured patients suffering from a traumatic injury, 50% experienced insurance churn within 1 year after injury. Compared to patients who remained on their insurance plan, patients who experienced insurance churn were younger and more likely male and non-White. The median time to insurance churn was 7.7 months for those with mild traumatic injury, 7.5 months for moderately or severely injured, and 7.1 months for the very severely injured. In multivariable analysis, increasing injury severity was associated with higher rates of insurance churn compared with mild injury, up to 14% increased risk for the very severely injured.Increasing severity of traumatic injury is associated with higher levels of health coverage churn amongst the privately insured. Lack of continuous access to health services may prolong recovery and further aggravate the medical and social impact of significant traumatic injury.Economic/decision study, Level II.

  View details for DOI 10.1097/TA.0000000000003861

  View details for PubMedID 36623273

• 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 Mukherjee, K., Schubl, S. D., Tominaga, G., Cantrell, S., Kim, B., Haines, K. L., Kaups, K. L., Barraco, R., Staudenmayer, K., Knowlton, L. M., Shiroff, A. M., Bauman, Z. M., Brooks, S. E., Kaafarani, H., Crandall, M., Nirula, R., Agarwal, S. K., Como, J. J., Haut, E. R., Kasotakis, G. 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

• A National Evaluation of Emergency General Surgery Outcomes Among Hospitalized Cardiac Patients. The Journal of surgical research Tennakoon, L., Hakes, N. A., Nassar, A. K., Spain, D. A., Knowlton, L. M. 2022; 283: 24-32

  Abstract

  INTRODUCTION: Emergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients.METHODS: We performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non-GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs.RESULTS: We identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P<0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P<0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8d, P<0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P<0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P<0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P<0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P<0.001).CONCLUSIONS: Emergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study.

  View details for DOI 10.1016/j.jss.2022.10.016

  View details for PubMedID 36368272

• Evaluating the Impact of the Covid-19 Pandemic on Emergency Medicaid Programs: Have Insurance Rates Improved among Trauma Patients? Handley, T. J., Boncompagni, A., Arnow, K. D., Sasnal, M., Trickey, A. W., Morris, A. M., Knowlton, L. LIPPINCOTT WILLIAMS & WILKINS. 2022: S88

  View details for Web of Science ID 000867877000219

• Faculty Lead Coaching as a Method to Enhance Feedback Culture and Communication Skills Development in Surgical Education-Needs Assessment (Study in Progress) Nassar, A., Sasnal, M., Tung, J., Ko, A., Esquivel, M., Knowlton, L. LIPPINCOTT WILLIAMS & WILKINS. 2022: S74

  View details for Web of Science ID 000867877000185

• Firearm-Related Injuries and the US Opioid Epidemic: A Nationwide Evaluation of Emergency Department Encounters Tennakoon, L. D., Nassar, A. K., Wanberg, J. A., Knowlton, L. LIPPINCOTT WILLIAMS & WILKINS. 2022: S45-S46

  View details for Web of Science ID 000867877000114

• EMERGENCY MEDICAID PROGRAMS MAY BE AN EFFECTIVE MEANS OF PROVIDING SUSTAINED INSURANCE AMONG TRAUMA PATIENTS: A STATEWIDE LONGITUDINAL ANALYSIS. The journal of trauma and acute care surgery Knowlton, L. M., Tran, L. D., Arnow, K., Trickey, A. W., Morris, A. M., Spain, D. A., Wagner, T. H. 2022

  Abstract

  INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to post-discharge resources, and provides patients with a path to sustain coverage through Medicaid. As HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status six months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment.METHODS: Using a customized longitudinal claims dataset for HPE-approved patients from the California Department of Health Care Services (DHCS), we analyzed adults with a primary trauma diagnosis (ICD-10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at six months. Univariate and multivariate analyses were performed.RESULTS: A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at six months. Compared to patients who did not sustain, those who sustained had higher injury severity score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001) and were more likely to be discharged to post-acute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%) and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < =15: aOR 1.51, p = 0.02) and surgery (aOR 1.85, p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR 0.05, p < 0.001) decreased the likelihood of Medicaid sustainment.CONCLUSION: HPE programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to healthcare services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain.LEVEL OF EVIDENCE: Epidemiologic, Level III.

  View details for DOI 10.1097/TA.0000000000003796

  View details for PubMedID 36138539

• Developing and Leading a Sustainable Organization for Early Career Acute Care Surgeons: Lessons from the Inaugural AAST Associate Member Council. The journal of trauma and acute care surgery Dumas, R. P., Bankhead, B. K., Coleman, J. R., Dhillon, N. K., Meizoso, J. P., Bessoff, K., Butler, W. J., Strickland, M., Dultz, L. A., Davis, K., Bulger, E. M., Reilly, P. M., Croce, M. A., Spain, D. A., Livingston, D. H., Brasel, K., Coimbra, R., Knowlton, L. M. 2022

  Abstract

  LEVEL OF EVIDENCE: N/A.

  View details for DOI 10.1097/TA.0000000000003734

  View details for PubMedID 35777976

• The Need to Routinely Convert Emergency Cricothyroidotomy to Tracheostomy: A Systematic Review and Meta-Analysis. Journal of the American College of Surgeons Choi, J., Anderson, T. N., Sheira, D., Sousa, J., Borghi, J. A., Spain, D. A., Knowlton, L. M. 2022; 234 (5): 947-952

  Abstract

  BACKGROUND: Traditional surgical teaching advocates converting emergency cricothyroidotomies to tracheostomies to mitigate the risk of subglottic stenosis. A conversion procedure that may risk losing a tenuous airway should have clear benefits over risks. We aimed to evaluate the necessity of routine cricothyroidotomy to tracheostomy conversion by conducting a systematic review and meta-analysis of contemporary literature.STUDY DESIGN: We performed a systematic review of experimental and observational studies (published between January 1, 2008, and March 1, 2021) reporting hospital outcomes of adults aged ≥18 years who underwent emergency cricothyroidotomies or tracheostomies. We followed PRISMA guidelines and assessed quality of data using GRADE methodology. Meta-analysis pooled incidence of procedure-specific complications (bleeding, subglottic stenosis, and others) using Freeman-Tukey double arcsine transformation and sensitivity analysis addressed survival bias.RESULTS: A total of 18 studies including 1246 patients were analyzed. Incidence of bleeding (5 [1 to 11]% vs 3 [1 to 7]%), subglottic stenosis (0 [0 to 3]% vs 0 [0 to 0]%) and other complications (12 [8 to 16]% vs 13 [5 to 23]%) were similar among patients undergoing emergency cricothyroidotomy or tracheostomy. Sensitivity analysis evaluating the incidence of complications among only survivors found similar results. Only one study reported complications attributable to cricothyroidotomy to tracheostomy conversion.CONCLUSIONS: Subglottic stenosis, the main harm conversion seeks to avoid, appears to be a rare complication after cricothyroidotomy. We did not find evidence supporting routine need to convert cricothyroidotomies to tracheostomies; for many patients, conversion is unlikely to rectify complications attributable to emergency cricothyroidotomy. However, our findings cannot be generalized to patients who require prolonged or permanent airway cannulation. Providers should consider performing cricothyroidotomy to tracheostomy selectively when the benefits clearly outweigh the risks of disrupting a secured airway.

  View details for DOI 10.1097/XCS.0000000000000114

  View details for PubMedID 35426409

• Introducing advanced surgical tasks simulation for surgical training. Annals of medicine and surgery (2012) Tuma, F., Knowlton, L. M., Nassar, A. K. 2022; 77: 103568

  Abstract

  Acquiring surgical skills is one of the major objectives of surgical training. Trainees face increasing challenges to meet the continuously evolving surgical techniques and approaches during the limited time course of their surgical training. The limited availability of training tools for teaching advanced surgical skills is an additional barrier. Educators have increasingly used simulation tools for surgical skills training around the globe. However, current simulation training modules and curricula focus mainly on basic surgical skills. Hence, the development of advanced virtual simulation modules offers a precious laparoscopic training opportunity. This article provides an educational technology-based review and proposal (with selected examples) of simulation training modules on advanced surgical skills that can be used for advanced surgical training approaches.

  View details for DOI 10.1016/j.amsu.2022.103568

  View details for PubMedID 35637992

  View details for PubMedCentralID PMC9142373

• Data Resources for Evaluating the Economic and Financial Consequences of Surgical Care in the United States. The journal of trauma and acute care surgery Scott, J. W., Ayoung-Chee, P., Lester, E. L., Bruns, B. R., Davis, K. A., Gore, A., Knowlton, L. M., Liu, C., Martin, R. S., Oh, E. J., Ross, S. W., Wandling, M., Minei, J. P., Staudenmayer, K. 2022

  Abstract

  V.

  View details for DOI 10.1097/TA.0000000000003631

  View details for PubMedID 35358106

• Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research. Journal of surgical education Choi, J., Tennakoon, L., Khan, S., Jaramillo, J. D., Rajasingh, C. M., Hakes, N. A., Forrester, J. D., Knowlton, L. M., Nassar, A. K., Weiser, T. G., Spain, D. A. 2022

  Abstract

  Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.

  View details for DOI 10.1016/j.jsurg.2022.02.008

  View details for PubMedID 35272969

• Duodenal perforation due to multiple foreign bodies: consideration for operative approach and surgical repair. Trauma surgery & acute care open Wright, K., Rajasingh, C. M., Fu, S. J., Tung, J., Visser, B. C., Knowlton, L. M. 2022; 7 (1): e001063

  View details for DOI 10.1136/tsaco-2022-001063

  View details for PubMedID 36532693

• Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism. JAMA surgery Knudson, M. M., Moore, E. E., Kornblith, L. Z., Shui, A. M., Brakenridge, S., Bruns, B. R., Cipolle, M. D., Costantini, T. W., Crookes, B. A., Haut, E. R., Kerwin, A. J., Kiraly, L. N., Knowlton, L. M., Martin, M. J., McNutt, M. K., Milia, D. J., Mohr, A., Nirula, R., Rogers, F. B., Scalea, T. M., Sixta, S. L., Spain, D. A., Wade, C. E., Velmahos, G. C. 1800: e216356

  Abstract

  Importance: Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events.Objective: To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE.Design, Setting, and Participants: This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days.Exposures: Investigational imaging, prophylactic measures used, and treatment of clots.Main Outcomes and Measures: The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT.Results: A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P<.001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P=.007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P=.04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P=.02). No deaths were attributed to PT or PE.Conclusions and Relevance: To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

  View details for DOI 10.1001/jamasurg.2021.6356

  View details for PubMedID 34910098

• Fatal Case of Perforated Cytomegalovirus Colitis: Case Report and Systematic Review. Surgical infections Fisher, A. T., Bessoff, K. E., Nicholas, V., Badger, J., Knowlton, L., Forrester, J. D. 2021

  Abstract

  Objective: We describe a patient with history of heart transplant on maintenance immunosuppression who presented with sigmoid colon perforation from cytomegalovirus (CMV) colitis and performed a systematic review of outcomes after perforated CMV colitis. Background: Cytomegalovirus enterocolitis is uncommon among solid organ transplant patients and can result in small or large bowel perforation. Methods: We systematically reviewed articles describing patients with CMV enterocolitis with small or large bowel perforations from PubMed, Embase, and Web of Science from database inception to February 2021. Results: Seventy-seven articles were identified containing 84 patients with perforated CMV enterocolitis. The most prevalent comorbid diagnosis was human immunodeficiency virus (HIV; 27 patients, 32%), and 37 patients (44%) were taking corticosteroids at time of presentation. The ileum was the most common location for a perforation (26 patients, 31%). Odds of survival were lower for patients with small bowel perforation (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.14-0.98) and HIV/acquired immunodeficiency syndrome (AIDS; OR, 0.32; 95% CI, 0.11-0.88). Odds of survival were higher for patients with large bowel perforation (OR, 2.64; 95% CI, 1.03-7.09), radiographically diagnosed perforation (OR, 3.45; 95% CI, 1.12-11.60) and those who received a CMV antiviral (OR, 9.19; 95% CI, 3.26-28.48). Conclusions: Perforated CMV enterocolitis is uncommon even in immunocompromised hosts. Clinicians should maintain a high level of suspicion for CMV-induced bowel perforation in this population because antiviral treatment is associated with increased odds of survival.

  View details for DOI 10.1089/sur.2021.173

  View details for PubMedID 34860604

• Out-of-Pocket Costs Among Patients With a New Cancer Diagnosis Enrolled in High-Deductible Health Plans vs Traditional Insurance. JAMA network open Fu, S. J., Rose, L., Dawes, A. J., Knowlton, L. M., Ruddy, K. J., Morris, A. M. 1800; 4 (12): e2134282

  Abstract

  Importance: The financial burden of a cancer diagnosis is increasing rapidly with advances in cancer care. Simultaneously, more individuals are enrolling in high-deductible health plans (HDHPs) vs traditional insurance than ever before.Objective: To characterize the out-of-pocket costs (OOPCs) of cancer care for individuals in HDHPs vs traditional insurance plans.Design, Setting, and Participants: This retrospective cohort study used the administrative claims data of a single national insurer in the US for 134 826 patients aged 18 to 63 years with a new diagnosis of breast, colorectal, lung, or other cancer from 2008 to 2018 with 24 months or more of continuous enrollment. Propensity score matching was performed to create comparator groups based on the presence or absence of an incident cancer diagnosis.Exposures: A new cancer diagnosis and enrollment in an HDHP vs a traditional health insurance plan.Main Outcomes and Measures: The primary outcome was OOPCs among individuals with breast, colon, lung, or all other types of cancer combined compared with those with no cancer diagnosis. A triple difference-in-differences analysis was performed to identify incremental OOPCs based on cancer diagnosis and enrollment in HDHPs vs traditional plans.Results: After propensity score matching, 134 826 patients remained in each of the cancer (73 572 women [55%]; median age, 53 years [IQR, 46-58 years]; 110 071 non-Hispanic White individuals [82%]) and noncancer (66 619 women [49%]; median age, 53 years [IQR, 46-59 years]; 105 023 non-Hispanic White individuals [78%]) cohorts. Compared with baseline costs of medical care among individuals without cancer, a breast cancer diagnosis was associated with the highest incremental OOPC ($714.68; 95% CI, $664.91-$764.45), followed by lung ($475.51; 95% CI, $340.16-$610.86), colorectal ($361.41; 95% CI, $294.34-$428.48), and all other types of cancer combined ($90.51; 95% CI, $74.22-$106.79). Based on the triple difference-in-differences analysis, compared with patients without cancer enrolled in HDHPs, those with breast cancer paid $1683.36 in additional yearly OOPCs (95% CI, $1576.66-$1790.07), those with colorectal cancer paid $1420.06 more (95% CI, $1232.31-$1607.80), those with lung cancer paid $467.25 more (95% CI, $130.13-$804.37), and those with other types of cancer paid $550.87 more (95% CI, $514.75-$586.99).Conclusions and Relevance: Patients with cancer and private insurance experienced sharp increases in OOPCs compared with those without cancer, which was amplified among those with HDHPs. These findings illustrate the degree to which HDHPs offer poorer protection than traditional insurance against unexpected health care expenses. Coupled with the increasing cost of cancer care, higher cost sharing in the form of increasing enrollment in HDHPs requires further research on the potential clinical consequences through delayed or foregone care.

  View details for DOI 10.1001/jamanetworkopen.2021.34282

  View details for PubMedID 34935922

• Virtual reality (VR) as a simulation modality for technical skills acquisition. Annals of medicine and surgery (2012) Nassar, A. K., Al-Manaseer, F., Knowlton, L. M., Tuma, F. 2021; 71: 102945

  Abstract

  Efforts continue to facilitate surgical skills training and provide accessible and safe training opportunities. Educational technology has played an essential role in minimizing the challenges facing traditional surgical training and providing feasible training opportunities. Simulation and virtual reality (VR) offer an important innovative training approach to enhance and supplement both technical and non-technical skills acquisition and overcome the many training challenges facing surgical training programs. To maximize the effectiveness of simulation modalities, an in-depth understanding of the cognitive learning theory is necessary. Knowing the stages and mental processes of skills acquisition when integrated with simulation applications can help trainees achieve maximal learning outcomes. This article aims to review important literature related to VR effectiveness and discuss the leading theories of technical skills acquisition related to VR simulation technologies.

  View details for DOI 10.1016/j.amsu.2021.102945

  View details for PubMedID 34840738

  View details for PubMedCentralID PMC8606692

• Financial Burden of Traumatic Injury Amongst the Privately Insured. Annals of surgery Fu, S. J., Arnow, K., Trickey, A., Spain, D. A., Morris, A., Knowlton, L. 2021

  Abstract

  OBJECTIVE: We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs.SUMMARY BACKGROUND DATA: Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown.METHODS: We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A two-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month out-of-pocket costs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure after injury.RESULTS: Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1,703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to HDHP enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12-month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however high-deductible health plan enrollees faced a 13% chance of CHE.CONCLUSIONS: Privately insured trauma patients face substantial out-of-pocket costs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.

  View details for DOI 10.1097/SLA.0000000000005225

  View details for PubMedID 34596072

• ACQUISITION OF MEDICAID AT THE TIME OF INJURY: AN OPPORTUNITY FOR SUSTAINABLE INSURANCE COVERAGE. The journal of trauma and acute care surgery Jaramillo, J. D., Arnow, K., Trickey, A. W., Dickerson, K., Wagner, T. H., Harris, A. H., Tran, L. D., Bereknyei, S., Morris, A. M., Spain, D. A., Knowlton, L. M. 2021

  Abstract

  INTRODUCTION: Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher injury severity (ISS>15) would be more likely to be approved for HPE.METHODS: We identified Medicaid and uninsured patients aged 18-64 years old with a primary trauma diagnosis (ICD-10) in a large level I trauma center between 2015-2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed.RESULTS: Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. HPE patients had higher injury severity score (ISS > 15: 14.8% vs. 5.7%, p < .001), longer median length of stay (LOS) (2 [IQR: 0,5] vs. 0 [0,1] days, p < .001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < .001) and discharged to post-acute services (11.9% vs. 0.9%, p < .001). Patient, hospital and policy factors contributed to HPE non-approval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic whites: aOR 1.58, p = .02) and increasing ISS (p ≤ .001) were associated with increased likelihood of HPE approval.CONCLUSION: The time of hospitalization due to injury is an underutilized opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention.LEVEL OF EVIDENCE: Epidemiologic, level III.

  View details for DOI 10.1097/TA.0000000000003195

  View details for PubMedID 33783416

• Are Statins Associated With Reduced Risk of Adhesion-Related Complications After Abdominal Surgery? JAMA network open Fu, S., Yelorda, K., Knowlton, L. 2021; 4 (2): e2037296

  View details for DOI 10.1001/jamanetworkopen.2020.37296

  View details for PubMedID 33533927

• Students and faculty perception of distance medical education outcomes in resource-constrained system during COVID-19 pandemic. A cross-sectional study. Annals of medicine and surgery (2012) Tuma, F., Nassar, A. K., Kamel, M. K., Knowlton, L. M., Jawad, N. K. 2021; 62: 377–82

  Abstract

  Introduction: The COVID-19 pandemic has imposed significant challenges on medical education worldwide, particularly in experience- and resource-limited regions of the world. Collaborative efforts of educators and academic institutions are necessary to facilitate the adaptation to the new educational reality. In this study, challenges and outcomes of a newly implemented distance education curriculum are examined to share findings and provide recommendations.Methods: An alternative distance education curriculum with online resources and virtual lectures was developed and implemented in February 2020at the Wasit University College of Medicine in Iraq. A post-implementation survey was developed for both faculty instructors and students to evaluate the program's effectiveness and perception. Results were compared between both groups. The study was approved by the University's Dean and exempted by the research committee for anonymity.Results: A total of 636 students and 81 instructors were surveyed. Approximately 33% of students and 51% of instructors found online education equivalent or superior to traditional face-to-face teaching methods. Almost 69% of students and 51% of instructors reported increased difficulties with virtual learning, primarily due to challenges with the available technology, unreliable internet connectivity, as well as perceive fatigue when listening to online lectures.Conclusions: Distance education provides a worthwhile alternative during the COVID-19 pandemic, including in regions of limited experience. Adequate preparation, good quality audio-visuals and Internet, and student engagement activities are recommended to improve the quality of education.

  View details for DOI 10.1016/j.amsu.2021.01.073

  View details for PubMedID 33552498

• COVID-19 Impact on Surgical Resident Education and Coping. The Journal of surgical research Wise, C. E., Bereknyei Merrell, S. n., Sasnal, M. n., Forrester, J. D., Hawn, M. T., Lau, J. N., Lin, D. T., Schmiederer, I. S., Spain, D. A., Nassar, A. K., Knowlton, L. M. 2021; 264: 534–43

  Abstract

  Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19.We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic.Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19.Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.

  View details for DOI 10.1016/j.jss.2021.01.017

  View details for PubMedID 33862581

• The impact of trauma systems on patient outcomes. Current problems in surgery Choi, J., Carlos, G., Nassar, A. K., Knowlton, L. M., Spain, D. A. 2021; 58 (1): 100840

  View details for DOI 10.1016/j.cpsurg.2020.100840

  View details for PubMedID 33431135

• Situating Artificial Intelligence in Surgery: A Focus on Disease Severity. Annals of surgery Korndorffer, J. R., Hawn, M. T., Spain, D. A., Knowlton, L. M., Azagury, D. E., Nassar, A. K., Lau, J. N., Arnow, K. D., Trickey, A. W., Pugh, C. M. 2020; 272 (3): 523-528

  Abstract

  Artificial intelligence (AI) has numerous applications in surgical quality assurance. We assessed AI accuracy in evaluating the critical view of safety (CVS) and intraoperative events during laparoscopic cholecystectomy. We hypothesized that AI accuracy and intraoperative events are associated with disease severity.One thousand fifty-one laparoscopic cholecystectomy videos were annotated by AI for disease severity (Parkland Scale), CVS achievement (Strasberg Criteria), and intraoperative events. Surgeons performed focused video review on procedures with ≥1 intraoperative events (n = 335). AI versus surgeon annotation of CVS components and intraoperative events were compared. For all cases (n = 1051), intraoperative-event association with CVS achievement and severity was examined using ordinal logistic regression.Using AI annotation, surgeons reviewed 50 videos/hr. CVS was achieved in ≤10% of cases. Hepatocystic triangle and cystic plate visualization was achieved more often in low-severity cases (P < 0.03). AI-surgeon agreement for all CVS components exceeded 75%, with higher agreement in high-severity cases (P < 0.03). Surgeons agreed with 99% of AI-annotated intraoperative events. AI-annotated intraoperative events were associated with both disease severity and number of CVS components not achieved. Intraoperative events occurred more frequently in high-severity versus low-severity cases (0.98 vs 0.40 events/case, P < 0.001).AI annotation allows for efficient video review and is a promising quality assurance tool. Disease severity may limit its use and surgeon oversight is still required, especially in complex cases. Continued refinement may improve AI applicability and allow for automated assessment.

  View details for DOI 10.1097/SLA.0000000000004207

  View details for PubMedID 33759839

• Emergency Medicaid Acquisition Through the Affordable Care Act: The Association Between Hospital Enrollment in California and Hospital Revenue. Medical care Tran, L. D., Knowlton, L. M., Wagner, T. H. 2020; 58 (8): 727–33

  Abstract

  BACKGROUND: Hospital Presumptive Eligibility (HPE) is a national policy stemming from the Affordable Care Act that allows qualified hospitals, working with state officials, to enroll eligible patients for temporary Medicaid coverage. Although all states are required to operate an HPE program, hospital participation is elective and variable. It is unclear which hospitals choose to participate in HPE and how participation affects hospital utilization and revenue.OBJECTIVE: We examined hospital factors associated with HPE participation in the state of California and assessed pre and post changes in hospital revenue and utilization for HPE and non-HPE hospitals.RESEARCH DESIGN: We performed a logistic regression to identify hospital attributes associated with HPE participation. We then used a difference in differences methodology with a hospital fixed effect to test whether HPE enrollment was associated with changes in annual revenues by payer source, uncompensated care costs, outpatient visits, and/or discharges.RESULTS: Three quarters (76%) of qualified hospitals elected to participate in HPE by the end of 2018. Hospitals with 100 or more beds had over 10 times greater odds of participating in HPE compared with smaller hospitals. Hospitals that did not provide outpatient care were significantly less likely to participate. Among hospitals included in trend analyses, enrollment in HPE was associated with increased annual net patient Medicaid revenue and decreased uncompensated care charges. We predicted that HPE enrollment was associated with an average of 9.7% (95% confidence interval: 3.4%-16.4%) increase in annual net patient Medicaid revenue. As of 2018, 33,000 adults and children were enrolled in California's HPE program per month.CONCLUSION: Hospital enrollment in the HPE program shifted costs from uncompensated care to Medicaid.

  View details for DOI 10.1097/MLR.0000000000001352

  View details for PubMedID 32692139

• Improving Geriatric Trauma Care via A Multi-disciplinary Age-Friendly Care Pathway Bharija, A., Mesias, M., Storr-Street, N., Ellsworth, A. M., Brown, A., Cheng, N., Knowlton, L., Tennakoon, L., Martin, M., Lu, A., Staudemayer, K. WILEY. 2020: S16–S17

  View details for Web of Science ID 000522602100044

• Creation and implementation of a novel clinical workflow based on the AAST uniform anatomic severity grading system for emergency general surgery conditions. Trauma surgery & acute care open Bessoff, K. E., Choi, J. n., Bereknyei Merrell, S. n., Nassar, A. K., Spain, D. n., Knowlton, L. M. 2020; 5 (1): e000552

  Abstract

  Emergency general surgery (EGS) conditions encompass a variety of diseases treated by acute care surgeons. The heterogeneity of these diseases limits infrastructure to facilitate EGS-specific quality improvement (QI) and research. A uniform anatomic severity grading system for EGS conditions was recently developed to fill this need. We integrated this system into our clinical workflow and examined its impact on research, surgical training, communication, and patient care.The grading system was integrated into our clinical workflow in a phased fashion through formal education and a written handbook. A documentation template was also deployed in our electronic medical record to prospectively assign severity scores at the time of patient evaluation. Mixed methods including a quantitative survey and qualitative interviews of trainees and attending surgeons were used to evaluate the impact of the new workflow and to identify obstacles to its adoption.We identified 2291 patients presenting with EGS conditions during our study period. The most common diagnoses were small bowel obstruction (n=470, 20.5%), acute cholecystitis (n=384, 16.8%), and appendicitis (n=370, 16.1%). A total of 21 qualitative interviews were conducted. Twenty interviewees (95.2%) had a positive impression of the clinical workflow, citing enhanced patient care and research opportunities. Fifteen interviewees (75.0%) reported the severity grading system was a useful framework for clinical management, with five participants (25.0%) indicating the system was useful to facilitate clinical communication. Participants identified solutions to overcome barriers to adoption of the clinical workflow.The uniform anatomic severity grading system can be readily integrated into a clinical workflow to facilitate prospective data collection for QI and research. The system is perceived as valuable by users. Educational initiatives that focus on increasing familiarity with the system and its benefits will likely improve adoption of the classification system and the clinical workflow that uses it.Level III.

  View details for DOI 10.1136/tsaco-2020-000552

  View details for PubMedID 32953998

  View details for PubMedCentralID PMC7481073

• Impact of shelter-in-place order for COVID-19 on trauma activations: Santa Clara County, California, March 2020. Trauma surgery & acute care open Forrester, J. D., Liou, R. n., Knowlton, L. M., Jou, R. M., Spain, D. A. 2020; 5 (1): e000505

  Abstract

  The shelter-in-place order for Santa Clara County, California on 16 March was the first of its kind in the USA. It was unknown what impact this order would have on trauma activations.We performed a retrospective analysis of institutional trauma registries among the two American College of Surgeons Level 1 trauma centers serving Santa Clara County, California. Trauma activation volumes at the trauma centers from January to March 2020 were compared with month-matched historical cohorts from 2018 to 2019.Only 81 (3%) patients were trauma activations at the trauma centers in the 15 days after the shelter-in-place order went into effect on 16 March 2020, compared with 389 activations during the same time period in 2018 and 2019 (p<0.0001). There were no other statistically significant changes to the epidemiology of trauma activations. Only one trauma activation had a positive COVID-19 test.Overall trauma activations decreased 4.8-fold after the shelter-in-place order went into effect in Santa Clara County on 16 March 2020, with no other effect on the epidemiology of persons presenting after traumatic injury.Shelter-in-place orders may reduce strain on healthcare systems by diminishing hospital admissions from trauma, in addition to reducing virus transmission.

  View details for DOI 10.1136/tsaco-2020-000505

  View details for PubMedID 32426529

  View details for PubMedCentralID PMC7228662

• Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes. The Journal of surgical research Choi, J. n., Bessoff, K. n., Bromley-Dulfano, R. n., Li, Z. n., Gupta, A. n., Taylor, K. n., Wadhwa, H. n., Seltzer, R. n., Spain, D. A., Knowlton, L. M. 2020

  Abstract

  The American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record.Our institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine-a machine learning algorithm attuned for small sample sizes-was used to compare the associations between the two classification systems and decision to operate and incidence of complications.67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%).This study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.

  View details for DOI 10.1016/j.jss.2020.10.016

  View details for PubMedID 33248670

• Using a virtual platform for personal protective equipment education and training. Medical education Nassar, A. K., Lin, D. T., Spain, D. A., Knowlton, L. M. 2020

  View details for DOI 10.1111/medu.14321

  View details for PubMedID 32914527

• Mortality After General Surgery Among Hospitalized Patients With Hematologic Malignancy Journal of Surgical Research Forrester, J. D., Syed, M., Tennakoon, L., Spain, D. A., Knowlton, L. M. 2020; 256: P502-511

  View details for DOI 10.1016/j.jss.2020.07.006

• The impact of trauma systems on patient outcomes Current Problems in Surgery Choi, J., Carlos, G., Nassar, A. K., Knowlton, L. M., Spain, D. A. 2020

  View details for DOI 10.1016/j.cpsurg.2020.100849

• Understanding Health Care Utilization and Mortality After Emergency General Surgery in Patients With Underlying Liver Disease. The American surgeon Tennakoon, L. n., Baiu, I. n., Concepcion, W. n., Melcher, M. L., Spain, D. A., Knowlton, L. M. 2020; 86 (6): 665–74

  Abstract

  Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD).We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs.Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001).Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.

  View details for DOI 10.1177/0003134820923304

  View details for PubMedID 32683972

• The Affordable Care Act and Insurance Status, Stage, and Timely Treatment Among Patients With Cancer: What Are the Possible Effects? JAMA network open Fu, S. n., Rose, L. n., Knowlton, L. n. 2020; 3 (2): e1921690

  View details for DOI 10.1001/jamanetworkopen.2019.21690

  View details for PubMedID 32074284

• Amyand hernia: considerations for operative approach and surgical repair. Trauma surgery & acute care open Garagliano, J. M., Jaramillo, J. D., Kopecky, K. E., Knowlton, L. M. 2020; 5 (1): e000466

  View details for DOI 10.1136/tsaco-2020-000466

  View details for PubMedID 32420454

• Traumatic Injuries Due to Interpersonal and Domestic Violence in the United States. The Journal of surgical research Tennakoon, L. n., Hakes, N. A., Knowlton, L. M., Spain, D. A. 2020; 254: 206–16

  Abstract

  Domestic and intimate partner violence (DV) are under-reported causes of injury. We describe the health care utilization of DV patients, hypothesizing they are at increased risk of mortality.We queried the 2014 Nationwide Emergency Department Sample for adult patients (18 y and older) with a primary diagnosis of trauma. DV was abstracted using International Statistical Classification of Diseases, ninth Revision codes for partner or spouse intimate violence, abuse, or neglect. The primary outcome was mortality; secondary outcomes included admission rates and charges.Among 14 million trauma patients, 654,356 (5.0%) had a diagnosis of DV. Compared with other trauma patients, DV patients were younger (34.6 versus 46.8 y, P < 0.001), more often male (69.5% versus 50.1%, P < 0.001), and more likely to be uninsured (31.5% versus 15.6%, P < 0.001). 9154 (1.4%) were injured because of intimate partner violence, of which 90.2% were female. Drug and alcohol abuse (22.2%), anxiety (1.8%), and depression (1.3%) were high among all DV trauma patients. DV emergency department charges were higher ($4462 versus $2,871, P < 0.001). In adjusted analyses, DV trauma patients had 2.1 higher odds of mortality (aOR: 2.31, P < 0.001). DV trauma patients were also associated with a $1516 increase in emergency department charges compared with non-DV trauma patients (95% CI: $1489-$1,542, P < 0.001).Injuries related to all types of DV are emerging as a public health crisis among both genders. To mitigate under-reporting, it is important to identify at-risk patients and provide them with appropriate resources.

  View details for DOI 10.1016/j.jss.2020.03.062

  View details for PubMedID 32470653

• Iatrogenic gallbladder perforation secondary to Veress needle placement: a complication of robotic nephrectomy. Trauma surgery & acute care open Jaramillo, J. D., Sun, A. J., Knowlton, L. M. 2020; 5 (1): e000442

  View details for DOI 10.1136/tsaco-2020-000442

  View details for PubMedID 32373715

• Balancing the Risks and Benefits of Surgical Prophylaxis Timing and Duration Do Matter JAMA SURGERY Hawn, M. T., Knowlton, L. 2019; 154 (7): 598–99

  View details for DOI 10.1001/jamasurg.2019.0570

  View details for Web of Science ID 000481522400005

• 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 Kim, L. D., Pfoh, E. R., Hu, B., Kou, L., Knowlton, L. M., Staudenmayer, K., Rothberg, M. B. 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

• Racial and Ethnic Disparities in Geographic Access to Trauma Care-A Multiple-Methods Study of US Urban Trauma Deserts JAMA NETWORK OPEN Knowlton, L. 2019; 2 (3)

  View details for Web of Science ID 000465424000058

• Racial and Ethnic Disparities in Geographic Access to Trauma Care-A Multiple-Methods Study of US Urban Trauma Deserts. JAMA network open Knowlton, L. M. 2019; 2 (3): e190277

  View details for PubMedID 30848802

• Racial and Ethnic Disparities in Geographic Access to Trauma Care-A Multiple-Methods Study of US Urban Trauma Deserts JAMA NETWORK OPEN Knowlton, L. 2019; 2 (3)

  View details for DOI 10.1001/jamanetworkopen.2019.0277

  View details for Web of Science ID 000465424000057

• Mucormycosis emboli: a rare cause of segmental bowel ischemia. Trauma surgery & acute care open Baiu, I., Knowlton, L. M. 2019; 4 (1): e000305

  View details for DOI 10.1136/tsaco-2019-000305

  View details for PubMedID 31245621

• THE IMPACT OF MEDICAID EXPANSION ON TRAUMA-RELATED EMERGENCY DEPARTMENT UTILIZATION: A NATIONAL EVALUATION OF POLICY IMPLICATIONS. The journal of trauma and acute care surgery Knowlton, L. M., Dehghan, M. S., Arnow, K. n., Trickey, A. W., Tennakoon, L. n., Morris, A. M., Spain, D. A. 2019

  Abstract

  The impact of the 2014 Affordable Care Act (ACA) upon national trauma-related emergency department (ED) utilization is unknown. We assessed ACA-related changes in ED use and payer mix, hypothesizing that post-ACA ED visits would decline and Medicaid coverage would increase disproportionately in regions of widespread policy adoption.We queried the National Emergency Department Sample (NEDS) for those with a primary trauma diagnosis, aged 18 to 64. Comparing pre-ACA (2012) to post-ACA (10/2014 to 09/2015), primary outcomes were change in ED visits and payer status; secondary outcomes were change in costs, discharge disposition and inpatient length of stay. Univariate and multivariate analyses were performed, including difference-in-differences analyses. We compared changes in ED trauma visits by payer in the West (91% in a Medicaid expansion state) versus the South (12%).Among 21.2 million trauma-related ED visits, there was a 13.3% decrease post-ACA. Overall, there was a 7.2% decrease in uninsured ED visits (25.5% vs. 18.3%, p<0.001) and a 6.6% increase in Medicaid coverage (17.6% vs. 24.2%, p<0.001). Trauma patients had 40% increased odds of having Medicaid post-ACA (vs. pre-ACA: aOR 1.40, p<0.001). Patients in the West had 31% greater odds of having Medicaid (vs. South: aOR 1.31, p<0.001). The post-ACA increase in Medicaid was greater in the West (vs. South: aOR 1.60, p<0.001). Post-ACA, inpatients were more likely to have Medicaid (vs. ED discharge: aOR 1.20, p<0.001) and there was a 25% increase in inpatient discharge to rehabilitation (aOR 1.24, p<0.001).Post-ACA, there was a significant increase in insured trauma patients and a decrease in injury-related ED visits, possibly resulting from access to other outpatient services. Ensuring sustainability of expanded coverage will benefit injured patients and trauma systems.Epidemiologic, level III.

  View details for DOI 10.1097/TA.0000000000002504

  View details for PubMedID 31524835

• Balancing the Risks and Benefits of Surgical Prophylaxis: Timing and Duration Do Matter. JAMA surgery Hawn, M. T., Knowlton, L. M. 2019

  View details for PubMedID 31017641

• The Economic Footprint of Acute Care Surgery in the United States: Implications for Systems Development. The journal of trauma and acute care surgery Knowlton, L. M., Minei, J., Tennakoon, L., Davis, K. A., Doucet, J., Bernard, A., Haider, A., Tres Scherer, L. R., Spain, D. A., Staudenmayer, K. L. 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

• Evaluating the collection, comparability and findings of six global surgery indicators. The British journal of surgery Holmer, H., Bekele, A., Hagander, L., Harrison, E. M., Kamali, P., Ng-Kamstra, J. S., Khan, M. A., Knowlton, L., Leather, A. J., Marks, I. H., Meara, J. G., Shrime, M. G., Smith, M., Soreide, K., Weiser, T. G., Davies, J. 2018

  Abstract

  BACKGROUND: In 2015, six indicators were proposed to evaluate global progress towards access to safe, affordable and timely surgical and anaesthesia care. Although some have been adopted as core global health indicators, none has been evaluated systematically. The aims of this study were to assess the availability, comparability and utility of the indicators, and to present available data and updated estimates.METHODS: Nationally representative data were compiled for all WHO member states from 2010 to 2016 through contacts with official bodies and review of the published and grey literature, and available databases. Availability, comparability and utility were assessed for each indicator: access to timely essential surgery, specialist surgical workforce density, surgical volume, perioperative mortality, and protection against impoverishing and catastrophic expenditure. Where feasible, imputation models were developed to generate global estimates.RESULTS: Of all WHO member states, 19 had data on the proportion of the population within 2h of a surgical facility, 154 had data on workforce density, 72 reported number of procedures, and nine had perioperative mortality data, but none could report data on catastrophic or impoverishing expenditure. Comparability and utility were variable, and largely dependent on different definitions used. There were sufficient data to estimate that worldwide, in 2015, there were 2038947 (i.q.r. 1884916-2281776) surgeons, obstetricians and anaesthetists, and 266·1 (95 per cent c.i. 220·1 to 344·4) million operations performed.CONCLUSION: Surgical and anaesthesia indicators are increasingly being adopted by the global health community, but data availability remains low. Comparability and utility for all indicators require further resolution.

  View details for PubMedID 30570764

• INTER-HOSPITAL VARIABILITY IN TIME TO DISCHARGE TO REHABILITATION AMONG INSURED TRAUMA PATIENTS. The journal of trauma and acute care surgery Knowlton, L. M., Harris, A. H., Tennakoon, L., Hawn, M. T., Spain, D. A., Staudenmayer, K. L. 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

• Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals. Journal of the American College of Surgeons Knowlton, L. M., Morris, A. M., Tennakoon, L., Spain, D. A., Staudenmayer, K. L. 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

• Geriatric Trauma Partnership: Targeting The Right Population Sheffrin, M., Bharija, A., Knowlton, L. M., Staudenmayer, K. WILEY. 2018: S157

  View details for Web of Science ID 000430468400462

• Trauma-induced insurance instability: Variation in insurance coverage for patients who experience readmission after injury. The journal of trauma and acute care surgery Rajasingh, C. M., Weiser, T. G., Knowlton, L. M., Tennakoon, L. n., Spain, D. A., Staudenmayer, K. L. 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

• A geospatial evaluation of timely access to surgical care in seven countries BULLETIN OF THE WORLD HEALTH ORGANIZATION Knowlton, L. M., Banguti, P., Chackungal, S., Chanthasiri, T., Chao, T. E., Dahn, B., Derbew, M., Dhar, D., Esquivel, M. M., Evans, F., Hendel, S., LeBrun, D. G., Notrica, M., Saavedra-Pozo, I., Shockley, R., Uribe-Leitz, T., Vannavong, B., McQueen, K. A., Spain, D. A., Weiser, T. G. 2017; 95 (6): 437–44

  Abstract

  To assess the consistent availability of basic surgical resources at selected facilities in seven countries.In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available.Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh.Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

  View details for PubMedID 28603310

  View details for PubMedCentralID PMC5463808

• Readmissions to the Hospital for Surgical Patients Discharged to Skilled Nursing Facilities Staudenmayer, K., Knowlton, L., Hawn, M., Kou, L., Kim, L. WILEY. 2017: S70–S71

  View details for Web of Science ID 000402876300201

• 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 Uribe-Leitz, T., Esquivel, M. M., Knowlton, L. M., Ciesla, D., Lin, F., Hsia, R. Y., Spain, D. A., Winchell, R. J., Staudenmayer, K. L. 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

• National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy. JAMA surgery Rosenberg, G. M., Knowlton, L. n., Rajasingh, C. n., Weng, Y. n., Maggio, P. M., Spain, D. A., Staudenmayer, K. L. 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

• A Multinational Evaluation of Timely Access to Basic Surgical Services Using Geospatial Analyses Knowlton, L., Esquivel, M., Uribe-Leitz, T., Mcqueen, K., Chackungal, S., LeBrun, D. G., Chao, T. E., Weiser, T. G., Spain, D. A. ELSEVIER SCIENCE INC. 2016: E118

  View details for DOI 10.1016/j.jamcollsurg.2016.08.296

  View details for Web of Science ID 000395825100255

• Trauma Surveillance in Cape Town, South Africa An Analysis of 9236 Consecutive Trauma Center Admissions JAMA SURGERY Nicol, A., Knowlton, L. M., Schuurman, N., Matzopoulos, R., Zargaran, E., Cinnamon, J., Fawcett, V., Taulu, T., Hameed, S. M. 2014; 149 (6): 549-556

  Abstract

  Trauma is a leading cause of death and disability worldwide. In many low- and middle-income countries, formal trauma surveillance strategies have not yet been widely implemented.To formalize injury data collection at Groote Schuur Hospital, the chief academic hospital of the University of Cape Town, a level I trauma center, and one of the largest trauma referral hospitals in the world.This was a prospective study of all trauma admissions from October 1, 2010, through September 30, 2011, at Groote Schuur Hospital. A standard admission form was developed with multidisciplinary input and was used for both clinical and data abstraction purposes. Analysis of data was performed in 3 parts: demographics of injury, injury risk by location, and access to and maturity of trauma services. Geographic information science was then used to create satellite imaging of injury "hot spots" and to track referral patterns. Finally, the World Health Organization trauma system maturity index was used to evaluate the current breadth of the trauma system in place.The demographics of trauma patients, the distribution of injury in a large metropolitan catchment, and the patterns of injury referral and patient movement within the trauma system.The minimum 34-point data set captured relevant demographic, geographic, incident, and clinical data for 9236 patients. Data field completion rates were highly variable. An analysis of demographics of injury (age, sex, and mechanism of injury) was performed. Most violence occurred toward males (71.3%) who were younger than 40 years of age (74.6%). We demonstrated high rates of violent interpersonal injury (71.6% of intentional injury) and motor vehicle injury (18.8% of all injuries). There was a strong association between injury and alcohol use, with alcohol implicated in at least 30.1% of trauma admissions. From a systems standpoint, the data suggest a mature pattern of referral consistent with the presence of an inclusive trauma system.The implementation of injury surveillance at Groote Schuur Hospital improved insights about injury risk based on demographics and neighborhood as well as access to service based on patterns of referral. This information will guide further development of South Africa's already advanced trauma system.

  View details for DOI 10.1001/jamasurg.2013.5267

  View details for Web of Science ID 000337909900015

  View details for PubMedID 24789507

• Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: Operative capacities of 78 district hospitals in 7 low- and middle-income countries SURGERY Lebrun, D. G., Chackungal, S., Chao, T. E., Knowlton, L. M., Linden, A. F., Notrica, M. R., Solis, C. V., McQueen, K. A. 2014; 155 (3): 365-373

  Abstract

  Surgery has been neglected in low- and middle-income countries for decades. It is vital that the Post-2015 Development Agenda reflect that surgery is an important part of a comprehensive global health care delivery model. We compare the operative capacities of multiple low- and middle-income countries and identify critical gaps in surgical infrastructure.The Harvard Humanitarian Initiative survey tool was used to assess the operative capacities of 78 government district hospitals in Bangladesh (n = 7), Bolivia (n = 11), Ethiopia (n = 6), Liberia (n = 11), Nicaragua (n = 10), Rwanda (n = 21), and Uganda (n = 12) from 2011 to 2012. Key outcome measures included infrastructure, equipment availability, physician and nonphysician surgical providers, operative volume, and pharmaceutical capacity.Seventy of 78 district hospitals performed operations. There was fewer than one surgeon or anesthesiologist per 100,000 catchment population in all countries except Bolivia. There were no physician anesthesiologists in any surveyed hospitals in Rwanda, Liberia, Uganda, or in the majority of hospitals in Ethiopia. Mean annual operations per hospital ranged from 374 in Nicaragua to 3,215 in Bangladesh. Emergency operations and obstetric operations constituted 57.5% and 40% of all operations performed, respectively. Availability of pulse oximetry, essential medicines, and key infrastructure (water, electricity, oxygen) varied widely between and within countries.The need for operative procedures is not being met by the limited operative capacity in numerous low- and middle-income countries. It is of paramount importance that this gap be addressed by prioritizing essential surgery and safe anesthesia in the Post-2015 Development Agenda.

  View details for DOI 10.1016/j.eurg.2013.10.008

  View details for Web of Science ID 000331991200001

  View details for PubMedID 24439745

• Liberian Surgical and Anesthesia Infrastructure: A Survey of County Hospitals WORLD JOURNAL OF SURGERY Knowlton, L. M., Chackungal, S., Dahn, B., Lebrun, D., Nickerson, J., McQueen, K. 2013; 37 (4): 721-729

  Abstract

  There is a significant burden of disease in low-income countries that can benefit from surgical intervention. The goal of this survey was to evaluate the current ability of the Liberian health care system to provide safe surgical care and to identify unmet needs in regard to trained personnel, equipment, infrastructure, and outcomes measurement.A comprehensive survey tool was developed to assess physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, equipment and medications, and the capacity of the surgical system to collect and evaluate surgical outcomes at district-level hospitals in Africa. This tool was implemented in a sampling of 11 county hospitals in Liberia (January 2011). Data were obtained from the Ministry of Health and by direct government-affiliated hospital site visits.The total catchment area of the 11 hospitals surveyed was 2,313,429--equivalent to roughly 67 % of the population of Liberia (3,476,608). There were 13 major operating rooms and 34 (1.5 per 100,000 population) physicians delivering surgical, obstetric, or anesthesia care including 2 (0.1 per 100,000 population) who had completed formal postgraduate training programs in these specialty areas. The total number of surgical cases for 2010 was 7,654, with approximately 43 % of them being elective procedures. Among the facilities that tracked outcomes in 2010, a total of 11 intraoperative deaths (145 per 100,000 operative cases) were recorded for 2009. The 30-day postoperative mortality at hospitals providing data was 44 (1,359 per 100,000 operative cases). Metrics were also used to evaluate surgical output, safety of anesthesia, and the burden of obstetric disease.A significant volume of surgical care is being delivered at county hospitals throughout Liberia. The density and quality of appropriately trained personnel and infrastructure remain critically low. There is strong evidence for continued development of emergency and essential surgical services, as well as improved surgical outcomes tracking, at county hospitals in Liberia. These results serve to inform the international community and donors of the ongoing global surgical and anesthesia crisis.

  View details for DOI 10.1007/s00268-013-1903-2

  View details for Web of Science ID 000317360900002

  View details for PubMedID 23404484

• Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010 LANCET Murray, C. J., Vos, T., Lozano, R., Naghavi, M., Flaxman, A. D., Michaud, C., Ezzati, M., Shibuya, K., Salomon, J. A., Abdalla, S., Aboyans, V., Abraham, J., Ackerman, I., Aggarwal, R., Ahn, S. Y., Ali, M. K., Alvarado, M., Anderson, H. R., Anderson, L. M., Andrews, K. G., Atkinson, C., Baddour, L. M., Bahalim, A. N., Barker-Collo, S., Barrero, L. H., Bartels, D. H., Basanez, M., Baxter, A., Bell, M. L., Benjamin, E. J., Bennett, D., Bernabe, E., Bhalla, K., Bhandari, B., Bikbov, B., Bin Abdulhak, A., Birbeck, G., Black, J. A., Blencowe, H., Blore, J. D., Blyth, F., Bolliger, I., Bonaventure, A., Boufous, S. A., Bourne, R., Boussinesq, M., Braithwaite, T., Brayne, C., Bridgett, L., Brooker, S., Brooks, P., Brugha, T. S., Bryan-Hancock, C., Bucello, C., Buchbinder, R., Buckle, G., Budke, C. M., Burch, M., Burney, P., Burstein, R., Calabria, B., Campbell, B., Canter, C. E., Carabin, H., Carapetis, J., Carmona, L., Cella, C., Charlson, F., Chen, H., Cheng, A. T., Chou, D., Chugh, S. S., Coffeng, L. E., Colan, S. D., Colquhoun, S., Colson, K. E., Condon, J., Connor, M. D., Cooper, L. T., Corriere, M., Cortinovis, M., de Vaccaro, K. C., Couser, W., Cowie, B. C., Criqui, M. H., Cross, M., Dabhadkar, K. C., Dahiya, M., Dahodwala, N., Damsere-Derry, J., Danaei, G., Davis, A., De Leo, D., Degenhardt, L., Dellavalle, R., Delossantos, A., Denenberg, J., Derrett, S., Des Jarlais, D. C., Dharmaratne, S. D., Dherani, M., Diaz-Torne, C., Dolk, H., Dorsey, E. R., Driscoll, T., Duber, H., Ebel, B., Edmond, K., Elbaz, A., Ali, S. E., Erskine, H., Erwin, P. J., Espindola, P., Ewoigbokhan, S. E., Farzadfar, F., Feigin, V., Felson, D. T., Ferrari, A., Ferri, C. P., Fevre, E. M., Finucane, M. M., Flaxman, S., Flood, L., Foreman, K., Forouzanfar, M. H., Fowkes, F. G., Fransen, M., Freeman, M. K., Gabbe, B. J., Gabriel, S. E., Gakidou, E., Ganatra, H. A., Garcia, B., Gaspari, F., Gillum, R. F., Gmel, G., Gonzalez-Medina, D., Gosselin, R., Grainger, R., Grant, B., Groeger, J., Guillemin, F., Gunnell, D., Gupta, R., Haagsma, J., Hagan, H., Halasa, Y. A., Hall, W., Haring, D., Maria Haro, J., Harrison, J. E., Havmoeller, R., Hay, R. J., Higashi, H., Hill, C., Hoen, B., Hoffman, H., Hotez, P. J., Hoy, D., Huang, J. J., Ibeanusi, S. E., Jacobsen, K. H., James, S. L., Jarvis, D., Jasrasaria, R., Jayaraman, S., Johns, N., Jonas, J. B., Karthikeyan, G., Kassebaum, N., Kawakami, N., Keren, A., Khoo, J., King, C. H., Knowlton, L. M., Kobusingye, O., Koranteng, A., Krishnamurthi, R., Laden, F., Lalloo, R., Laslett, L. L., Lathlean, T., Leasher, J. L., Lee, Y. Y., Leigh, J., Levinson, D., Lim, S. S., Limb, E., Lin, J. K., Lipnick, M., Lipshultz, S. E., Liu, W., Loane, M., Ohno, S. L., Lyons, R., Mabweijano, J., MacIntyre, M. F., Malekzadeh, R., Mallinger, L., Manivannan, S., Marcenes, W., March, L., Margolis, D. J., Marks, G. B., Marks, R., Matsumori, A., Matzopoulos, R., Mayosi, B. M., McAnulty, J. H., McDermott, M. M., McGill, N., McGrath, J., Elena Medina-Mora, M., Meltzer, M., Mensah, G. A., Merriman, T. R., Meyer, A., Miglioli, V., Miller, M., Miller, T. R., Mitchell, P. B., Mock, C., Mocumbi, A. O., Moffitt, T. E., Mokdad, A. A., Monasta, L., Montico, M., Moradi-Lakeh, M., Moran, A., Morawska, L., Mori, R., Murdoch, M. E., Mwaniki, M. K., Naidoo, K., Nair, M. N., Naldi, L., Narayan, K. M., Nelson, P. K., Nelson, R. G., Nevitt, M. C., Newton, C. R., Nolte, S., Norman, P., Norman, R., O'Donnell, M., O'Hanlon, S., Olives, C., Omer, S. B., Ortblad, K., Osborne, R., Ozgediz, D., Page, A., Pahari, B., Pandian, J. D., Panozo Rivero, A., Patten, S. B., Pearce, N., Perez Padilla, R., Perez-Ruiz, F., Perico, N., Pesudovs, K., Phillips, D., Phillips, M. R., Pierce, K., Pion, S., Polanczyk, G. V., Polinder, S., Pope, C. A., Popova, S., Porrini, E., Pourmalek, F., Prince, M., Pullan, R. L., Ramaiah, K. D., Ranganathan, D., Razavi, H., Regan, M., Rehm, J. T., Rein, D. B., Remuzzi, G., Richardson, K., Rivara, F. P., Roberts, T., Robinson, C., Rodriguez De Leon, F., Ronfani, L., Room, R., Rosenfeld, L. C., Rushton, L., Sacco, R. L., Saha, S., Sampson, U., Sanchez-Riera, L., Sanman, E., Schwebel, D. C., Scott, J. G., Segui-Gomez, M., Shahraz, S., Shepard, D. S., Shin, H., Shivakoti, R., Singh, D., Singh, G. M., Singh, J. A., Singleton, J., Sleet, D. A., Sliwa, K., Smith, E., Smith, J. L., Stapelberg, N. J., Steer, A., Steiner, T., Stolk, W. A., Stovner, L. J., Sudfeld, C., Syed, S., Tamburlini, G., Tavakkoli, M., Taylor, H. R., Taylor, J. A., Taylor, W. J., Thomas, B., Thomson, W. M., Thurston, G. D., Tleyjeh, I. M., Tonelli, M., Towbin, J. R., Truelsen, T., Tsilimbaris, M. K., Ubeda, C., Undurraga, E. A., Van der Werf, M. J., van Os, J., Vavilala, M. S., Venketasubramanian, N., Wang, M., Wang, W., Watt, K., Weatherall, D. J., Weinstock, M. A., Weintraub, R., Weisskopf, M. G., Weissman, M. M., White, R. A., Whiteford, H., Wiebe, N., Wiersma, S. T., Wilkinson, J. D., Williams, H. C., Williams, S. R., Witt, E., Wolfe, F., Woolf, A. D., Wulf, S., Yeh, P., Zaidi, A. K., Zheng, Z., Zonies, D., Lopez, A. D. 2012; 380 (9859): 2197-2223

  Abstract

  Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time.We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights.Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions.Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results.Bill & Melinda Gates Foundation.

  View details for Web of Science ID 000312387000016

  View details for PubMedID 23245608

• Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010 LANCET Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., Shibuya, K., Salomon, J. A., Abdalla, S., Aboyans, V., Abraham, J., Ackerman, I., Aggarwal, R., Ahn, S. Y., Ali, M. K., Alvarado, M., Anderson, H. R., Anderson, L. M., Andrews, K. G., Atkinson, C., Baddour, L. M., Bahalim, A. N., Barker-Collo, S., Barrero, L. H., Bartels, D. H., Basanez, M., Baxter, A., Bell, M. L., Benjamin, E. J., Bennett, D., Bernabe, E., Bhalla, K., Bhandari, B., Bikbov, B., Bin Abdulhak, A., Birbeck, G., Black, J. A., Blencowe, H., Blore, J. D., Blyth, F., Bolliger, I., Bonaventure, A., Boufous, S. A., Bourne, R., Boussinesq, M., Braithwaite, T., Brayne, C., Bridgett, L., Brooker, S., Brooks, P., Brugha, T. S., Bryan-Hancock, C., Bucello, C., Buchbinder, R., Buckle, G. R., Budke, C. M., Burch, M., Burney, P., Burstein, R., Calabria, B., Campbell, B., Canter, C. E., Carabin, H., Carapetis, J., Carmona, L., Cella, C., Charlson, F., Chen, H., Cheng, A. T., Chou, D., Chugh, S. S., Coffeng, L. E., Colan, S. D., Colquhoun, S., Colson, K. E., Condon, J., Connor, M. D., Cooper, L. T., Corriere, M., Cortinovis, M., de Vaccaro, K. C., Couser, W., Cowie, B. C., Criqui, M. H., Cross, M., Dabhadkar, K. C., Dahiya, M., Dahodwala, N., Damsere-Derry, J., Danaei, G., Davis, A., De Leo, D., Degenhardt, L., Dellavalle, R., Delossantos, A., Denenberg, J., Derrett, S., Des Jarlais, D. C., Dharmaratne, S. D., Dherani, M., Diaz-Torne, C., Dolk, H., Dorsey, E. R., Driscoll, T., Duber, H., Ebel, B., Edmond, K., Elbaz, A., Ali, S. E., Erskine, H., Erwin, P. J., Espindola, P., Ewoigbokhan, S. E., Farzadfar, F., Feigin, V., Felson, D. T., Ferrari, A., Ferri, C. P., Fevre, E. M., Finucane, M. M., Flaxman, S., Flood, L., Foreman, K., Forouzanfar, M. H., Fowkes, F. G., Franklin, R., Fransen, M., Freeman, M. K., Gabbe, B. J., Gabriel, S. E., Gakidou, E., Ganatra, H. A., Garcia, B., Gaspari, F., Gillum, R. F., Gmel, G., Gosselin, R., Grainger, R., Groeger, J., Guillemin, F., Gunnell, D., Gupta, R., Haagsma, J., Hagan, H., Halasa, Y. A., Hall, W., Haring, D., Maria Haro, J., Harrison, J. E., Havmoeller, R., Hay, R. J., Higashi, H., Hill, C., Hoen, B., Hoffman, H., Hotez, P. J., Hoy, D., Huang, J. J., Ibeanusi, S. E., Jacobsen, K. H., James, S. L., Jarvis, D., Jasrasaria, R., Jayaraman, S., Johns, N., Jonas, J. B., Karthikeyan, G., Kassebaum, N., Kawakami, N., Keren, A., Khoo, J., King, C. H., Knowlton, L. M., Kobusingye, O., Koranteng, A., Krishnamurthi, R., Lalloo, R., Laslett, L. L., Lathlean, T., Leasher, J. L., Lee, Y. Y., Leigh, J., Lim, S. S., Limb, E., Lin, J. K., Lipnick, M., Lipshultz, S. E., Liu, W., Loane, M., Ohno, S. L., Lyons, R., Ma, J., Mabweijano, J., MacIntyre, M. F., Malekzadeh, R., Mallinger, L., Manivannan, S., Marcenes, W., March, L., Margolis, D. J., Marks, G. B., Marks, R., Matsumori, A., Matzopoulos, R., Mayosi, B. M., McAnulty, J. H., McDermott, M. M., McGill, N., McGrath, J., Elena Medina-Mora, M., Meltzer, M., Mensah, G. A., Merriman, T. R., Meyer, A., Miglioli, V., Miller, M., Miller, T. R., Mitchell, P. B., Mocumbi, A. O., Moffitt, T. E., Mokdad, A. A., Monasta, L., Montico, M., Moradi-Lakeh, M., Moran, A., Morawska, L., Mori, R., Murdoch, M. E., Mwaniki, M. K., Naidoo, K., Nair, M. N., Naldi, L., Narayan, K. M., Nelson, P. K., Nelson, R. G., Nevitt, M. C., Newton, C. R., Nolte, S., Norman, P., Norman, R., O'Donnell, M., O'Hanlon, S., Olives, C., Omer, S. B., Ortblad, K., Osborne, R., Ozgediz, D., Page, A., Pahari, B., Pandian, J. D., Rivero, A. P., Patten, S. B., Pearce, N., Perez Padilla, R., Perez-Ruiz, F., Perico, N., Pesudovs, K., Phillips, D., Phillips, M. R., Pierce, K., Pion, S., Polanczyk, G. V., Polinder, S., Pope, C. A., Popova, S., Porrini, E., Pourmalek, F., Prince, M., Pullan, R. L., Ramaiah, K. D., Ranganathan, D., Razavi, H., Regan, M., Rehm, J. T., Rein, D. B., Remuzzi, G., Richardson, K., Rivara, F. P., Roberts, T., Robinson, C., De Leon, F. R., Ronfani, L., Room, R., Rosenfeld, L. C., Rushton, L., Sacco, R. L., Saha, S., Sampson, U., Sanchez-Riera, L., Sanman, E., Schwebel, D. C., Scott, J. G., Segui-Gomez, M., Shahraz, S., Shepard, D. S., Shin, H., Shivakoti, R., Singh, D., Singh, G. M., Singh, J. A., Singleton, J., Sleet, D. A., Sliwa, K., Smith, E., Smith, J. L., Stapelberg, N. J., Steer, A., Steiner, T., Stolk, W. A., Stovner, L. J., Sudfeld, C., Syed, S., Tamburlini, G., Tavakkoli, M., Taylor, H. R., Taylor, J. A., Taylor, W. J., Thomas, B., Thomson, W. M., Thurston, G. D., Tleyjeh, I. M., Tonelli, M., Towbin, J. R., Truelsen, T., Tsilimbaris, M. K., Ubeda, C., Undurraga, E. A., Van der Werf, M. J., van Os, J., Vavilala, M. S., Venketasubramanian, N., Wang, M., Wang, W., Watt, K., Weatherall, D. J., Weinstock, M. A., Weintraub, R., Weisskopf, M. G., Weissman, M. M., White, R. A., Whiteford, H., Wiersma, S. T., Wilkinson, J. D., Williams, H. C., Williams, S. R., Witt, E., Wolfe, F., Woolf, A. D., Wulf, S., Yeh, P., Zaidi, A. K., Zheng, Z., Zonies, D., Lopez, A. D., Murray, C. J. 2012; 380 (9859): 2163-2196

  Abstract

  Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs).Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis.Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350,000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa.Rates of YLDs per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world.Bill & Melinda Gates Foundation.

  View details for Web of Science ID 000312387000015

  View details for PubMedID 23245607

• Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010 LANCET Lozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., Aboyans, V., Abraham, J., Adair, T., Aggarwal, R., Ahn, S. Y., Alvarado, M., Anderson, H. R., Anderson, L. M., Andrews, K. G., Atkinson, C., Baddour, L. M., Barker-Collo, S., Bartels, D. H., Bell, M. L., Benjamin, E. J., Bennett, D., Bhalla, K., Bikbov, B., Bin Abdulhak, A., Birbeck, G., Blyth, F., Bolliger, I., Boufous, S. A., Bucello, C., Burch, M., Burney, P., Carapetis, J., Chen, H., Chou, D., Chugh, S. S., Coffeng, L. E., Colan, S. D., Colquhoun, S., Colson, K. E., Condon, J., Connor, M. D., Cooper, L. T., Corriere, M., Cortinovis, M., de Vaccaro, K. C., Couser, W., Cowie, B. C., Criqui, M. H., Cross, M., Dabhadkar, K. C., Dahodwala, N., De Leo, D., Degenhardt, L., Delossantos, A., Denenberg, J., Des Jarlais, D. C., Dharmaratne, S. D., Dorsey, E. R., Driscoll, T., Duber, H., Ebel, B., Erwin, P. J., Espindola, P., Ezzati, M., Feigin, V., Flaxman, A. D., Forouzanfar, M. H., Fowkes, F. G., Franklin, R., Fransen, M., Freeman, M. K., Gabriel, S. E., Gakidou, E., Gaspari, F., Gillum, R. F., Gonzalez-Medina, D., Halasa, Y. A., Haring, D., Harrison, J. E., Havmoeller, R., Hay, R. J., Hoen, B., Hotez, P. J., Hoy, D., Jacobsen, K. H., James, S. L., Jasrasaria, R., Jayaraman, S., Johns, N., Karthikeyan, G., Kassebaum, N., Keren, A., Khoo, J., Knowlton, L. M., Kobusingye, O., Koranteng, A., Krishnamurthi, R., Lipnick, M., Lipshultz, S. E., Ohno, S. L., Mabweijano, J., MacIntyre, M. F., Mallinger, L., March, L., Marks, G. B., Marks, R., Matsumori, A., Matzopoulos, R., Mayosi, B. M., McAnulty, J. H., McDermott, M. M., McGrath, J., Mensah, G. A., Merriman, T. R., Michaud, C., Miller, M., Miller, T. R., Mock, C., Mocumbi, A. O., Mokdad, A. A., Moran, A., Mulholland, K., Nair, M. N., Naldi, L., Narayan, K. M., Nasseri, K., Norman, P., O'Donnell, M., Omer, S. B., Ortblad, K., Osborne, R., Ozgediz, D., Pahari, B., Pandian, J. D., Rivero, A. P., Padilla, R. P., Perez-Ruiz, F., Perico, N., Phillips, D., Pierce, K., Pope, C. A., Porrini, E., Pourmalek, F., Raju, M., Ranganathan, D., Rehm, J. T., Rein, D. B., Remuzzi, G., Rivara, F. P., Roberts, T., De Leon, F. R., Rosenfeld, L. C., Rushton, L., Sacco, R. L., Salomon, J. A., Sampson, U., Sanman, E., Schwebel, D. C., Segui-Gomez, M., Shepard, D. S., Singh, D., Singleton, J., Sliwa, K., Smith, E., Steer, A., Taylor, J. A., Thomas, B., Tleyjeh, I. M., Towbin, J. A., Truelsen, T., Undurraga, E. A., Venketasubramanian, N., Vijayakumar, L., Vos, T., Wagner, G. R., Wang, M., Wang, W., Watt, K., Weinstock, M. A., Weintraub, R., Wilkinson, J. D., Woolf, A. D., Wulf, S., Yeh, P., Yip, P., Zabetian, A., Zheng, Z., Lopez, A. D., Murray, C. J. 2012; 380 (9859): 2095-2128

  Abstract

  Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.Bill & Melinda Gates Foundation.

  View details for Web of Science ID 000312387000012

  View details for PubMedID 23245604

• Challenges of Surgery in Developing Countries: A Survey of Surgical and Anesthesia Capacity in Uganda's Public Hospitals WORLD JOURNAL OF SURGERY Linden, A. F., Sekidde, F. S., Galukande, M., Knowlton, L. M., Chackungal, S., McQueen, K. A. 2012; 36 (5): 1056-1065

  Abstract

  There are large disparities in access to surgical services due to a multitude of factors, including insufficient health human resources, infrastructure, medicines, equipment, financing, logistics, and information reporting. This study aimed to assess these important factors in Uganda's government hospitals as part of a larger study examining surgical and anesthesia capacity in low-income countries in Africa.A standardized survey tool was administered via interviews with Ministry of Health officials and key health practitioners at 14 public government hospitals throughout the country. Descriptive statistics were used to analyze the data.There were a total of 107 general surgeons, 97 specialty surgeons, 124 obstetricians/gynecologists (OB/GYNs), and 17 anesthesiologists in Uganda, for a rate of one surgeon per 100,000 people. There was 0.2 major operating theater per 100,000 people. Altogether, 53% of all operations were general surgery cases, and 44% were OB/GYN cases. In all, 73% of all operations were performed on an emergency basis. All hospitals reported unreliable supplies of water and electricity. Essential equipment was missing across all hospitals, with no pulse oximeters found at any facilities. A uniform reporting mechanism for outcomes did not exist.There is a lack of vital human resources and infrastructure to provide adequate, safe surgery at many of the government hospitals in Uganda. A large number of surgical procedures are undertaken despite these austere conditions. Many areas that need policy development and international collaboration are evident. Surgical services need to become a greater priority in health care provision in Uganda as they could promise a significant reduction in morbidity and mortality.

  View details for DOI 10.1007/s00268-012-1482-7

  View details for Web of Science ID 000304096700018

  View details for PubMedID 22402968

• Surgical care during humanitarian crises: a systematic review of published surgical caseload data from foreign medical teams. Prehospital and disaster medicine Nickerson, J. W., Chackungal, S., Knowlton, L., McQueen, K., Burkle, F. M. 2012; 27 (2): 184-189

  Abstract

  Humanitarian surgery is often organized and delivered with short notice and limited time for developing unique strategies for providing care. While some surgical pathologies can be anticipated by the nature of the crisis, the role of foreign medical teams in treating the existing and unmet burden of surgical disease during crises is unclear. The purpose of this study was to examine published data from crises during the years 1990 through 2011 to understand the role of foreign medical teams in providing surgical care in these settings.A literature search was completed using PubMed, MEDLINE, and EMBASE databases to locate relevant manuscripts published in peer-reviewed journals. A qualitative review of the surgical activities reported in the studies was performed.Of 185 papers where humanitarian surgical care was provided by a foreign medical team, only 11 articles met inclusion criteria. The reporting of surgical activities varied significantly, and pooled statistical analysis was not possible. The quality of reporting was notably poor, and produced neither reliable estimates of the pattern of surgical consultations nor data on the epidemiology of the burden of surgical diseases. The qualitative trend analysis revealed that the most frequent procedures were related to soft tissue or orthopedic surgery. Procedures such as caesarean sections, hernia repairs, and appendectomies also were common. As length of deployment increased, the surgical caseload became more reflective of the existing, unmet burden of surgical disease.This review suggests that where foreign medical teams are indicated and requested, multidisciplinary surgical teams capable of providing a range of emergency and essential surgical, and rehabilitation services are required. Standardization of data collection and reporting tools for surgical care are needed to improve the reporting of surgical epidemiology in crisis-affected populations.

  View details for DOI 10.1017/S1049023X12000556

  View details for PubMedID 22591739

• Best practice guidelines on surgical response in disasters and humanitarian emergencies: report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space. Prehospital and disaster medicine Chackungal, S., Nickerson, J. W., Knowlton, L. M., Black, L., Burkle, F. M., Casey, K., Crandell, D., Demey, D., Di Giacomo, L., Dohlman, L., Goldstein, J., Gosney, J. E., Ikeda, K., Linden, A., Mullaly, C. M., O'Connell, C., Redmond, A. D., Richards, A., Rufsvold, R., Santos, A. L., Skelton, T., McQueen, K. 2011; 26 (6): 429-437

  Abstract

  The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.

  View details for DOI 10.1017/S1049023X12000064

  View details for PubMedID 22475370

• Consensus statements regarding the multidisciplinary care of limb amputation patients in disasters or humanitarian emergencies: report of the 2011 Humanitarian Action Summit Surgical Working Group on amputations following disasters or conflict. Prehospital and disaster medicine Knowlton, L. M., Gosney, J. E., Chackungal, S., Altschuler, E., Black, L., Burkle, F. M., Casey, K., Crandell, D., Demey, D., Di Giacomo, L., Dohlman, L., Goldstein, J., Gosselin, R., Ikeda, K., Le Roy, A., Linden, A., Mullaly, C. M., Nickerson, J., O'Connell, C., Redmond, A. D., Richards, A., Rufsvold, R., Santos, A. L., Skelton, T., McQueen, K. 2011; 26 (6): 438-448

  Abstract

  Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systems the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.

  View details for DOI 10.1017/S1049023X12000076

  View details for PubMedID 22559308

• Rwandan Surgical and Anesthesia Infrastructure: A Survey of District Hospitals WORLD JOURNAL OF SURGERY Notrica, M. R., Evans, F. M., Knowlton, L. M., McQueen, K. A. 2011; 35 (8): 1770-1780

  Abstract

  In low-income countries, unmet surgical needs lead to a high incidence of death. Information on the incidence and safety of current surgical care in low-income countries is limited by the paucity of data in the literature. The aim of this survey was to assess the surgical and anesthesia infrastructure in Rwanda as part of a larger study examining surgical and anesthesia capacity in low-income African countries.A comprehensive survey tool was developed to assess the physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, and equipment and medications at district-level hospitals in sub-Saharan Africa. The survey was administered at 21 district hospitals in Rwanda using convenience sampling.There are only nine Rwandan anesthesiologists and 17 Rwandan surgeons providing surgical care for a population of more than 10 million. The specialty-trained Rwandan surgeons and anesthesiologists are practicing almost exclusively at referral hospitals, leaving surgical care at district hospitals to the general practice physicians and nurses. All of the district hospitals reported some lack of surgical infrastructure including limited access to oxygen, anesthesia equipment and medications, monitoring equipment, and trained personnel.This survey provides strong evidence of the need for continued development of emergency and essential surgical services at district hospitals in Rwanda to improve health care and to comply with World Health Organization recommendations. It has identified serious deficiencies in both financial and human resources-areas where the international community can play a role.

  View details for DOI 10.1007/s00268-011-1125-4

  View details for Web of Science ID 000293705300011

  View details for PubMedID 21562869

• Is coronary graft Doppler more sensitive for indiviual graft flows than TEE during CABG surgery? JOURNAL OF CARDIAC SURGERY Morin, J., Mistry, B. F., Knowlton, L. 2007; 22 (4): 356-358

  Abstract

  In this case report we describe a situation where despite a normal TEE exam immediately postcardiopulmonary bypass, there was no flow in the left internal mammary artery graft to the left anterior descending artery. This was picked up by coronary Doppler and subsequently repaired.

  View details for DOI 10.1111/j.1540-8191.2007.00423.x

  View details for Web of Science ID 000247943500020

  View details for PubMedID 17661786

• Recombinant activated factor VII in cardiac surgery: A systematic review ANNALS OF THORACIC SURGERY Warren, O., Mandal, K., Hadjianastassiou, V., Knowlton, L., Panesar, S., John, K., Darzi, A., Athanasiou, T. 2007; 83 (2): 707-714

  Abstract

  Postoperative hemorrhage is a common complication in cardiac surgery, and it is associated with a considerable increase in morbidity, mortality, and cost. Recombinant activated factor VII (rFVIIa) is an emerging hemostatic agent, increasingly used in cardiac surgery. This article systematically reviews the evidence regarding the efficacy, safety, and cost of rFVIIa in this setting. Although definitive evidence from randomized controlled trials is lacking, the use of rFVIIa in patients experiencing refractory postoperative hemorrhage seems promising and relatively safe. However further research is required to definitively establish its clinical utility in the postoperative cardiac patient.

  View details for DOI 10.1016/j.athoracsur.2006.10.033

  View details for Web of Science ID 000243716600070

  View details for PubMedID 17258029