Outcome and cost of trauma among the elderly: a real-life model of a single-payer reimbursement system

Factors Influencing Geriatric Orthopaedic Trauma Mortality

INTRODUCTION

This study aimed to: (1) evaluate the independent risk factors related to survival and mortality and (2) predict survival in geriatric orthopaedic trauma patients admitted to our institution's ICU as a Level 1 or 2 trauma activation.

METHODS

A retrospective review was performed on patients age >60, over a 10 year period, who were involved in a multi-trauma with orthopaedic injuries. Variables evaluated include: sex, age, Injury Severity Score (ISS), mechanism of injury, number and type of orthopaedic injury, anticoagulant use, comorbidities, length of stay in intensive care unit (ICU), type of ICU, ventilator use, vasopressors use, incidence of multiple organ dysfunction syndrome (MODS), number of surgeries, and 1-month and 6-month mortality. A Kaplan-Meier estimator and Cox proportional hazards analysis were used to predict and assess survival probability.

RESULTS

174 patients were included, with an average mortality of 47.7%. Deceased patients had a significantly greater age, ISS, vasopressor usage, ICU stay, incidence of MODF, incidence of genitourinary disease, anticoagulant usage, ventilator usage, number of orthopaedic surgeries, and orthopaedic injuries. The relative risk for mortality within the first month was significantly associated with increased age, ISS, high-energy trauma, length of ICU stay, MODS, psychiatric disease, and anticoagulant use. Patients with an ISS ≤30 were significantly more likely to survive than patients with an ISS of >30. Greater age, ISS, length of ICU stay, incidence of MODS, anticoagulant, and ventilator use were significantly predictive of lower survival rates. Mechanism of injury, number of orthopaedic surgeries and orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival.

CONCLUSIONS

An ISS >30 at admission is strongly predictive of a lower probability of survival. Genitourinary disease was associated with increased mortality. Low age, ISS, length of stay in ICU, incidence of MODS, anticoagulant use, and ventilator use, are significantly predictive of survival. Number of orthopaedic surgeries, orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. These indications help us to better understand factors predictive of death among geriatric orthopaedic trauma patients, and improve the way we can diagnose and care for them.

Surgical Management of Facial Fractures in Geriatric Patients

ABSTRACT

Facial fractures comprise a substantial part of traumatology. Due to aging of the population, over the last 20 years, there has been a pattern of redistribution of these fractures with a higher incidence at an older age. The aim of this study was to retrospectively analyze the epidemiology, pattern, and surgical management of facial fractures in geriatric patients presenting at a single tertiary trauma center.This study included patients aged ≥70 years who presented with facial bone fractures between 2008 and 2017 and were treated with surgical interventions. Parameters such as age, sex, American Society of Anesthesiologists classification, Glasgow Coma Scale score, fracture type, fracture mechanism, concomitant injuries, duration of hospitalization, and postoperative complications were evaluated.A total of 300 patients were included: 118 men (39.3%) and 182 women (60.7%). The mean age was 78.8 years. An orbital floor fracture was the most common injury (35.1%). The most common cause of fracture was a fall at home (67%). A total of 113 patients (37.7%) had 162 concomitant injuries, 35 patients (11.7%) suffered from polytrauma, and 7 patients developed postoperative complications. The average length of stay was 1.67 days in the intensive care unit and 5.50 days in the standard ward. Polytrauma, pre-existing medical conditions, and oral anticoagulation had a significant impact on the duration of hospitalization.Facial fractures are common in combination with other injuries. Women are more often affected than men, and falling at home is the most common cause of facial injuries. Postoperative complications are rare.

What predicts mortality in the elderly patient presenting as a trauma call? A report from a Major Trauma Centre

PURPOSE

Within the UK there is a continued expansion of the population over the age of 65, this currently accounts for 17.8% of the British population. We review the impact that centralization of Major Trauma has had, as well as analysing for significant predictors of poor outcome.

METHOD

All patients presenting to Leeds Major Trauma Centre as a 'Major Trauma' who were equal to or over the age of 65 were included in this study. Prospectively collected data from the Trauma Audit Research Network (TARN) was collated to include the above data set from the 1st April 2012 - 1st April 2016. The 1st April 2012 represents the commencement of the Major Trauma Network within Yorkshire. To allow more quantative assessment of patients' co-morbidities, they were coded as per Charlson Co-morbidity Index for analysis.

RESULTS

1167 patients presented within the above timeframe. Mean age was 79.5 (range 65-103.5). Mean ISS was 14.8 of the entire cohort. Mortality was 12.9% of the entire cohort. The leading mechanisms of injury were from low energy falls <2m-59.89%, Fall >2m-23.05% and Road Traffic Collision - 16.45%.

CONCLUSION

Mortality rates since the commencement of the Major Trauma Network within this age group have reduced. This is likely secondary to centralization of major trauma. Variables found to be statistically significant with increased mortality were increasing age, head injury, presence of Chronic Lung Disease, presence of metastases, decreased GCS and increased ISS.

Interpersonal Violence Is Associated With Increased Severity of Geriatric Facial Trauma

PURPOSE

The geriatric population is rapidly increasing in number with increased demand on health care resources including those spent on the treatment of maxillofacial trauma. The purpose of this analysis was to investigate the independent and cumulative associations between potential risk factors (age, gender, mechanism of injury, drug use, and alcohol use) for and the severity of geriatric facial trauma.

METHODS

This was a cross-sectional analysis of secondary data of geriatric (individuals aged ≥65 years) facial trauma using the Allegheny General Hospital Trauma Registry database. Data were collected for diagnosis codes that reflected facial trauma (International Classification of Diseases, Ninth Revision codes 802.0 to 802.9, 800.1 to 801.9, and 803.0 to 804.9) and specific mechanisms of injury (E810 to E819, motor vehicle traffic accidents; E880 to E888, accidental falls; and E960 to E969, injury purposely inflicted by other persons). The Facial Injury Severity Scale (FISS) is a validated measurement that was used to determine the severity of the facial trauma and calculated through analysis of the abstracted data obtained from the trauma registry and patient records. Pearson correlations, 2-way independent t test, 1-way analysis of variance, and multiple linear regression were used to test hypotheses for independent and cumulative associations between the risk factors for and the severity of geriatric facial trauma. Statistical significance was set at the P < .05 level.

RESULTS

The sample was composed of 229 patients with a mean age of 72.3 ± 4.5 years. A statistically significant association between mechanism of injury and the severity of geriatric facial trauma (P = .019) was found. Specifically, interpersonal violence (assault) was associated with the greatest facial trauma severity (FISS score, 4.2) when compared with motor vehicle collisions (FISS score, 2.2; P = .011) and falls (FISS score, 2.4; P = .016).

CONCLUSIONS

Interpersonal violence (assault) is associated with increased severity of geriatric facial trauma compared with other risk factors.

Racial/ethnic and insurance status disparities in discharge to posthospitalization care for patients with traumatic brain injury

OBJECTIVES

Professional, posthospitalization care (PHC) can improve outcomes among patients with traumatic brain injury. We examined disparities in discharge to PHC by patients' race/ethnicity and insurance type.

PARTICIPANTS

A total of 6061 adults hospitalized for unintentional traumatic brain injury in Oregon, 2008 to 2011.

MAIN OUTCOME MEASURE

Posthospitalization care was assessed on the basis of discharge disposition. Multivariable logistic regression was used to estimate effects of race/ethnicity and insurance on referral to PHC while controlling for potential confounders. Generalized estimating equations were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs), accounting for clustering of data by hospital.

RESULTS

28% of patients were discharged to PHC. While controlling for potential confounders, Hispanics were less likely to be discharged to PHC (OR, 0.62; CI, 0.40-0.96) than non-Hispanic whites. Compared with patients with private insurance, uninsured patients were less likely to be discharged to PHC (OR, 0.19; CI, 0.11-0.32) whereas patients with public insurance (OR, 1.65; CI, 1.33-2.05) and worker's compensation (OR, 1.66; CI, 1.09-2.52) were more likely to be discharged to PHC.

CONCLUSIONS

Results suggest that racial/ethnic and insurance disparities exist in discharge to postacute care after hospitalization for traumatic brain injury. Future research should examine factors that might contribute to and reduce these inequities in care.

Geriatric trauma: demographics, injuries, and mortality

OBJECTIVES

To identify injuries that elderly sustain during high-energy trauma and determine which are associated with mortality.

DESIGN

Retrospective review of prospectively collected database.

SETTING

Academic trauma center.

PATIENTS

Patients selected from database of all trauma admissions from January 2004 through June 2009. Study population consisted of patients directly admitted from scene of injury who sustained high-energy trauma with at least one orthopaedic injury and were 65 years or older (n = 597).

INTERVENTION

Review of demographics, trauma markers, injuries, and disposition statuses.

MAIN OUTCOME MEASUREMENTS

Statistical analysis using χ test, Student t test, and logistic regression analysis.

RESULTS

The most common fractures were of the rib, distal radius, pelvic ring, facial bones, proximal humerus, clavicle, ankle, and sacrum. The injuries associated with the highest mortality rates were fractures of the cervical spine with neurological deficit (47%), at the C2 level (44%), and of the proximal femur (25%), pelvic ring (25%), clavicle (24%), and distal humerus (24%). The fractures significantly associated with mortality were fractures of the clavicle (P = 0.001), foot joints (P = 0.001), proximal humerus or shaft and head of the humerus (P = 0.002), sacroiliac joint (P = 0.004), and distal ulna (P = 0.002).

CONCLUSIONS

Elderly patients present with significantly worse injuries, remain in the hospital longer, require greater use of resources after discharge, and die at 3 times the rate of the younger population. Although the high mortality rates associated with cervical spine, hip, and pelvic ring fractures were not unexpected, the injuries that were statistically associated with mortality were unexpected. Injuries such as clavicle fracture were statistically associated with mortality. As our population ages and becomes more active, the demographic may gain in clinical importance.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The variation of acute treatment costs of trauma in high-income countries

BACKGROUND

In order to assist health service planning, understanding factors that influence higher trauma treatment costs is essential. The majority of trauma costing research reports the cost of trauma from the perspective of the receiving hospital. There has been no comprehensive synthesis and little assessment of the drivers of cost variation, such as country, trauma, subgroups and methods. The aim of this review is to provide a synthesis of research reporting the trauma treatment costs and factors associated with higher treatment costs in high income countries.

METHODS

A systematic search for articles relating to the cost of acute trauma care was performed and included studies reporting injury severity scores (ISS), per patient cost/charge estimates; and costing methods. Cost and charge values were indexed to 2011 cost equivalents and converted to US dollars using purchasing power parities.

RESULTS

A total of twenty-seven studies were reviewed. Eighty-one percent of these studies were conducted in high income countries including USA, Australia, Europe and UK. Studies either reported a cost (74.1%) or charge estimate (25.9%) for the acute treatment of trauma. Across studies, the median per patient cost of acute trauma treatment was $22,448 (IQR: $11,819-$33,701). However, there was variability in costing methods used with 18% of studies providing comprehensive cost methods. Sixty-three percent of studies reported cost or charge items incorporated in their cost analysis and 52% reported items excluded in their analysis. In all publications reviewed, predictors of cost included Injury Severity Score (ISS), surgical intervention, hospital and intensive care, length of stay, polytrauma and age.

CONCLUSION

The acute treatment cost of trauma is higher than other disease groups. Research has been largely conducted in high income countries and variability exists in reporting costing methods as well as the actual costs. Patient populations studied and the cost methods employed are the primary drivers for the treatment costs. Targeted research into the costs of trauma care is required to facilitate informed health service planning.

The elderly trauma patient: an investment for the future?

BACKGROUND

The cost of care in elderly (ELD) trauma patients is high compared with younger patients, but the association between age and reimbursement relative to cost is less clear. The purpose of this study was to explore the relationship between total costs (TC) and reimbursement in young (YNG) and ELD trauma patients.

METHODS

The National Trauma Registry of the American College of Surgeons was queried for patients admitted to a level I trauma center between January 2002 and December 2004. YNG patients (18-64 years) were compared with ELD patients (> or =65 years) for mechanism of injury, Injury Severity Score, and outcome variables. Data obtained from the hospital cost accounting system included TC, total payment, and net margin (P-L). Virtually, all patients were reimbursed based on the fixed diagnostic-related group payment.

RESULTS

There were 641 ELD and 3,470 YNG patients included in the study. ELD patients were more commonly injured via a blunt mechanism than the YNG patients (97% vs. 83%; p < 0.001). The ELD were more severely injured (Injury Severity Score 14.9 +/- 10.8 vs. 13.3 +/- 10.9), developed more complications (54% vs. 34%), and died more frequently (17% vs. 4.7%; all p < 0.05). TC for the ELD were significantly higher than the YNG ($20,788.92 +/- $28,305.54 vs. $19,161.11 +/- $30,441.56; p = 0.02). Total payment ($20,049.75 +/- $29,754.52 vs. $16,766.14 +/- $31,169.15) and P-L (-$739.18 +/- $17,207.84 vs. -$2,294.98 +/- $22,309.51; both p < 0.05) were significantly better for the ELD cohort. However, a financial loss was realized for all patients with trauma.

CONCLUSION

When compared with YNG trauma patients, reimbursement in the ELD appears favorable. However, compensation via diagnostic-related group payment fails to cover costs even in the ELD. Reimbursement for all patients with trauma is suboptimal and needs to be improved.

Ankle fractures in the elderly: initial and long-term outcomes

BACKGROUND

Surgical management of ankle fractures will be an increasing part of the orthopaedic practice for aging adults. To date, there are few studies comparing outcomes after ankle fracture surgery between patients over and under 65 years. The purpose of this study was to evaluate short- and long-term outcomes after surgical treatment of isolated malleolar fractures in both the elderly and non-elderly population.

MATERIALS AND METHODS

Charts and radiographs were reviewed for 25 patients over age 65 and 46 patients under age 65 who underwent operative treatment of an ankle fracture during a 2-year period. Postoperative complications and need for placement in a skilled nursing facility following discharge were noted. The SF-36 and the Olerud and Molander Ankle Score were completed. Mean duration of followup in patients greater than 65 was 27 months and 24 months for patients less than or equal to 65 years.

RESULTS

Patients over 65 had a higher number of postoperative complications (40% vs. 11%, p < 0.007), and required nursing home placement more frequently than patients under 65 (p < 0.0001). At long-term followup, the data showed no significant difference in patient reported physical outcomes.

CONCLUSION

Early postoperative outcomes after operative fixation of ankle fractures suggest significantly worse outcomes for patients over age 65. However, long-term function in the elderly was comparable to patients under age 65 in this sample. The elderly population had a significantly better mental composite score than the non-elderly.

Relationship of age, injury severity, injury type, comorbid conditions, level of care, and survival among older motor vehicle trauma patients

The purpose of this secondary data analysis was to compare age, injury severity, injury types, selected comorbidities, level of care (at trauma center [TC] and non-trauma center [NTC] hospitals), and survival among older motor vehicle trauma patients (N = 1,478). Patients admitted to both levels of care had similar comorbid conditions. TC patients had a higher injury severity, whereas NTC patients had a greater proportion of soft tissue injuries. Results of logistic regression analyses subsequent to group comparisons revealed that higher injury severity was associated with TC admission. The likelihood of TC admission of severely injured patients decreased in the presence of spinal, internal, and head injuries. Internal injuries, liver, renal, and cardiovascular diseases were associated with non-survival while hypertension was associated with survival. Special attention is needed when triaging older trauma patients because their injuries may be covert, thus putting them at risk for admission to a level of care that may be inappropriate given the extent of their injuries.

Survey of trauma patients requiring maxillofacial intervention, ages 56 to 91 years, with length of stay analysis

PURPOSE

The purpose of this study was to analyze trauma patients, ages 55 and older, sustaining multiple injuries including maxillofacial trauma. Factors influencing length of intensive care unit stay (ICUS) and length of total hospital stay were delineated and examined to determine if specific causes of increased length of stay could be elucidated, and, once known, if these causes could translate into recommendations tailored to the oral and maxillofacial surgery trauma practice.

PATIENTS AND METHODS

One hundred ninety-six patients, 55 years of age or older, who received either consultation alone, or consultation with surgical treatment, by oral and maxillofacial surgeons, from January 1991 to August 1998 were included in this study. Variables of interest included location of traumatic event, mechanism of injury, patient age and gender, comorbidities on presentation, Injury Severity Score (ISS), specific injuries incurred, ICUS, length of hospital stay (LOS), surgical interventions, and disposition.

RESULTS

Complications were the statistically significant factor determining length of ICU stay. ICUS, complications incurred, and ISS were the important predictors of total LOS. The significant complications affecting LOS were infectious, respiratory, and hematologic complications.

CONCLUSION

The number of complications the patient incurs after an injury can predict length of ICUS. Length of ICUS, ISS, and number of complications incurred were the strongest predictors for total length of hospital stay. Other variables, including age, gender, living or dead, blunt versus penetrating injury, ISS, fracture site (skull, midface, or lower face), and comorbidities on presentation were not statistically significant in this patient population. Infectious, respiratory, and hematologic complications were the complications most closely correlated with increasing length of ICUS and total hospital stay.

Trauma in the elderly: intensive care unit resource use and outcome

BACKGROUND

As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity.

METHODS

This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis.

RESULTS

Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30.

CONCLUSION

Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.

Comparison of Safety and Cost of Percutaneous versus Surgical Tracheostomy

Tracheostomy continues to be a standard procedure for the management of long-term ventilator-dependent patients. Traditionally the procedure has been performed by surgeons in the operating theater using an open technique. This routine practice has recently been challenged by the introduction of bedside percutaneous dilatational tracheostomy (PDT), which has been reported to be a cost-effective alternative. The purpose of this study is to evaluate and compare the safety, procedure time, cost, and utilization of percutaneous and surgical tracheostomies at a university hospital. A retrospective medical chart review was performed on all ventilator-dependent intensive care unit patients at the University of Virginia Medical Center undergoing tracheostomy during a 23-month period beginning December 26, 1996. Of the 213 patients identified for review, 74 and 139 patients received percutaneous and surgical tracheostomies, respectively. Of 74 percutaneous tracheostomies, 73 reviewed were performed by general surgeons, pulmonary physicians, or anesthesiologists in the intensive care unit; all open tracheostomies were performed by surgeons in the operating room, and one percutaneous procedure was performed in the operating room. Perioperative complications occurred in five of 74 patients (6.76%) during PDT; of these, three patients (4.1%) experienced major complications requiring emergent operative exploration of the neck. Three patients (2.2%) experienced perioperative complications during surgical tracheostomy. The mean procedure time was significantly shorter for the percutaneous procedure. Average charges per patient in an uncomplicated case including professional fees, inventory, bronchoscopy (if performed), and operating room charges were $1753.01 and $2604.00 for percutaneous and standard tracheostomies, respectively. These charges do not include the charges associated with surgical intervention after PDT complications. In contrast to previously published reports showing complications clustered during a physician's first 30 percutaneous cases, our study demonstrated no relationship between complication occurrence and physician experience. That is, no learning curve associated with performing PDT was evident. In addition there was no association seen between physician specialty and complication rate. PDT in the intensive care unit costs less than surgical tracheostomy performed in the operating room and can be performed in less time. Several other studies have recommended that bronchoscopy during PDT provides additional safety; however, in our series all three major complications took place during bronchoscopy-assisted percutaneous procedures. Our series suggests that PDT carries an appreciable risk of major complications. Careful patient selection and additional experience with the procedure may decrease complication rates to an acceptable level.

Blunt Chest Trauma in the Elderly Patient: How Cardiopulmonary Disease Affects Outcome

Blunt trauma patients with rib fractures have significant risk of morbidity and mortality. The risk of complications increases with age and cardiopulmonary disease. We reviewed our experience at a community hospital Level II trauma center over a 5-year period. A review of the trauma registry revealed 62 patients over the age of 65 with multiple rib fractures and no associated injuries. Thirty-one patients with cardiopulmonary disease (CPD+) were compared with 31 patients without cardiopulmonary disease (CPD-). Charts were reviewed for morbidity, mortality, the need to upgrade level of care (readmission to the hospital or intensive care unit), and length of hospitalization. Complications occurred in 17 of 31 CPD+ patients and in four of 31 CPD- patients ( P < 0.001). The only three deaths were in CPD+ patients. Ten CPD+ patients and four CPD- patients required an upgrade in the level of care ( P < 0.05). The CPD+ patients had longer hospitalization than the CPD- patients: 8.5 versus 4.3 days ( P < 0.05). We conclude that elderly patients with multiple rib fractures and cardiopulmonary disease are at significant risk for complications that result in readmission to the hospital and intensive care unit and prolonged length of hospitalization. Admission to the intensive care unit with attention to cardiac and pulmonary status upon transfer to the ward is warranted.

The injured elderly in the trauma intensive care unit

The injured elderly patient in the ICU presents many challenges. Demographic changes in western society will dramatically increase the patient population in question, and new, older, subsets are growing. The association of severe injury, preinjury comorbidity, and the aging process narrows the ability of the patient to respond to the stress of injury. When compared with younger patients, the elderly have greater mortality, morbidity, and higher costs. Age alone, however, does not predict outcome. Although aggressive or maximally supportive care is advocated, controlled data supporting this approach are lacking. Significant economic, sociologic, and ethical issues confront the care providers in almost every case. Continued and heightened study of all aspects of our injured elders focusing on the determinants of outcome is required. A realistic appraisal of the limitations of care and a reassessment of the financial implications of providing extended care are critical to the continuing ability to respond to this growing need.