National cost of trauma care by payer status

Complication reporting in trauma: An environmental scan and comparison of nationwide trauma registry data

BACKGROUND

To explore variability in quality measurement, this study aimed to compare abstraction and definitions of complications reported across trauma registries in Canada.

METHODS

A literature search was performed to identify active trauma registries used in Canadian hospitals. Registry characteristics, data abstraction, and reported complications and definitions based on registry data dictionaries were compared.

RESULTS

Nine registries were included, most of which were provincial-level registries (67 ​%). A total of 53 individual complications were identified. Twenty-one (40 ​%) were recorded by only one registry each whereas 5 (9 ​%) were collected by all. Of the 32 complications collected by ​> ​1 registry, 18 (56 ​%) had different definitions. Of the 18 with different definitions, 12 (67 ​%), 5 (28 ​%), and 1 (6 ​%) had 2, 3, and 4 different definitions across registries, respectively.

CONCLUSIONS

Complications reported by trauma registries are variable. Reliable benchmarking is likely challenging, and efforts to standardize complication reporting may be a valuable undertaking.

Barriers and facilitators associated with the upscaling of the Transmural Trauma Care Model: a qualitative study

BACKGROUND

To assess the barriers and facilitators associated with upscaling the Transmural Trauma Care Model (TTCM), a multidisciplinary and patient-centred transmural rehabilitation care model.

METHODS

Semi-structured interviews were conducted with eight trauma surgeons, eight hospital-based physiotherapists, eight trauma patients, and eight primary care physiotherapists who were part of a trauma rehabilitation network. Audio recordings of the interviews were made and transcribed verbatim. Data were analysed using a framework method based on the "constellation approach". Identified barriers and facilitators were grouped into categories related to structure, culture, and practice.

RESULTS

Various barriers and facilitators to upscaling were identified. Under structure, barriers and facilitators belonged to one of five themes: "financial structure", "communication structure", "physical structures and resources", "rules and regulations", and "organisation of the network". Under culture, the five themes were "commitment", "job satisfaction", "acting as a team", "quality and efficiency of care", and "patients' experience". Under practice, the two themes were "practical issues at the outpatient clinic" and "knowledge gained".

CONCLUSION

The success of upscaling the TTCM differed across hospitals and settings. The most important prerequisites for successfully upscaling the TTCM were adequate financial support and presence of "key actors" within an organisation who felt a sense of urgency for change and/or expected the intervention to increase their job satisfaction.

TRIAL REGISTRATION

NL8163 The Netherlands National Trial Register, date of registration 16-11-2019.

The Impact of Relocating a Trauma Center: Retrospective Observations on Payer Demographics and Cost-Analysis

BACKGROUND

Standardization of trauma centers improves quality of care, yet that comes with financial challenges. The decision to designate a trauma center typically focuses on access, quality of care, and the needs of the local community, but less often considers the financial viability of the trauma center. A level-1 trauma center was relocated in 2017 and this presented an opportunity to compare financial data at two separate locations in the same city.

METHODS

A retrospective review was performed on the local trauma registry and billing database in all patients aged ≥19 years on the trauma service before and after the move.

RESULTS

3041 patients were included (pre-move: 1151; post-move: 1890). After the move, patients were older (9.5 years), and more were females (14.9%) and white (16.5%). Increases in blunt injuries (7.6%), falls (14.8%), and motor vehicle accidents (1.7%) were observed after the move. After the move, patients were less likely to be discharged home (6.5%) and more likely to go to a skilled nursing facility (3%) or inpatient rehabilitation (5.5%). Post-move more patients had Medicare (12.6%) or commercial (8.5%) insurance and charges per patient decreased by $2,833, while charges collected per patient increased by $2425. Patients were seen from a broader distribution of zip codes post-move.

DISCUSSION

Relocating a trauma center did improve financial viability for this institution. Future studies should consider the impact on the surrounding community and other trauma centers.

LEVEL OF EVIDENCE

Level IV.

The association between lactate to albumin ratio and outcomes at early phase in patients with traumatic brain injury

BACKGROUND

The majority of traumatic brain injury (TBI) cases result in death in the early phase; predicting short-term progno-sis of affected patients is necessary to prevent this. This study aimed to examine the association between the lactate-to-albumin ratio (LAR) on admission and outcomes in the early phase of TBI.

METHODS

This retrospective observational study included patients with TBI who visited our emergency department between January 2018 and December 2020. TBI was considered as an head abbreviated injury scale (AIS) score of 3 or higher and other AIS of 2 or lower. The primary and secondary outcomes were 24-h mortality and massive transfusion (MT), respectively.

RESULTS

In total, 460 patients were included. The 24-h mortality was 12.6% (n=28) and MT was performed in 31 (6.7%) patients. In the multivariable analysis, LAR was associated with 24-h mortality (odds ratio [OR], 2.021; 95% confidence interval [CI], 1.301-3.139) and MT (OR, 1.898; 95% CI, 1.288-2.797). The areas under the curve of LAR for 24-h mortality and MT were 0.805 (95% CI, 0.766-0.841) and 0.735 (95% CI, 0.693-0.775), respectively.

CONCLUSION

LAR was associated with early-phase outcomes in patients with TBI, including 24-h mortality and MT. LAR may help predict these outcomes within 24 h in patients with TBI.

Association of Trauma Molecular Endotypes With Differential Response to Transfusion Resuscitation Strategies

Importance

It is not clear which severely injured patients with hemorrhagic shock may benefit most from a 1:1:1 vs 1:1:2 (plasma:platelets:red blood cells) resuscitation strategy. Identification of trauma molecular endotypes may reveal subgroups of patients with differential treatment response to various resuscitation strategies.

Objective

To derive trauma endotypes (TEs) from molecular data and determine whether these endotypes are associated with mortality and differential treatment response to 1:1:1 vs 1:1:2 resuscitation strategies.

Design, Setting, and Participants

This was a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized clinical trial. The study cohort included individuals with severe injury from 12 North American trauma centers. The cohort was taken from the participants in the PROPPR trial who had complete plasma biomarker data available. Study data were analyzed on August 2, 2021, to October 25, 2022.

Exposures

TEs identified by K-means clustering of plasma biomarkers collected at hospital arrival.

Main Outcomes and Measures

An association between TEs and 30-day mortality was tested using multivariable relative risk (RR) regression adjusting for age, sex, trauma center, mechanism of injury, and injury severity score (ISS). Differential treatment response to transfusion strategy was assessed using an RR regression model for 30-day mortality by incorporating an interaction term for the product of endotype and treatment group adjusting for age, sex, trauma center, mechanism of injury, and ISS.

Results

A total of 478 participants (median [IQR] age, 34.5 [25-51] years; 384 male [80%]) of the 680 participants in the PROPPR trial were included in this study analysis. A 2-class model that had optimal performance in K-means clustering was found. TE-1 (n = 270) was characterized by higher plasma concentrations of inflammatory biomarkers (eg, interleukin 8 and tumor necrosis factor α) and significantly higher 30-day mortality compared with TE-2 (n = 208). There was a significant interaction between treatment arm and TE for 30-day mortality. Mortality in TE-1 was 28.6% with 1:1:2 treatment vs 32.6% with 1:1:1 treatment, whereas mortality in TE-2 was 24.5% with 1:1:2 treatment vs 7.3% with 1:1:1 treatment (P for interaction = .001).

Conclusions and Relevance

Results of this secondary analysis suggest that endotypes derived from plasma biomarkers in trauma patients at hospital arrival were associated with a differential response to 1:1:1 vs 1:1:2 resuscitation strategies in trauma patients with severe injury. These findings support the concept of molecular heterogeneity in critically ill trauma populations and have implications for tailoring therapy for patients at high risk for adverse outcomes.

Using medicare claims to estimate risk-adjusted performance of Pennsylvania trauma centers

Trauma centers use registry data to benchmark performance using a standardized risk adjustment model. Our objective was to utilize national claims to develop a risk adjustment model applicable across all hospitals, regardless of designation or registry participation. Patients from 2013-14 Pennsylvania Trauma Outcomes Study (PTOS) registry data were probabilistically matched to Medicare claims using demographic and injury characteristics. Pairwise comparisons established facility linkages and matching was then repeated within facilities to link records. Registry models were estimated using GLM and compared with five claims-based LASSO models: demographics, clinical characteristics, diagnosis codes, procedures codes, and combined demographics/clinical characteristics. Area under the curve and correlation with registry model probability of death were calculated for each linked and out-of-sample cohort. From 29 facilities, a cohort comprising 16,418 patients were linked between datasets. Patients were similarly distributed: median age 82 (PTOS IQR: 74-87 vs. Medicare IQR: 75-88); non-white 6.2% (PTOS) vs. 5.8% (Medicare). The registry model AUC was 0.86 (0.84-0.87). Diagnosis and procedure codes models performed poorest. The demographics/clinical characteristics model achieved an AUC = 0.84 (0.83-0.86) and Spearman = 0.62 with registry data. Claims data can be leveraged to create models that accurately measure the performance of hospitals that treat trauma patients.

Trauma patients with limited English proficiency: Outcomes from two level one trauma centers

BACKGROUND

Outcomes for surgical patients with limited English proficiency (LEP) may be worse compared to patients with English proficiency. We sought to evaluate the association of LEP with outcomes for trauma patients.

METHODS

Admitted adult patients on trauma service at two Level One trauma centers from 2015 to 2019 were identified.

RESULTS

12,562 patients were included in total; 7.3% had LEP. On multivariable analyses, patients with LEP had lower odds of discharge to post-acute care versus home compared to patients with English proficiency (OR 0.69; 95% CI 0.58-0.83; p < 0.001) but had similar length of stay (Beta coefficient 1.16; 95% CI 0.00-2.32; p = 0.05), and 30-day readmission (OR 1.08; 95% CI 0.87-1.35; p = 0.46).

CONCLUSIONS

Trauma patients with LEP had comparable short-term outcomes to English proficient patients but were less likely to be discharged to post-acute care facilities. The role of structural barriers, family preferences, and other factors merit future investigation.

Cost-Effectiveness of Universal Screening for Blunt Cerebrovascular Injury: A Markov Analysis

BACKGROUND

Blunt cerebrovascular injury (BCVI) is a significant cause of morbidity and mortality after blunt trauma. Numerous screening strategies exist, although which is used is institution- and physician-dependent. We sought to identify the most cost-effective screening strategy for BCVI, hypothesizing that universal screening would be optimal among the screening strategies studied.

STUDY DESIGN

A Markov decision analysis model was used to compare the following screening strategies for identification of BCVI: (1) no screening; (2) Denver criteria; (3) extended Denver criteria; (4) Memphis criteria; and (5) universal screening. The base-case scenario modeled 50-year-old patients with blunt traumatic injury excluding isolated extremity injures. Patients with BCVI detected on imaging were assumed to be treated with antithrombotic therapy, subsequently decreasing risk of stroke and mortality. One-way sensitivity analyses were performed on key model inputs. A single-year horizon was used with an incremental cost-effectiveness ratio threshold of $100,000 per quality-adjusted life-year.

RESULTS

The most cost-effective screening strategy for patients with blunt trauma among the strategies analyzed was universal screening. This method resulted in the lowest stroke rate, mortality, and cost, and highest quality-adjusted life-year. An estimated 3,506 strokes would be prevented annually as compared with extended Denver criteria (incremental cost-effectiveness ratio of $71,949 for universal screening vs incremental cost-effectiveness ratio of $12,736 for extended Denver criteria per quality-adjusted life-year gained) if universal screening were implemented in the US. In 1-way sensitivity analyses, universal screening was the optimal strategy when the incidence of BCVI was greater than 6%.

CONCLUSIONS

This model suggests universal screening may be the cost-effective strategy for BCVI screening in blunt trauma for certain trauma centers. Trauma centers should develop institutional protocols that take into account individual BCVI rates.

The cost of treatments for retained traumatic hemothorax: A decision analysis

INTRODUCTION

Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies.

METHODS

A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy.

RESULTS

In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900.

CONCLUSION

Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.

Trauma Prevalence and Resource Utilization during 4 COVID-19 “Surges”: A National Analysis of Trauma Patients from 92 Trauma Centers

Introduction

We aim to assess the trends in trauma patient volume, injury characteristics, and facility resource utilization that occurred during four surges in COVID-19 cases.

Methods

A retrospective cohort study of 92 American College of Surgeons (ACS)-verified trauma centers (TCs) in a national hospital system during 4 COVID-19 case surges was performed. Patients who were directly transported to the TC and were an activation or consultation from the emergency department (ED) were included. Trends in injury characteristics, patient demographics & outcomes, and hospital resource utilization were assessed during four COVID-19 case surges and compared to the same dates in 2019.

Results

The majority of TCs were within a metropolitan or micropolitan division. During the pandemic, trauma admissions decreased overall, but displayed variable trends during Surges 1-4 and across U.S. regions and TC levels. Patients requiring surgery or blood transfusion increased significantly during Surges 1-3, whereas the proportion of patients requiring plasma and/or platelets increased significantly during Surges 1-2. Patients admitted to the hospital had significantly higher Injury Severity Score (ISS) and mortality as compared to pre-pandemic during Surge 1 and 2. Patients with Medicaid or uninsured increased significantly during the pandemic. Hospital length of stay (LOS) decreased significantly during the pandemic and more trauma patients were discharged home.

Conclusions

Trauma admissions decreased during Surge 1, but increased during Surge 2, 3 and 4. Penetrating injuries and firearm-related injuries increased significantly during the pandemic, patients requiring surgery or packed red blood cells (PRBCs) transfusion increased significantly during Surges 1-3. The number of patients discharged home increased during the pandemic and was accompanied by a decreased hospital length of stay (LOS).

Financial Burden of Traumatic Injury Amongst the Privately Insured

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 (OOPCs).

SUMMARY OF 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 2-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month OOPCs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure (CHE) 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 $1703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to high deductible health plan 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 OOPCs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.

Adult Trauma Patients with Autism Spectrum Disorder: A Case-Control Study to Evaluate Disparities After Injury

BACKGROUND

Adult trauma patients with autism spectrum disorder (ASD) may have distinct care needs that have not been previously described. We hypothesized that due to differences in clinical care and disposition issues, injured adults with ASD would have increased lengths of stay, higher mortality, and increased rates of complications compared to adults without ASD.

METHODS

The Pennsylvania Trauma Outcomes Study database was queried from 2010-2018 for trauma patients with ASD. Case-control matching was performed for two controls per ASD patient accounting for age, gender, injury mechanism, and injury severity score. Primary outcomes included length of stay, mortality, and complication rate. Univariate analysis compared presentation and clinical care between the two groups. Multivariate regression and Kaplan-Meier curves modeled length of stay. Significance was defined as p < 0.05.

RESULTS

A total of 185 patients with ASD were matched to 370 controls. Age (mean +/- standard deviation) was 33.4 +/- 16.5 years. Gender was 81.1% male. Mechanisms were 88.1% blunt, 5.9% penetrating, and 5.9% burns. Significant clinical differences identified in patients with ASD vs. case-controls included presenting verbal GCS (median [IQR]) (5 [2] vs. 5 [0], p < 0.01), proportion of patients intubated at presentation (20.0% vs. 13.0%, p = 0.031), and hospital length of stay (4 [6] days vs. 3 [4] days, p = 0.002). Adult patients with ASD were less likely to be discharged home and more often discharged to a skilled nursing facility (p < 0.01). There were no differences in mortality, rates of complications, imaging, or operations. Multivariate regression analysis controlling for demographic and clinical differences revealed the diagnosis of ASD independently contributed 3.13 days (95% Confidence Interval: 1.85 to 4.41 days) to injured adults' length of stay. Kaplan-Meier curves showed injured patients with ASD were less likely to be discharged than case-controls starting from time of admission (log rank test, p < 0.001).

CONCLUSIONS

This statewide analysis suggests injured patients with ASD have increased lengths of stay without other clinical or outcome differences. Given significant differences in discharge destination, these findings support early involvement of a multidisciplinary care collaborative. Further research is needed to identify factors that contribute to disparities in care for adults with ASD.

The Statewide Epidemiology of Mucormycosis Among Trauma Patients in Florida

OBJECTIVES

Mucormycosis is a rare angioinvasive infection caused by filamentous fungi with a high lethality among the immunocompromised. In healthy people, the innate immune system is sufficient to prevent infection. The exception to this is deep tissue exposure seen during trauma. The purpose of this study is to evaluate the epidemiology of mucormycosis using a statewide population-based data set.

METHODS

This is a retrospective cohort study of all hospital admissions for mucormycosis within the state of Florida from 1997 through the beginning of 2020. A distribution map was created to evaluate for geographic variation. Botanical growth zones, based on plant hardiness, used by state environmental agencies and landscapers were also used to detect possible patterns based on climate conditions throughout Florida. A multivariable regression analysis was performed to account for confounders and limit bias.

RESULTS

A total of 1190 patients were identified for mucormycosis infection. Only 86 of these patients were admitted for trauma. Cutaneous infections were more prevalent among trauma patients while non-trauma patients had more pulmonary infections (P = .04). Trauma patients with infection tended to be younger and less likely to suffer from comorbidities such as immunosuppression (36% vs 46%, P = .07) and diabetes (22.1% vs 47.1%, P ≤ .0001) as compared to their non-trauma counterparts. Mortality was similar with 17.8% for non-trauma patients and 15.1% for traumatized patients (AOR .80 [.42, 1.52]). Length of stay was longer for trauma patients (37.3 vs 23.0, P < .0001). Infections were less prominent in plant hardiness Zone 9 and Zone 10 as compared to Zone 8 (AOR .71 [.61, .82]; AOR .54 [.46, .64], respectively).

CONCLUSION

Trauma patients who develop infection from mucormycosis are at high risk of death despite being a younger and healthier population. Mucormycosis infections were primarily soft tissue based among trauma patients. These infections are more prevalent in colder regions within Florida.

The Shortage of Trauma Surgeons in the US

BACKGROUND

As the United States (US) population increases, the demand for more trauma surgeons (TSs) will increase. There are no recent studies comparing the TS density temporally and geographically. We aim to evaluate the density and distribution of TSs by state and region and its impact on trauma patient mortality.

METHODS

A retrospective cohort analysis of the American Medical Association Physician Masterfile (PM), 2016 US Census Bureau, and Centers for Disease Control and Prevention (CDC's) Web-based Injury Statistics Query and Reporting System (WISQARS) to determine TS density. TS density was calculated by dividing the number of TSs per 1 000 000 population at the state level, and divided by 500 admissions at the regional level. Trauma-related mortality by state was obtained through the CDC's WISQARS database, which allowed us to estimate trauma mortality per 100 000 population.

RESULTS

From 2007 to 2014, the net increase of TS was 3160 but only a net increase of 124 TSs from 2014 to 2020. Overall, the US has 12.58 TSs/1 000 000 population. TS density plateaued from 2014 to 2020. 33% of states have a TS density of 6-10/1 000 000 population, 43% have a density of 10-15, 12% have 15-20, and 12% have a density >20. The Northeast has the highest density of TSs per region (2.95/500 admissions), while the Midwest had the lowest (1.93/500 admissions).

CONCLUSION

The density of TSs in the US varies geographically, has plateaued nationally, and has implications on trauma patient mortality. Future studies should further investigate causes of the TS shortage and implement institutional and educational interventions to properly distribute TSs across the US and reduce geographic disparities.

Effectiveness and cost-effectiveness of the Transmural Trauma Care Model investigated in a multicenter trial with a controlled before-and-after design: A study protocol

Objective

The rehabilitation of trauma patients in primary care is challenging, and there are no guidelines for optimal treatment. Also, the organization of care is not well‐structured. The Transmural Trauma Care Model (TTCM) has been developed in the Netherlands, aiming to improve patient outcomes by optimizing the organization and the quality of the rehabilitation process in primary care. A recent feasibility study showed that implementation of the TTCM at a Dutch Level 1 trauma center was feasible, patient outcomes were improved, and costs were reduced. This study aims to assess the effectiveness and cost‐effectiveness of the TTCM compared to the usual care in a multicenter trial.

Methods

A multicenter trial with a controlled before‐and‐after design will be performed at 10 hospitals in the Netherlands. First, participating hospitals will include 322 patients in the control group, receiving usual care as provided in these specific hospitals. Subsequently, the TTCM will be implemented in all participating hospitals, and hospitals will include an additional 322 patients in the intervention group. The TTCM consists of a multidisciplinary team at the outpatient clinic (trauma surgeon and hospital‐based physical therapist), an educated and trained network of primary care trauma physical therapists, and structural communication between them. Co‐primary outcomes will investigate generic and disease‐specific, health‐related quality of life. Secondary outcomes will include pain, patient satisfaction, perceived recovery, and patient‐reported physical functioning. For the economic evaluation, societal and healthcare costs will be measured. Measurements will take place at baseline and after 6 weeks, 3, 6, and 9 months. Analyses will be based on the intention‐to‐treat principle. Missing data will be handled using longitudinal data analyses in the effect analyses and by multivariate imputation in the economic evaluation.

Conclusion

This trial with a controlled before‐and‐after design will give insight into the effectiveness and cost‐effectiveness of the TTCM in a multicenter trial.

Predicting Discharge Disposition in Trauma Patients: Development, Validation, and Generalization of a Model Using the National Trauma Data Bank

Background

Limited work has been done in predicting discharge disposition in trauma patients; most studies use single institutional data and have limited generalizability. This study develops and validates a model to predict, at admission, trauma patients’ discharge disposition using NTDB, transforms the model into an easy-to-use score, and subsequently evaluates its generalizability on institutional data.

Methods

NTDB data were used to build and validate a binary logistic regression model using derivation-validation (ie, train-test) approach to predict patient disposition location (home vs non-home) upon admission. The model was then converted into a trauma disposition score (TDS) using an optimization-based approach. The generalizability of TDS was evaluated on institutional data from a single Level I trauma center in the U.S.

Results

A total of 614 625 patients in the NTDB were included in the study; 212 684 (34.6%) went to a non-home location. Patients with a non-home disposition compared to home had significantly higher age (69 ± 19.7 vs 48.3 ± 20.3) and ISS (11.2 ± 8.2 vs 8.2 ± 6.3); P < .001. Older age, female sex, higher ISS, comorbidities (cancer, cardiovascular, coagulopathy, diabetes, hepatic, neurological, psychiatric, renal, substance abuse), and Medicare insurance were independent predictors of non-home discharge. The logistic regression model’s AUC was 0.8; TDS achieved a correlation of 0.99 and performed similarly well on institutional data (n = 3161); AUC = 0.8.

Conclusion

We developed a score based on a large national trauma database that has acceptable performance on local institutions to predict patient discharge disposition at the time of admission. TDS can aid in early discharge preparation for likely-to-be non-home patients and may improve hospital efficiency.

Geospatial characteristics of non-motor vehicle and assault-related trauma events in greater Phoenix, Arizona

BACKGROUND

Injury-causing events are not randomly distributed across a landscape, but how they are associated with the features and characteristics of the places where they occur in Arizona (AZ) remains understudied. Clustering of trauma events and associations with areal sociodemographic characteristics in the greater Phoenix (PHX), AZ region can promote understanding and inform efforts to ameliorate a leading cause of death and disability for Arizonans. The outcomes of interest are trauma events unrelated to motor vehicle crashes (MVC) and the subgroup of trauma events due to interpersonal assaults.

METHODS

A retrospective, ecological study was performed incorporating data from state and national sources for the years 2013-2017. Geographically weighted regression models explored associations between the rates of non-MVC trauma events (n/10,000 population) and the subgroup of assaultive trauma events per 1000 and areal characteristics of socioeconomic deprivation (areal deprivation index [ADI]), the density of retail alcohol outlets for offsite consumption, while controlling for race/ethnicity, population density, and the percentage urban population.

RESULTS

The 63,451 non-MVC traumas within a 3761 mile2 study area encompassing PHX and 22 surrounding communities, an area with nearly 60% of the state's population and 54% of the trauma events in the AZ State Trauma Registry for the years 2013-2017. Adjusting for confounders, ADI was associated with the rates of non-MVC and assaultive traumas in all census block groups studied (mean coefficients 0.05 sd. 0.001 and 0.07 sd. 0.002 for non-MVC and assaultive trauma, respectively). Alcohol retail outlet density was also associated with non-MVC and assaultive traumas in fewer block groups compared to ADI.

CONCLUSION

Socioeconomic deprivation and alcohol outlet density were associated with injury producing events in the greater PHX area. These features persist in the environment before and after the traumas occur. Ongoing research is warranted to identify the most influential areal predictors of traumatic injury-causing events in the greater PHX area to inform and geographically target prevention initiatives.

Cost-effectiveness evaluation of the PROPPR trial transfusion protocols

BACKGROUND

There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period.

STUDY DESIGN AND METHODS

International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments.

RESULTS

The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained.

CONCLUSION

The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population

OBJECTIVE

The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications.

DESIGN

Retrospective case control study.

SETTING

Academic level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with long bone, lower extremity fractures requiring operative fixation.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Postoperative hospital admissions, emergency room (ER) visits, and reoperations.

RESULTS

399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003).

CONCLUSIONS

Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

Medical and productivity costs after trauma

Background

Well-advised priority setting in prevention and treatment of injuries relies on detailed insight into costs of injury. This study aimed to provide a detailed overview of medical and productivity costs due to injury up to two years post-injury and compare these costs across subgroups for injury severity and age.

Methods

A prospective longitudinal cohort study followed all adult (≥18 years) injury patients admitted to a hospital in Noord-Brabant, the Netherlands. Patients filled out questionnaires 1 week, 1, 3, 6, 12 and 24 months after trauma, including items on health care consumption from the medical consumption questionnaire (iMCQ) and productivity loss from the productivity cost questionnaire (PCQ). Furthermore, injury severity was defined by Injury Severity Score (ISS). Data on diagnostics was retrieved from hospital registries. We calculated medical costs, consisting of in-hospital costs and post-hospital medical costs, and productivity costs due to injury up to two years post-injury.

Results

Approximately 50% (N = 4883) of registered patients provided informed consent, and 3785 filled out at least one questionnaire. In total, the average costs per patient were €12,190. In-hospital costs, post-hospital medical costs and productivity costs contributed €4810, €5110 and €5830, respectively. Total costs per patient increased with injury severity, from €7030 in ISS1-3 to €23,750 in ISS16+ and were lowest for age category 18-24y (€7980), highest for age category 85 years and over (€15,580), and fluctuated over age groups in between.

Conclusion

Both medical costs and productivity costs generally increased with injury severity. Furthermore, productivity costs were found to be a large component of total costs of injury in ISS1-8 and are therefore a potentially interesting area with regard to reducing costs.

Trauma in elderly patients: a study of prevalence, comorbidities and gender differences

AIM

Trauma, in geriatric patients, increases with age, and is a leading cause of disability and institutionalization, resulting in morbidity and mortality. The aim of our study was to analyse the prevalence of trauma, the related risk factors, mortality and sex differences in the prevalence in a geriatric population.

PATIENTS AND METHOD

We observed 4,554 patients (≥65 years) with home injuries or car accidents. Patients were evaluated with ISS (Injury Severity Score) and major trauma with ATLS (Advanced Trauma Life Support). The instrumental investigation was in the first instance, targeted X-Ray or whole-body CT.

RESULTS

In over four years of study we treated 4,554 geriatric: 2,809 females and 1,745 Males. When the type of trauma was analysed the most common was head injury, followed by fractures of lower and upper limbs. In our experience hospitalization mainly involved patients over 80. In all patients mortality during assessment was 0.06%.

DISCUSSION

The geriatric patient is often defined as a "frail elderly", for the presence of a greater "injury sensitivity". This is due to the simultaneous presence of comorbidity, progressive loss of full autonomy and exposure to a high risk of traumatic events. Optimal management of the trauma patient can considerable reduce mortality and morbidity.

CONCLUSIONS

Falls and injuries in geriatric age are more frequent in women than in men. Among typical elder comorbidities, osteoporosis certainly causes a female preponderance in the prevalence of fractures. Our discharge data demonstrate that disability, which requires transfer to health care institutions, has a greater effect on women than men.

Blunt versus penetrating trauma: Is there a resource intensity discrepancy?

BACKGROUND

The rising cost of healthcare requires responsible allocation of resources. Not all trauma centers see the same types of patients. We hypothesized that patients with blunt injuries require more resources than patients with penetrating injuries.

METHODS

This was a retrospective analysis of all highest-level activation trauma patients at our busy urban Level I Trauma Center over five years. Data included demographics, injuries, hospital charges, and resources used. A p value < 0.05 was significant.

RESULTS

4578 patients were included (2037 blunt and 2541 penetrating). Blunt patients were more severely injured, more often admitted, required more radiographic studies, had longer hospital, intensive care unit, and mechanical ventilation days, and therefore, higher hospital charges.

CONCLUSIONS

Within one center, patients with blunt injuries required more resources than those with penetrating injuries. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution.

Cured into Destitution: Catastrophic Health Expenditure Risk Among Uninsured Trauma Patients in the United States

OBJECTIVE

To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk.

BACKGROUND

Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk.

METHODS

We performed a retrospective review, using data from the 2007-2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18-64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income.

RESULTS

Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286-$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196-$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%-71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16).

CONCLUSIONS

Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.

The associations between injury mechanism and extended hospital stay among pediatric patients: findings from a trauma Center in Saudi Arabia

BACKGROUND

A hospitalized patient's length of stay (LOS) can have a significant impact on the performance and operating costs of a healthcare facility. Among pediatric patients, traumatic injuries are common causes of emergency room visits and hospitalizations. In Saudi Arabia, little is known about the burden of pediatric traumas on population health and the healthcare facilities. Therefore, the aim of this study was to investigate the associations between traumatic pediatric injury mechanisms and extended LOS in a trauma center.

METHODS

Data was obtained from the trauma registry. From 2001 to 2018, trauma patients between the ages of 0 and 18 years old with LOSs of > 0 days were analyzed. The independent variable was the injury mechanism, which was classified as follows: falls, burns, drowning, motor vehicle collisions, motorcycle collisions, pedestrian, and intentional injuries. The dependent variable was an extended LOS defined as ≥21 days. A multivariate logistic regression analysis was used to evaluate the associations between the injury mechanisms and an extended LOS.

RESULTS

A total of 5563 pediatric patients were included in this study. Of those, 774 (14%) had extended LOSs. Those patients with extended LOSs suffered more severe injuries than those with short hospital stays as measured by the Injury Severity Score (mean scores: 15.4 vs. 6.8, p < 0.01), the Glasgow Coma Scale score (mean scores: 10.4 vs, 14.0, p < 0.01), and the Revised Trauma Score (mean scores: 9.9 vs. 11.0, p < 0.01). Approximately one half of the patients with extended LOSs were admitted due to motor vehicle injuries. In addition, those patients were almost five times more likely to have extended LOSs than the patients who suffered fall injuries (odds ratio: 4.8, 95% confidence interval: 3.2-7.1).

CONCLUSIONS

Based on the study results, motor vehicle injuries were significantly associated with extended hospitalizations. Prevention is instrumental for reducing healthcare utilization; therefore, these findings call for public health professionals and policymakers to plan, design, and implement preventive measures to reduce the traffic injury burden. In addition, increased traffic law enforcement, such as the use of car restraints, is warranted to reduce the preventable injuries and improve the overall population health.

Macroeconomic trends and practice models impacting acute care surgery

Acute care surgery (ACS) diagnoses are responsible for approximately a quarter of the costs of inpatient care in the US government, and individuals will be responsible for a larger share of the costs of this healthcare as the population ages. ACS as a specialty thus has the opportunity to meet a significant healthcare need, and by optimizing care delivery models do so in a way that improves both quality and value. ACS practice models that have maintained or added emergency general surgery (EGS) and even elective surgery have realized more operative case volume and surgeon satisfaction. However, vulnerabilities exist in the ACS model. Payer mix in a practice varies by geography and distribution of EGS, trauma, critical care, and elective surgery. Critical care codes constitute approximately 25% of all billing by acute care surgeons, so even small changes in reimbursement in critical care can have significant impact on professional revenue. Staffing an ACS practice can be challenging depending on reimbursement and due to uneven geographic distribution of available surgeons. Empowered by an understanding of economics, using team-oriented leadership inherent to trauma surgeons, and in partnership with healthcare organizations and regulatory bodies, ACS surgeons are positioned to significantly influence the future of healthcare in the USA.

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis

BACKGROUND

Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure.

METHODS

As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure.

RESULTS

Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001).

CONCLUSIONS

The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

Using a Validated Middle-Age and Geriatric Risk Tool to Identify Early (<48 Hours) Hospital Mortality and Associated Cost of Care

OBJECTIVES

(1) To demonstrate that a validated trauma triage score for middle-aged and geriatric patients could identify those at high risk of mortality within the first 2 days of hospitalization and (2) determine the cost of care for this cohort of patients.

DESIGN

Prospective cohort study.

SETTING

Single level 1 trauma center.

PATIENTS

Patients 55 years of age and older who were evaluated in the emergency department setting by orthopaedics or who met the American College of Surgeons Tier 1-3 criteria.

INTERVENTION

Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle-aged patients, using patient's demographic, injury severity, and functional status; main outcome measurements: length of stay, inpatient mortality, time between presentation and time of death, and direct variable costs of hospitalization.

RESULTS

A total of 1470 consecutive patients (mean age of 72.2 ± 11.9 years) were enrolled in this study, 17 of whom died within 48 hours of presentation to the emergency department. These patients had a significantly higher trauma triage score than the rest of the cohort with a score of 50.9% ± 37.2% versus 3.3% ± 9.5%, P < 0.001 indicating that they had a mean risk of inpatient mortality of over 50%. Mean total cost per day was much higher in the cohort of patients who died within 48 hours of admission compared with all other trauma patients [$49,367 ± $79,057 vs. $3966 ± $2897 (P = 0.031)].

CONCLUSIONS

To achieve value-based care in this high-risk cohort, targeted cost savings while improving patient outcomes and/or expediting goals-of-care and end-of-life goals is necessary and the STTGMA score allows for stratification of these patients in both mortality risk and cost profile.

Evaluation of a Novel Wireless Transmission System for Trauma Ultrasound Examinations From Moving Ambulances

Objective

To determine if physicians trained in ultrasound interpretation perceive a difference in image quality and usefulness between Extended Focused Assessment with Sonography ultrasound examinations performed at bedside in a hospital vs. by emergency medical technicians minimally trained in medical ultrasound on a moving ambulance and transmitted to the hospital via a novel wireless system. In particular, we sought to demonstrate that useful images could be obtained from patients in less than optimal imaging conditions; that is, while they were in transport.

Methods

Emergency medical technicians performed the examinations during transport of blunt trauma patients. Upon patient arrival at the hospital, a bedside Extended Focused Assessment with Sonography examination was performed by a physician. Both examinations were recorded and later reviewed by physicians trained in ultrasound interpretation.

Results

Data were collected on 20 blunt trauma patients over a period of 13 mo. Twenty ultrasound-trained physicians blindly compared transmitted vs. bedside images using 11 Questionnaire for User Interaction Satisfaction scales. Four paired samples t-tests were conducted to assess mean differences between ratings for ambulatory and base images.

Conclusion

Although there is a slight tendency for the average rating across all subjects and raters to be slightly higher in the base than in the ambulatory condition, none of these differences are statistically significant. These results suggest that the quality of the ambulatory images was viewed as essentially as good as the quality of the base images.

Trends in Orthopedic Fracture and Injury Severity: A Level I Trauma Center Experience

The purpose of this study was to define the trends in fracture complexity and overall injury severity of orthopedic trauma patients at a level I trauma center. A retrospective review of a prospectively collected trauma database was performed to determine the Injury Severity Score (ISS) and AO/OTA classification of the most common fractures among all patients presenting from 1995 to 1999 and from 2008 to 2012. Inclusion criteria were lower extremity fractures of the femur and tibia and pelvic fractures within the years of interest. Exclusion criteria were age younger than 18 years, pathologic fractures, and insufficient medical records to determine ISS or AO/OTA classification. The total number of fractures increased from 4869 between 1995 and 1999 to 5902 between 2008 and 2012. There was an increase in the percentage of lower extremity periarticular fractures (20.7% to 23.4%, P<.001) and the percentage of pelvic and acetabular fractures (32.7% to 39.9%, P<.001) and a decrease in the percentage of lower extremity extra-articular fractures (46.6% to 36.7%, P<.001). The ratios of tibial pilon and plateau fractures relative to extra-articular tibial fractures increased from 0.29 to 0.60 (P<.001) and from 0.49 to 0.81 (P<.001), respectively. The average ISS had increased from 2008 to 2012 compared with from 1995 to 1999 (19.2 vs 15.1, P<.001). The complexity of certain lower extremity fractures and the severity of injury of patients treated at this referral institution are high and continue to increase. As US health care economics continue to change, with provider and hospital reimbursements shifting toward a patient outcomes basis with potential penalties for complications and readmissions, hospitals and providers must recognize these trends. Trauma centers must continue to measure the complexity of fracture care provided to properly risk-stratify their patient population. [Orthopedics. 2018; 41(2):e211-e216.].

Black Males, Trauma, and Mental Health Service Use: A Systematic Review

OBJECTIVE

To systematically review the evidence of and synthesize results from relevant studies that have examined barriers and facilitators to professional mental health service use for Black male trauma survivors ages 18 and older.

METHODS

A thorough search of selected databases that included EBSCO, ProQuest, and Web of Science Core Collection and careful consideration of inclusion and exclusion criteria yielded a final six studies for detailed review.

RESULTS

Black male trauma survivors were significantly less likely to be utilizing mental health services than other sex-ethnic groups. High levels of daily crises, a lack of knowledge of steps to obtain services, and service eligibility issues were significant individual barriers to mental health service use for Black males, whereas social support, occupational disability, and PTSD symptoms severity were significant facilitators for mental health service use.

CONCLUSION

Exposure to trauma, whether through witnessing or direct victimization, is often a daily reality for many Black males. Findings from this review suggest that 56-74% of Black males exposed to traumatic events may have an unmet need for mental health services. Future research examining the relationship between trauma and mental health service use for Black men and factors that moderate and/or mediate this relationship is warranted.

What are the Costs of Trauma Center Readiness? Defining and Standardizing Readiness Costs for Trauma Centers Statewide

Trauma center readiness costs are incurred to maintain essential infrastructure and capacity to provide emergent services on a 24/7 basis. These costs are not captured by traditional hospital cost accounting, and no national consensus exists on appropriate definitions for each cost. Therefore, in 2010, stakeholders from all Level I and II trauma centers developed a survey tool standardizing and defining trauma center readiness costs. The survey tool underwent minor revisions to provide further clarity, and the survey was repeated in 2013. The purpose of this study was to provide a follow-up analysis of readiness costs for Georgia's Level I and Level II trauma centers. Using the American College of Surgeons Resources for Optimal Care of the Injured Patient guidelines, four readiness cost categories were identified: Administrative, Clinical Medical Staff, Operating Room, and Education/Outreach. Through conference calls, webinars and face-to-face meetings with financial officers, trauma medical directors, and program managers from all trauma centers, standardized definitions for reporting readiness costs within each category were developed. This resulted in a survey tool for centers to report their individual readiness costs for one year. The total readiness cost for all Level I trauma centers was $34,105,318 (avg $6,821,064) and all Level II trauma centers was $20,998,019 (avg $2,333,113). Methodology to standardize and define readiness costs for all trauma centers within the state was developed. Average costs for Level I and Level II trauma centers were identified. This model may be used to help other states define and standardize their trauma readiness costs.

The modified rapid emergency medicine score: A novel trauma triage tool to predict in-hospital mortality

BACKGROUND

Trauma systems currently rely on imperfect and subjective tools to prioritize responses and resources, thus there is a critical need to develop a more accurate trauma severity score. Our objective was to modify the Rapid Emergency Medicine (REMS) Score for the trauma population and test its accuracy as a predictor of in-hospital mortality when compared to other currently used scores, including the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the "Mechanism, Glasgow Coma Scale, Age and Arterial Pressure" (MGAP) score, and the Shock Index (SI) score.

METHODS

The two-part study design involved both a modification step and a validation step. The first step incorporated a retrospective analysis of a local trauma database (3680 patients) where three components of REMS were modified to more accurately represent the trauma population. Using clinical judgment and goodness-of-fit tests, systolic blood pressure was substituted for mean arterial pressure, the weighting of age was reduced, and the weighting of Glasgow Coma Scale was increased. The second part comprised validating the new modified REMS (mREMS) score retrospectively on a U.S. National Trauma Databank (NTDB) that included 429,711 patients admitted with trauma in 2012. The discriminate power of mREMS was compared to other trauma scores using the area under the receiver operating characteristic (AUC) curve.

RESULTS

Overall the mREMS score with an AUC of 0.967 (95% CI: 0.963-0.971) was demonstrated to be higher than RTS (AUC 0.959 [95% CI: 0.955-0.964]), ISS (AUC 0.780 [95% CI 0.770-0.791]), MGAP (AUC 0.964 [95% CI: 0.959-0.968]), and SI (AUC 0.670 [95% CI: 0.650-0.690]) in predicting in-hospital mortality on the NTDB.

CONCLUSION

In the trauma population, mREMS is an accurate predictor of in-hospital mortality, outperforming other used scores. Simple and objective, mREMS may hold value in the pre-hospital and emergency department setting in order to guide trauma team responses.

The financial impact and drivers of hospital charges in contralateral prophylactic mastectomy and reconstruction: a Nationwide Inpatient Sample hospital analysis

PURPOSE

Rates of contralateral prophylactic mastectomy (CPM) have increased over the last decade; it is important for surgeons and hospital systems to understand the economic drivers of increased costs in these patients. This study aims to identify factors affecting charges in those undergoing CPM and reconstruction.

METHODS

Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample was undertaken (2009-2012), identifying women aged ≥18 with unilateral breast cancer undergoing unilateral mastectomy with CPM and immediate breast reconstruction (IBR) (CPM group), in addition to unilateral mastectomy and IBR alone (UM group). Generalized linear modeling with gamma regression and a log-link function provided mean marginal hospital charge (MMHC) estimates associated with the presence or absence of patient, hospital and operative characteristics, postoperative complications, and length of stay (LOS).

RESULTS

Overall, 70,695 women underwent mastectomy and reconstruction for unilateral breast cancer; 36,691 (51.9%) in the CPM group, incurring additional MMHCs of $20,775 compared to those in the UM group (p < 0.001). In the CPM group, MMHCs were reduced in those aged >60 years (p < 0.001), while African American or Hispanic origin increased MMHCs (p < 0.001). Diabetes, depression, and obesity increased MMHCs (p < 0.001). MMHCs increased with larger (p < 0.001) hospitals, Western location (p < 0.001), greater household income (p < 0.001), complications (p < 0.001), and increasing LOS (p < 0.001). MMHCs decreased in urban teaching hospitals and Midwest or Southern regions (p < 0.001).

CONCLUSION

There are many patient and hospital factors affecting charges; this study provides surgeons and hospital systems with transparent, quantitative charge data in patients undergoing contralateral prophylactic mastectomy and immediate breast reconstruction.

Blunt Traumatic Extracranial Cerebrovascular Injury and Ischemic Stroke

Background

Ischemic stroke occurs in a significant subset of patients with blunt traumatic cerebrovascular injury (TCVI). The patients are victims of motor vehicle crashes, assaults or other high-energy collisions, and suffer ischemic stroke due to injury to the extracranial carotid or vertebral arteries.

Summary

An increasing number of patients with TCVI are being identified, largely because of the expanding use of computed tomography angiography for screening patients with blunt trauma. Patients with TCVI are particularly challenging to manage because they often suffer polytrauma, that is, numerous additional injuries including orthopedic, chest, abdominal, and head injuries. Presently, there is no consensus about optimal management.

Key Messages

Most literature about TCVI and stroke has been published in trauma, general surgery, and neurosurgery journals; because of this, and because these patients are managed primarily by trauma surgeons, patients with stroke due to TCVI have been essentially hidden from view of neurologists. This review is intended to bring this clinical entity to the attention of clinicians and investigators with specific expertise in neurology and stroke.

Nationwide secondary overtriage in level 3 and level 4 trauma centers: are these transfers necessary?

BACKGROUND

Secondary overtriage (SO) refers to the interfacility transfer of trauma patients who are rapidly discharged home without surgical intervention by the receiving institution. SO imposes a financial hardship on patients and strains trauma center resources. Most studies on SO have been conducted from the perspective of the receiving hospital, which is usually a level 1 trauma center. Having previously studied SO from the referring rural hospital's perspective, we sought to identify variables contributing to SO at the national level.

METHODS

Using data from the 2008-2012 National Trauma Data Bank, we isolated patients transferred to level 1 trauma centers who were: (1) discharged home within 48 h and (2) did not undergo any surgical procedure. This population was subsequently compared with similar patients treated at and discharged directly from level 3 and 4 centers. Multivariate logistic regression analysis was used to isolate variables that independently influenced a patient's risk of undergoing SO. Injury patterns were characterized by use of subspecialty consultants.

RESULTS

A total of 99,114 patients met inclusion criteria, of which 13.2% were discharged directly from level 3 or 4 trauma centers, and 86.8% of them were transferred to a level 1 trauma center before discharge. The mean Injury Severity Score of the nontransfer and transfer groups was 5.4 ± 4.5 and 7.3 ± 5.7, respectively. Multivariate regression analysis showed that Injury Severity Score > 15, alcoholism, smoking, drug use, and certain injury patterns involving the head, vertebra, and face were associated with being transferred. In this minimally injured population, factors protective against transfers were: age > 65 y, female gender, systolic blood pressure <80, a head computed tomography scan and orthopedic injuries.

CONCLUSIONS

SO results from the complex interplay of variables including patient demographics, facility characteristics, and injury type. The inability to exclude a potentially devastating neurologic injury seems to drive SO.

An analysis of geriatric recidivism in the era of accountable care organizations

BACKGROUND

To date, there are almost 500 accountable care organizations (ACOs) across the United States emphasizing cost-effective care. Readmission largely impacts health care cost; therefore, we sought to determine factors associated with geriatric trauma readmissions (recidivism) within our institution.

METHODS

All admissions from 2000 to 2011 attributed to patients 65 years or older at our Level II trauma center, recently verified by Medicare as an ACO, were queried. Patients were classified as recidivist or nonrecidivist. The first admissions of recidivist patients were compared with the nonrecidivist admissions with respect to sex, age, race, primary insurance, admission Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), hospital length of stay, mechanism of injury (MOI), preexisting conditions, and discharge destination. Factors found to be significant predictors of recidivism in univariate analyses were subsequently incorporated into a multivariate logistic regression model. In addition, the second admission's MOI was compared with the first admission's MOI, and the proportion of first, second, and third admissions attributed to falls was calculated. A p < 0.05 was significant.

RESULTS

Between 2000 and 2011, a total of 4,963 unique patients were admitted to the trauma center at 65 years or older. This population was composed of 287 recidivists (5.8%) and 4,676 nonrecidivists (94.2%). When placed in a multivariate logistic regression, female sex, admission GCS score of 15, history of head trauma, and preexisting pulmonary disease were identified as significant predictors of recidivism. A trend toward increasing proportion of injuries attributed to falls was found with each subsequent trauma admission (81.5% [234 of 287] of first admissions, 88.2% [253 of 287] of second admissions, and 90.5% [19 of 21] of third admissions).

CONCLUSION

Our study identifies specific factors that should be targeted by social service and prevention resources to inhibit recidivism in the elderly. In the brave new world of ACOs, trauma centers must identify high-risk populations for the consumption of limited resources.

LEVEL OF EVIDENCE

Care management study, level IV. Prognostic study, level III.

Trauma System Overtriage: Are We on Track?

The American College of Surgeons (ACS) recommends trauma overtriage rate (OT) below 50 per cent to maximize efficiency while ensuring optimal care. This retrospective study was undertaken to evaluate OT rates in our Level I trauma center using the most recent criteria and guidelines. OT rates during a 12-month period were measured using six definitions based on combinations of Injury Severity Score (ISS), length of hospital stay (LOS, in days), procedures, and disposition after the emergency department. Reason for trauma activation was 55 per cent criteria, 16 per cent guidelines, 11 per cent paramedic judgment, five per cent no reason, and 13 per cent no documentation. OT rates ranged from 22.6 per cent (ISS less than 9, LOS 1 day or less, no consults) to 48.2 per cent (ISS less than 9, LOS 3 days or less, with procedures/consults) and were in compliance with ACS recommendations. Physiologic assessment criteria and anatomic injury had the lowest OT rates and contained all mortalities. Passenger space intrusion (PSI), pedestrian versus automobile (criterion and guideline), and extrication (guideline) all had consistently high rates of OT. We conclude that PSI should be reduced to a guideline, the pedestrian versus automobile criterion and guideline should be combined, and extrication could be removed from the triage scheme.