Geographic Distribution of Orthopaedic Trauma Resources and Service Use in the United States: A Cross Sectional Analysis

BACKGROUND

Management of orthopaedic injury is an essential component of comprehensive trauma care, and availability of orthopaedic surgeons impacts trauma system capacity and accessibility of care. We sought to estimate the geographic distribution of orthopaedic injury in the United States and identify regions needing additional orthopaedic trauma resources.

METHODS

In this retrospective cross-sectional study using 2014 Agency for Healthcare Research and Quality State Inpatient Datasets from 26 states and the District of Columbia, administrative data were used to determine hospital referral region (HRR)-level incidence of orthopaedic trauma and surgical care. Factors associated with HRR-level orthopaedic trauma volume were identified using negative binomial regression, and model parameters were used to estimate injury incidence and operative volume in unobserved HRRs. The primary outcomes of interest were HRR-level incidence of orthopaedic injury, polytrauma, and emergency orthopaedic surgery, as well and the number of emergency orthopaedic surgery patients per orthopaedic surgeon.

RESULTS

Orthopaedic injury incidence and operative patients per orthopaedic surgeon were associated with HRR-level volume of medical service use, population characteristics, geographic characteristics, and existing trauma care resources. Orthopaedic injury incidence ranged from 20 patients/HRR to 33,260 patients/HRR. Polytrauma incidence ranged from < 10 patients/HRR to 12,140 patients/HRR. Emergency orthopaedic surgery incidence ranged from < 10 patients/HRR to 18,759 patients/HRR. The volume of operative orthopaedic trauma patients per orthopaedic surgeon ranged from < 10 patients/surgeon to 224 patients and/or surgeon.

DISCUSSION

The incidence of orthopaedic injury and volume of injury patients per orthopaedic surgeon varies substantially across HRRs in the United States. Regions with high patient volume and moderate patient-to-provider ratios may be ideal settings for orthopaedic trauma training programs or post-fellowship professional opportunities. Future research should examine the impact of high volume orthopaedic trauma volume and high patient-to-provider ratios on health outcomes.

Workplace mistreatment and mental health in female surgeons in Pakistan

Background

Despite workplace mistreatment, which includes harassment, bullying and gender discrimination(GD)/bias, being serious problems for female surgeons, there are limited data from lower–middle-income countries like Pakistan. This study explored harassment and GD/bias experienced by female surgeons in Pakistan, and the effects of these experiences on mental health and well-being.

Methods

A nationwide survey was conducted between July and September 2019 in collaboration with the Association of Women Surgeons of Pakistan, an organization consisting of female surgeons and trainees in Pakistan. An anonymous online survey was emailed directly, disseminated via social media platforms (such as Facebook, Twitter and Instagram), and sent to surgical programmes in Pakistan.

Results

A total of 146 women surgeons responded to the survey; 67.1 per cent were trainees and the rest attending surgeons. Overall, 57.5 per cent of surgeons reported experiencing harassment, most common being verbal (64.0 per cent) and mental (45.9 per cent), but this mostly went unreported (91.5 per cent). On multivariable analysis adjusted for age and specialty, workplace harassment (odds ratio 2.02 (95 per cent c.i. 1.09 to 4.45)) and bullying (odds ratio 5.14 (95 per cent c.i. 2.00–13.17)) were significantly associated with severe self-perceived burnout, while having a support system was protective against feelings of depression (odds ratio 0.35 (95 per cent c.i. 0.16 to 0.74)). The overwhelming majority (91.3 per cent) believed that more institutional support groups were needed to help surgeons with stress reduction (78.8 per cent), receiving mentorship (74.7 per cent) and work–life balance (67.8 per cent).

Conclusion

Workplace mistreatment, in particular harassment and bullying, has a damaging impact on the mental well-being of female surgeons, particularly trainees. The absence of support groups in Pakistan should be urgently addressed so that surgeons, especially trainees, may cope better with potentially harmful workplace stressors.

Long-term patient-reported outcomes and patient-reported outcome measures after injury: the National Trauma Research Action Plan (NTRAP) scoping review

BACKGROUND

The aim of this scoping review is to identify and summarize patient-reported outcome measures (PROMs) that are being used to track long-term patient-reported outcomes (PROs) after injury and can potentially be included in trauma registries.

METHODS

Online databases were used to identify studies published between 2013 and 2019, from which we selected 747 articles that involved survivors of acute physical traumatic injury aged 18 years or older at time of injury and used PROMs to evaluate recovery between 6 months and 10 years postinjury. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results.

RESULTS

Most studies were observational, with relatively small sample sizes, and predominantly on traumatic brain injury or orthopedic patients. The number of PROs assessed per study varied from one to 12, for a total of 2052 PROs extracted, yielding 74 unique constructs (physical health, 25 [34%]; mental health, 27 [37%]; social health, 12 [16%]; cognitive health, 7 [10%]; and quality of life, 3 [4%]). These 74 constructs were assessed using 355 different PROMs. Mental health was the most frequently examined outcome domain followed by physical health. Health-related quality of life, which appeared in more than half of the studies (n = 401), was the most common PRO evaluated, followed by depressive symptoms. Physical health was the domain with the highest number of PROMs used (n = 157), and lower-extremity functionality was the PRO that contributed most PROMs (n = 33).

CONCLUSION

We identified a wide variety of PROMs available to track long-term PROs after injury in five different health domains: physical, mental, social, cognitive, and quality of life. However, efforts to fully understand the health outcomes of trauma patients remain inconsistent and insufficient. Defining PROs that should be prioritized and standardizing the PROMs to measure them will facilitate the incorporation of long-term outcomes in national registries to improve research and quality of care.

LEVEL OF EVIDENCE

Systematic Reviews & Meta-analyses, Level IV.

A Qualitative Analysis of Surgical Faculty and Surgical Resident Perceptions of Potential Barriers to Implementing a Novel Surgical Education Curriculum

OBJECTIVE

Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum.

DESIGN, SETTING, AND PARTICIPANTS

Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method.

RESULTS

Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors.

CONCLUSIONS

Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program.

Quantifying lives lost due to variability in emergency general surgery outcomes: Why we need a national emergency general surgery quality improvement program

BACKGROUND

Nearly 4 million Americans present to hospitals with conditions requiring emergency general surgery (EGS) annually, facing significant morbidity and mortality. Unlike elective surgery and trauma, there is no dedicated national quality improvement program to improve EGS outcomes. Our objective was to estimate the number of excess deaths that could potentially be averted through EGS quality improvement in the United States.

METHODS

Adults with the American Association for the Surgery of Trauma-defined EGS diagnoses were identified in the Nationwide Emergency Department Sample 2006 to 2014. Hierarchical logistic regression was performed to benchmark treating hospitals into reliability adjusted mortality quintiles. Weighted generalized linear modeling was used to calculate the relative risk of mortality at each hospital quintile, relative to best-performing quintile. We then calculated the number of excess deaths at each hospital quintile versus the best-performing quintile using techniques previously used to quantify potentially preventable trauma deaths.

RESULTS

Twenty-six million EGS patients were admitted, and 6.5 million (25%) underwent an operation. In-hospital mortality varied from 0.3% to 4.1% across the treating hospitals. Relative to the best-performing hospital quintile, an estimated 158,177 (153,509-162,736) excess EGS deaths occurred at lower-performing hospital quintiles. Overall, 47% of excess deaths occurred at the worst-performing hospitals, while 27% of all excess deaths occurred among the operative cohort.

CONCLUSION

Nearly 200,000 excess EGS deaths occur across the United States each decade. A national initiative to enable structures and processes of care associated with optimal EGS outcomes is urgently needed to achieve "Zero Preventable Deaths after Emergency General Surgery."

LEVEL OF EVIDENCE

Care management, level IV.

National estimates of intestinal ostomy creation and reversal for trauma

BACKGROUND

Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal.

METHODS

Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal.

RESULTS

A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal.

CONCLUSION

The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal.

LEVEL OF EVIDENCE

Epidemiology, level III.

Sex differences in long-term outcomes after traumatic injury: A mediation analysis

BACKGROUND

We sought to examine the association and potential mediators between sex and long-term trauma outcomes.

METHODS

Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis.

RESULTS

2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes.

CONCLUSIONS

There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors.

Concordance of Resident and Patient Perceptions of Culturally Dexterous Patient Care Skills

PURPOSE

Disparities in surgical care persist. To mitigate these disparities, we are implementing and testing the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS), a curriculum to improve surgical residents' cultural dexterity during clinical encounters. We analyzed baseline data to look for concordance between residents' self-perceived cultural dexterity skills and patients' perceptions of their skills. We hypothesized that residents would rate their skills in cultural dexterity higher than patients would perceive those skills.

METHODS

Prior to the implementation of the curriculum, surgical residents at 5 academic medical centers completed a self-assessment of their skills in culturally dexterous patient care using a modified version of the Cross-Cultural Care Survey. Randomly selected surgical inpatients at these centers completed a similar survey about the quality of culturally dexterous care provided by a surgery resident on their service. Likert scale responses for both assessments were classified as high (agree/strongly agree) or low (neutral/disagree/strongly disagree) competency. Resident and patient ratings of cultural dexterity were compared. Assessments were considered dexterous if 75% of responses were in the high category. Univariate and multivariate analysis was conducted using STATA 16.

RESULTS

A total of 179 residents from 5 surgical residency programs completed self-assessments prior to receiving the PACTS curriculum, including 88 (49.2%) women and 97 (54.2%) junior residents (PGY 1-2s), of whom 54.7% were White, 19% were Asian, and 8.9% were Black/African American. A total of 494 patients with an average age of 55.1 years were surveyed, of whom 238 (48.2%) were female and 320 (64.8%) were White. Fifty percent of residents viewed themselves as culturally dexterous, while 57% of patients reported receiving culturally dexterous care; this difference was not statistically significant (p = 0.09). Residents who perceived themselves to be culturally dexterous were more likely to self-identify as non-White as compared to White (p < 0.05). On multivariate analysis, White patients were more likely to report highly dexterous care, whereas Black patients were more likely to report poorly dexterous care (p < 0.05).

CONCLUSIONS

At baseline, half of patients reported receiving culturally dexterous care from surgical residents at 5 academic medical centers in the United States. This was consistent with residents' self-assessment of their cultural dexterity skills. White patients were more likely to report receiving culturally dexterous care as compared to non-White patients. Non-White residents were more likely to feel confident in their cultural dexterity skills. A novel curriculum has been designed to improve these interactions between patients and surgical residents.

Factors Affecting Women Surgeons' Careers in Low-Middle-Income Countries: An International Survey

BACKGROUND

Despite increasing numbers of women surgeons globally, barriers to career advancement persist. While these barriers have been extensively discussed in high-income countries (HICs), the topic has received minimal attention in lower-middle-income countries (LMICs) like Pakistan.

METHODS

The Association of Women Surgeons of Pakistan (AWSP)-an organization in Pakistan consisting of female surgeons and trainees-carried out this international cross-sectional study over July-Sept 2019. An anonymous online survey was disseminated via social media platforms and various institutions across Pakistan and internationally.

RESULTS

A total of 218 female surgeons responded to the survey, with 146 (67%) from Pakistan and 72 (33%) from HICs. While HIC surgeons were more likely to report gender discrimination/bias (GD/bias) during residency (29.2% vs 11.6%; p = 0.001), more Pakistani surgeons reported that GD/bias negatively affected their job satisfaction (80.7% vs. 64.9%; p = 0.024). GD/bias manifested most commonly as differences in mentoring relationships (72%). A higher percentage Pakistani surgeons reported having experienced a family-related interruption in their career (24.7% vs. 11.1%; p = 0.019). The vast majority (95%) felt that surgery was perceived as a masculine field, and the majority (56.4%) of respondents reported having been told that they could not be a surgeon because of their gender.

CONCLUSION

Our study highlights keys factors that must be addressed to provide equal career opportunities to women surgeons. It is the responsibility of surgical educators, policy makers, and healthcare organizations to facilitate women surgeons' career progression by developing systems that support equitable career growth for women surgeons.

A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care

BACKGROUND

There are well-documented disparities in outcomes for injured Black and Hispanic patients in the United States. However, patient level characteristics cannot fully explain the differences in outcomes and system-level factors, including the trauma center designation of the hospital to which a patient presents, may contribute to their worse outcomes. We aim to determine if Black and Hispanic patients are more likely to be undertriaged, compared with white patients.

METHODS

This is a retrospective, cross-sectional, population-based study that uses data from the 2014 Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases. We included data from all states with available State Inpatient Databases data that included both race and hospital characteristics needed for analysis (n = 18). Logistic regression was used to identify predictors of severely injured (Injury Severity Score ≥16) patients being brought to a trauma center.

RESULTS

We identified 70,970 severely injured trauma patients with complete data. Non-Hispanic White represented 74.1% of the study population, 9.8% were non-Hispanic Black, and 9.7% were Hispanic. After adjustment for other demographic and injury characteristics, Non-Hispanic Black and Hispanic patients were more likely to be undertriaged, compared with white patients (odds ratio, 1.20; 95% confidence interval, 1.12-1.29 and odds ratio, 1.39; 95% confidence interval, 1.29-1.48, respectively). Male sex and older age were associated with higher odds of undertriage, whereas urban residence, high injury severity, and penetrating injury were associated with lower odds of undertriage.

CONCLUSIONS

Severely injured Black and Hispanic trauma patients are more likely to be undertriaged than otherwise similar white patients. The factors that contribute to racial and ethnic disparities in receiving trauma center care need to be identified and addressed to provide equitable trauma care.

Comparing the Association Between Insurance and Mortality in Ovarian, Pancreatic, Lung, Colorectal, Prostate, and Breast Cancers

BACKGROUND

Insurance coverage is associated with better cancer outcomes; however, the relative importance of insurance coverage may differ between cancers. This study compared the association between insurance coverage at diagnosis and cancer-specific mortality (CSM; insurance sensitivity) in 6 cancers.

PATIENTS AND METHODS

Using the SEER cancer registry, data were abstracted for individuals diagnosed with ovarian, pancreatic, lung, colorectal, prostate, or breast cancer in 2007 through 2010. The association between insurance coverage at diagnosis and CSM was modeled using a Fine and Gray competing-risks regression adjusted for demographics. An interaction term combining insurance status and cancer type was used to test whether insurance sensitivity differed between cancers. Separate models were fit for each cancer. To control for lead-time bias and to assess whether insurance sensitivity may be mediated by earlier diagnosis and treatment, additional models were fit adjusting for disease stage and treatment.

RESULTS

Lack of insurance was associated with an increased hazard of CSM in all cancers (P<.01). The magnitude of the effect differed significantly between cancers (Pinteraction=.04), ranging from an adjusted hazard ratio of 1.13 (95% CI, 1.01-1.28) in ovarian and 1.19 (95% CI, 1.11-1.29) in pancreatic cancer to 2.19 (95% CI, 2.02-2.37) in breast and 2.98 (95% CI, 2.54-3.49) in prostate cancer. The benefit of insurance was attenuated after adjusting for stage and treatment (eg, screening/early treatment effect), with the largest reductions in prostate, breast, and colorectal cancers.

CONCLUSIONS

Greater insurance sensitivity was seen in screening-detected malignancies with effective treatments for early-stage disease (eg, prostate, breast, and colorectal cancers). Given that this differential is significantly reduced after adjusting for stage and treatment, our results suggest that a significant portion (but not all) of the benefit of insurance coverage is due to detection and treatment of certain curable early-stage cancers.

Gender discrimination against female surgeons: A cross-sectional study in a lower-middle-income country

Introduction

Although gender discrimination and bias (GD/bias) experienced by female surgeons in the developed world has received much attention, GD/bias in lower-middle-income countries like Pakistan remains unexplored. Thus, our study explores how GD/bias is perceived and reported by surgeons in Pakistan.

Method

A single-center cross-sectional anonymous online survey was sent to all surgeons practicing/training at a tertiary care hospital in Pakistan. The survey explored the frequency, source and impact of GD/bias among surgeons.

Results

98/194 surgeons (52.4%) responded to the survey, of which 68.4% were males and 66.3% were trainees. Only 19.4% of women surgeons reported 'significant' frequency of GD/bias during residency. A higher percentage of women reported 'insignificant' frequency of GD/bias during residency, as compared to males (61.3% vs. 32.8%; p = 0.004). However, more women surgeons reported facing GD/bias in various aspects of their career/training, including differences in mentorship (80.6% vs. 26.9%; p < 0.005) and differences in operating room opportunities (77.4% vs. 32.8%; p < 0.005). The source was most frequently reported to be co-residents of the opposite gender. Additionally, a high percentage of female surgeons reported that their experience of GD/bias had had a significant negative impact on their career/training progression, respect/value in the surgical team, job satisfaction and selection of specialty.

Conclusion

Although GD/bias has widespread impacts on the training/career of female surgeons in Pakistan, most females fail to recognize this GD/bias as "significant". Our results highlight a worrying lack of recognition of GD/bias by female surgeons, representing a major barrier to gender equity in surgery in Pakistan and emphasizing the need for future research.

Epidemiology of 577 Pediatric Firearm Fatalities: A 2-year Review of the National Trauma Data Bank

The purpose of this study was to delineate the epidemiology of pediatric firearm injuries, including ethno-demographic patterns with impact on years of potential life lost (YPLL). A 2-year review of the National Trauma Data Bank (2007 to 2008) was conducted. Firearm fatalities in records of patients younger than 18 years were identified. Data were analyzed by demographic and injury characteristics and YPLL was calculated by ethnicity. A total of 577 deaths were identified in the pediatric group. Blacks accounted for 49.7 per cent of the fatalities; Hispanics, 19.2 per cent; whites, 17.7 per cent, and other ethnicity, 13.4 per cent. Median Injury Severity Score was 25 with a median Glasgow Coma Scale score of 3. Traumatic brain injury was present in 84.2 per cent of the records. Assault accounted for 72.8 per cent, self-inflicted injury 12.7 per cent, and unintentional injuries were 8.2 per cent. Most firearm fatalities occurred at home (33.6%). By emergency department (ED) disposition, 29.3 per cent died in the ED, 32.9 per cent were admitted to the intensive care unit, and 30.0 per cent taken to the operating room. Blacks had a total of 17,446 YPLL, Hispanics 6,776 YPLL, and whites 6,718 YPLL. Pediatric firearm fatalities still remain an important public health concern. Inclusive gun control policies focused on primary prevention of accidental injuries may be more effective in mitigating its impact.

Long-term patient-reported outcome measures after injury: National Trauma Research Action Plan (NTRAP) scoping review protocol

Background

A significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics.

Objectives

To describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury.

Methods

A systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.

Dissemination

This scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals.

Reduced chronic pain: Another benefit of recovery at an inpatient rehabilitation facility over a skilled nursing facility?

BACKGROUND

We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF).

METHODS

Trauma patients admitted to 3 Level-I trauma centers were interviewed to evaluate the presence of daily pain requiring medication, functional outcomes, and physical and mental health-related quality-of-life at 6-12 months post-injury. Inverse-probability-of-treatment-weighting (IPTW)-adjusted analyses were performed to compare outcomes between patients who were discharged to IRF vs SNF.

RESULTS

A total of 519 patients were included: 389 discharged to IRFs and 130 to SNFs. In adjusted analyses, IRF was associated with a significant reduction in the likelihood of chronic pain after injury (28.3% vs. 44.7%; OR:0.49; 95% CI, 0.26-0.91; P = .02). However, there were no significant differences in functional outcome or SF-12 composite scores between groups.

CONCLUSION

Our findings suggest that injured patients discharged to an IRF as compared to a SNF had less chronic pain and analgesic use.

What is trauma? Qualitatively assessing stakeholder perceptions in Santa Cruz de la Sierra, Bolivia

Addressing the burden of injury in low-resource settings requires development of trauma systems. This study aimed to describe perceptions of trauma in Santa Cruz, Bolivia to better inform strategies for trauma system development. In 2015-2016, we conducted 16 individual and 11 group interviews with key stakeholders involved with or exposed to trauma. A pile sorting activity showed participants pictures of injury mechanisms to explore perceptions of trauma. Responses were analysed for themes using content and discourse analysis. Among 27 interviews, six were with physicians, seven with first responders, three with community members, and 11 with trauma patients. Pictures commonly categorised as trauma depicted a road traffic incident (92.6%), fall (88.9%), gunshot wound (88.9%), and burn (85.2%). Fewer respondents stated intoxication (51.9%) or drowning (40.7%) were trauma. Coding of responses revealed five themes: trauma definition, mechanism, physical injury, management, and psychological trauma. Medical personnel focused more on trauma as mechanism, physical injury, and management, whereas laypersons commonly described trauma as psychological. Varied understanding of what represents trauma could influence trauma registry data collection. Laypersons' focus on psychological trauma may affect use of designated trauma care hospitals. These viewpoints must be considered when designing policies and interventions for trauma system strengthening.

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients

Importance

Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation.

Objective

To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act.

Design, Setting, and Participants

Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states.

Interventions/Exposure

Policy implementation in January 2014.

Main Outcomes and Measures

Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation.

Results

A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation.

Conclusions and relevance

This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population

BACKGROUND

In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system.

METHODS

Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation.

RESULTS

Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011).

CONCLUSIONS

In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.

The National Burden of Orthopedic Injury: Cross-Sectional Estimates for Trauma System Planning and Optimization

BACKGROUND

Management of orthopedic injuries is a critical component of comprehensive trauma care. As patterns of injury incidence and recovery change in the face of emerging injury prevention efforts and technologies and an aging US population, assessment of the burden of orthopedic injury is essential to optimize trauma system planning. We sought to estimate the incidence of orthopedic injury requiring emergency orthopedic surgery in the United States.

METHODS

Using nationally representative samples from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, we estimated the incidence of orthopedic injury, polytrauma with orthopedic injury, and emergency operative orthopedic procedures performed for the management of traumatic injury. We used multivariable logistic regression to identify patient, injury, and hospital characteristics associated with odds of emergency orthopedic surgery.

RESULTS

A total of 7,214,915 patients were diagnosed with orthopedic injury in 2013-2014, resulting in 1,167,656 emergency orthopedic surgical procedures. Fall-related injuries accounted for 51% of health care encounters and 61% of emergency orthopedic surgical procedures. Odds of emergency orthopedic surgery were 2.04 times greater for patients with polytrauma, compared with isolated orthopedic injury (P < 0.001).

CONCLUSIONS

The total burden or orthopedic injury in the United States is substantial, and there is considerable heterogeneity in demand for care and practice patterns in the orthopedic trauma community. Population-based trauma system planning and tailored care delivery models would likely optimize initial treatment, recovery, and health outcomes for orthopedic trauma patients.