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Vadlakonda A, Cho NY, Chervu N, Porter G, Curry J, Sakowitz S, Coaston T, Rook JM, Juillard C, Benharash P. Association of uninsured status and rurality with risk of financial toxicity after pediatric trauma. Surgery 2024; 176:455-461. [PMID: 38772775 DOI: 10.1016/j.surg.2024.03.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/18/2024] [Accepted: 12/14/2023] [Indexed: 05/23/2024]
Abstract
BACKGROUND Pediatric traumatic injury is associated with long-term morbidity as well as substantial economic burden. Prior work has labeled the catastrophic out-of-pocket medical expenses borne by patients as financial toxicity. We hypothesized uninsured rural patients to be vulnerable to exorbitant costs and thus at greatest risk of financial toxicity. METHODS Pediatric patients (<18 years) experiencing traumatic injury were identified in the 2016-2019 National Inpatient Sample. Patients were considered to be at risk of financial toxicity if their hospitalization cost exceeded 40% of post-subsistence income. Individual family income was computed using a gamma distribution probability density function with parameters derived from publicly available US Census Bureau data, in accordance with prior work. A multivariable logistic regression was developed to assess factors associated with risk of financial toxicity. RESULTS Of an estimated 225,265 children identified for study, 34,395 (15.3%) were Rural. Rural patients were more likely to experience risk of financial toxicity (29.1 vs 22.2%, P < .001) compared to Urban patients. After adjustment, rurality (reference: urban status; adjusted odds ratio 1.45, 95% confidence interval 1.36-1.55) and uninsured status (reference: private; adjusted odds ratio 1.85, 95% confidence interval 1.67-2.05) remained linked to increased odds of risk of financial toxicity. Specifically among those with private insurance, Rural patients experienced markedly higher predicted risk of financial toxicity, relative to Urban. CONCLUSION Our findings suggest a complex interplay between rural status and insurance type in the prediction of risk of financial toxicity after pediatric trauma. To target policy interventions, future studies should characterize the patients and communities at greatest risk of financial devastation among rural pediatric trauma patients.
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Affiliation(s)
- Amulya Vadlakonda
- Department of Surgery, University of California, Los Angeles, CA. https://twitter.com/amulyavad
| | - Nam Yong Cho
- Department of Surgery, University of California, Los Angeles, CA
| | - Nikhil Chervu
- Department of Surgery, University of California, Los Angeles, CA
| | - Giselle Porter
- Department of Surgery, University of California, Los Angeles, CA
| | - Joanna Curry
- Department of Surgery, University of California, Los Angeles, CA
| | - Sara Sakowitz
- Department of Surgery, University of California, Los Angeles, CA
| | - Troy Coaston
- Department of Surgery, University of California, Los Angeles, CA
| | - Jordan M Rook
- Department of Surgery, University of California, Los Angeles, CA; Greater Los Angeles Veterans Administration Healthcare System, Los Angeles CA; National Clinician Scholars Program, University of California, Los Angeles, CA; Fielding School of Public Health, University of California, Los Angeles, CA
| | - Catherine Juillard
- Division of General Surgery (Trauma and Surgical Critical Care Section), University of California, Los Angeles, CA
| | - Peyman Benharash
- Department of Surgery, University of California, Los Angeles, CA.
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Fracasso JL, Ahmed N. Trauma centers: an underfunded but essential asset to the community. Trauma Surg Acute Care Open 2024; 9:e001436. [PMID: 38974218 PMCID: PMC11227843 DOI: 10.1136/tsaco-2024-001436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/14/2024] [Indexed: 07/09/2024] Open
Abstract
Research indicates that specialized trauma centers, especially those of level I and II designation, can generate revenue if financial support is provided, and most importantly provide better outcomes for an injured patient by reducing length of stay and mortality when compared with treatment at hospitals without trauma center designation. Costs associated with trauma center operation have risen over the past few years in association with growing patient volumes and inflation. Documentation regarding costs for trauma center operations is sparse, and there exists a large variance between reported numbers based on their region. In most cases, the greatest proportion of funds are spent on clinical personnel while the smallest fraction is dedicated to educational and prevention programs. Studies confirm that as a product of these rising costs and a lack of state and federal funding that trauma centers remain uniquely financially vulnerable. Multiple strategies have been implemented to mitigate these costs but have proven insufficient. Legislations providing patients with expanded access to healthcare such as the Affordable Healthcare Act have failed to deliver on their intended purposes, and managed care organizations have moved to protect their own interest at the expense of trauma patient mortality. In lieu of concerted federal support, states and municipalities have explored solutions to support trauma centers such as small fees added to fines or encouraging charitable donations, although these programs have not seen ubiquitous implementation. Most trauma centers have begun incorporating activation costs to recoup losses from their low reimbursement rate, but these have continued to inflate, and pose a growing burden on vulnerable patients. Lack of funding from external sources such as state or federal appropriations poses a tangible threat to trauma centers for closure, and with multiple trauma centers acting as critical pillars of healthcare infrastructure for disadvantaged communities as well as the impact of this lack of funding being so broad and systemic, multiple 'trauma deserts' may emerge, leaving communities-especially disadvantaged communities which rely on the safety-net function of many high designation trauma centers-deprived of an essential treatment resource and increasing annual mortalities that could have otherwise been averted.
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Affiliation(s)
- Joseph L Fracasso
- Surgery, Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, New Jersey, USA
| | - Nasim Ahmed
- Surgery, Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, New Jersey, USA
- Department of Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
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Cho NY, Vadlakonda A, Curry J, Tran Z, Tillou A, de Virgilio C, Benharash P. Association of rurality with short-term outcomes of peripheral vascular trauma. Surgery 2024; 176:205-210. [PMID: 38614911 DOI: 10.1016/j.surg.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/24/2024] [Accepted: 03/14/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Peripheral vascular trauma is a major contributing factor to long-term disability and mortality among patients with traumatic injuries. However, an analysis focusing on individuals at a high risk of experiencing limb loss due to rural and urban peripheral vascular trauma is lacking. METHOD This was a retrospective analysis of the 2016 to 2020 Nationwide Readmissions Database. Patients (≥18 years) undergoing open or endovascular procedures after admission for peripheral vascular trauma were identified using the 2016 to 2020 Nationwide Readmissions Database. Patients from rural regions were considered Rural, whereas the remainder comprised Urban. The primary outcome of the study was primary amputation. Multivariable regression models were developed to evaluate rurality with outcomes of interest. RESULTS Of 29,083 patients, 4,486 (15.6%) were Rural. Rural were older (41 [28-59] vs 37 [27-54] years, P < .001), with a similar distribution of female sex (23.0 vs 21.3%, P = .09) and transfers from other facilities (2.8 vs 2.5%, P = .34). After adjustment, Rural status was not associated with the odds of mortality (P = .82), with urban as reference. Rural status was, however, associated with greater odds of limb amputation (adjusted odds ratio 1.85, 95% confidence interval 1.47-2.32) and reduced index hospitalization cost by $7,100 (95% confidence interval $3,500-10,800). Additionally, compared to patients from urban locations, rurality was associated with similar odds of non-home discharge and 30-day readmission. Over the study period, the marginal effect of rurality on the risk-adjusted rates of amputation significantly increased (P < .001). CONCLUSION Patients who undergo peripheral vascular trauma management in rural areas appear to increasingly exhibit a higher likelihood of amputation, with lower incremental costs and a lower risk of 30-day readmission. These findings underscore disparities in access to optimal trauma vascular care as well as limited resources in rural regions.
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Affiliation(s)
- Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA. https://twitter.com/NamYong_Cho
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joanna Curry
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Acute Care Surgery, Department of Surgery, Loma Linda University Health, CA. https://twitter.com/DrZacharyTran
| | - Areti Tillou
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Trauma and Emergency Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), Division of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Goddard SD, Jarman MP, Hashmi ZG. Societal Burden of Trauma and Disparities in Trauma Care. Surg Clin North Am 2024; 104:255-266. [PMID: 38453300 DOI: 10.1016/j.suc.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.
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Affiliation(s)
- Sabrina D Goddard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA
| | - Molly P Jarman
- The Department of Surgery, Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, One Brigham Circle,1620 Tremont Street, Suite 2-016, Boston, MA 02120, USA
| | - Zain G Hashmi
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA.
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Hsuan C, Vanness DJ, Zebrowski A, Carr BG, Norton EC, Buckler DG, Wang Y, Leslie DL, Dunham EF, Rogowski JA. Racial and ethnic disparities in emergency department transfers to public hospitals. Health Serv Res 2024; 59:e14276. [PMID: 38229568 PMCID: PMC10915485 DOI: 10.1111/1475-6773.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVE To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. DATA SOURCES AND STUDY SETTING ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). STUDY DESIGN Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. DATA COLLECTION/EXTRACTION METHODS We examined 1,265,588 adult ED patients transferred from 187 hospitals. PRINCIPAL FINDINGS Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. CONCLUSIONS Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.
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Affiliation(s)
- Charleen Hsuan
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - David J. Vanness
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Alexis Zebrowski
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Brendan G. Carr
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Edward C. Norton
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
- Department of EconomicsUniversity of MichiganAnn ArborMichiganUSA
| | - David G. Buckler
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Yinan Wang
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Douglas L. Leslie
- Department of Public Health Sciences, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Eleanor F. Dunham
- Department of Emergency Medicine, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Jeannette A. Rogowski
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
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Krashin JW, Black P, Brannen E, Gard CC, Lin Y, Greenwood-Ericksen M, Trujillo VY, Burkhardt G, Schreiber CA. Geographic Access to Early Pregnancy Loss Management. Obstet Gynecol 2024; 143:435-439. [PMID: 38207328 PMCID: PMC10926981 DOI: 10.1097/aog.0000000000005505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/16/2023] [Indexed: 01/13/2024]
Abstract
Early pregnancy loss (EPL) is common, but patients face barriers to the most effective medication (mifepristone followed by misoprostol) and procedural (uterine aspiration) management options. This cross-sectional geospatial analysis evaluated access in New Mexico to mifepristone and misoprostol and uterine aspiration in emergency departments (comprehensive) and to uterine aspiration anywhere in a hospital (aspiration) for EPL. Access was defined as a 60-minute car commute. We collected data from hospital key informants and public databases and performed logistical regression to evaluate associations between access and rurality, area deprivation, race, and ethnicity. Thirty-five of 42 (83.3%) hospitals responded between October 2020 and August 2021. Two hospitals (5.7%) provided comprehensive management; 24 (68.6%) provided aspiration. Rural and higher deprivation areas had statistically significantly lower adjusted odds ratios for comprehensive management (0.03-0.07 and 0.3-0.4, respectively) and aspiration (0.03-0.06 and 0.1-0.3, respectively) access. Mifepristone and uterine aspiration implementation would address disparate access to EPL treatment.
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Affiliation(s)
- Jamie W Krashin
- Department of Obstetrics and Gynecology, the Department of Geography and Environmental Studies, and the Department of Emergency Medicine, University of New Mexico, Lovelace Medical Center, and the Department of Economics, Applied Statistics, and International Business, New Mexico State University, Albuquerque, New Mexico; and the Department of Obstetrics & Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
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Acosta JA. The role of race and insurance in trauma patients' mortality: A cross-sectional analysis based on a nationwide sample. PLoS One 2024; 19:e0298886. [PMID: 38359054 PMCID: PMC10868734 DOI: 10.1371/journal.pone.0298886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 01/31/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Persistent disparities in trauma in-hospital mortality owing to insurance status and race remain a prominent issue within healthcare. This study explores the relationships among insurance status, race, length of stay (LOS) in-hospital mortality outcomes in trauma patients at extreme risk of mortality (EROM) trauma patients. METHODS Data was retrieved from the National Inpatient Sample, focusing on high-acuity trauma patients from 2007 to 2020, aged 18-64 years. Patients were identified using specific All Patient Refined Diagnosis Related Groups codes. Emphasis was placed on those with EROM owing to their resource-intensive nature and the potential influence of insurance on outcomes. Patients aged 65 years or older were excluded owing to distinct trauma patterns, as were those diagnosed with burns or non-trauma conditions. RESULTS The study encompassed 70,381 trauma inpatients with EROM, representing a national estimate of 346,659. Being insured was associated with a 34% decrease in the odds of in-hospital mortality compared to being uninsured. The in-hospital mortality risk associated with insurance status varied over time, with insurance having no impact on in-hospital mortality during hospitalizations of less than 2 days (short LOS). In the overall group, Black patients showed an 8% lower risk of in-hospital mortality compared to White patients, while they experienced a 33% higher risk of in-hospital mortality during short LOS. CONCLUSION Insured trauma inpatients demonstrated a significant reduction in the odds of in-hospital mortality compared to their uninsured counterparts, although this advantage was not present in the short LOS group. Black patients experienced lower in-hospital mortality rates compared to White patients, but this trend reversed in the short LOS group. These findings underscore the intricate relationships between insurance status, race, and duration of hospitalization, highlighting the need for interventions to improve patient outcomes.
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Affiliation(s)
- José A. Acosta
- New Mexico Department of Health, Santa Fe, New Mexico, United States of America
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Mitchnik IY, Regev S, Rivkind AI, Fogel I. Disparities in trauma care education: An observational study of the ATLS course within a national trauma system. Injury 2023; 54:110860. [PMID: 37328347 DOI: 10.1016/j.injury.2023.110860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 05/15/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Disparities in trauma systems, including gaps between trauma center levels, affect patient outcomes. Advanced Trauma Life Support (ATLS) is a standard method of care that improves the performance of lower-level trauma systems. We sought to study potential gaps in ATLS education within a national trauma system. METHODS This prospective observational study examined the characteristics of 588 surgical board residents and fellows taking the ATLS course. The course is required for board certification in adult trauma specialties (general surgery, emergency medicine, and anesthesiology), pediatric trauma specialties (pediatric emergency medicine and pediatric surgery), and trauma consulting specialties (all other surgical board specialties). We compared the differences in course accessibility and success rates within a national trauma system which includes seven level 1 trauma centers (L1TC) and twenty-three non-level 1 hospitals (NL1H). RESULTS Resident and fellow students were 53% male, 46% employed in L1TC, and 86% were in the final stages of their specialty program. Only 32% were enrolled in adult trauma specialty programs. Students from L1TC had a 10% higher ATLS course pass rate than NL1H (p = 0.003). Trauma center level was associated with higher odds to pass the ATLS course, even after adjustment to other variables (OR = 1.925 [95% CI = 1.151 to 3.219]). Compared to NL1H, the course was two-three times more accessible to students from L1TC and 9% more accessible to adult trauma specialty programs (p = 0.035). The course was more accessible to students at early levels of training in NL1H (p < 0.001). Female students and trauma consulting specialties enrolled in L1TC programs were more likely to pass the course (OR = 2.557 [95% CI = 1.242 to 5.264] and 2.578 [95% CI = 1.385 to 4.800], respectively). CONCLUSIONS Passing the ATLS course is affected by trauma center level, independent of other student factors. Educational disparities between L1TC and NL1H include ATLS course access for core trauma residency programs at early training stages. Some gaps are more pronounced among consulting trauma specialties and female surgeons. Educational resources should be planned to favor lower-level trauma centers, specialties dealing in trauma care, and residents early in their postgraduate training.
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Affiliation(s)
- Ilan Y Mitchnik
- Israel Defense Force Medical Corps, Tel Hashomer, Ramat Gan, Israel; Department of Military Medicine, Hebrew University, Jerusalem, Israel; Military Medical Academy, Israel Defense Force, Negev, Israel.
| | - Stav Regev
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham I Rivkind
- Department of General Surgery and Shock Trauma Center, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
| | - Itay Fogel
- Israel Defense Force Medical Corps, Tel Hashomer, Ramat Gan, Israel; Department of Military Medicine, Hebrew University, Jerusalem, Israel; Military Medical Academy, Israel Defense Force, Negev, Israel
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Yamamoto T, Hanazato M, Hikichi H, Kondo K, Osaka K, Kawachi I, Aida J. Change in Geographic Accessibility to Dental Clinics Affects Access to Care. J Dent Res 2023; 102:719-726. [PMID: 37204154 PMCID: PMC10286177 DOI: 10.1177/00220345231167771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Access to dental clinics is a feature of the neighborhood service environment that may influence oral health care utilization. However, residential selection poses a challenge to causal inference. By studying the involuntary relocation of survivors of the 2011 Great East Japan Earthquake and Tsunami (GEJE), we examined the association between changes in geographic distance to dental clinics and dental visits. Longitudinal data from a cohort of older residents in Iwanuma City directly impacted by the GEJE were analyzed in this study. The baseline survey was conducted in 2010, 7 mo before the occurrence of GEJE, and a follow-up was conducted in 2016. Using Poisson regression models, we estimated the incidence rate ratios (IRR) and 95% confidence intervals (CIs) for the uptake of denture use (as a proxy for dental visits) according to changes in distance from the nearest dental clinic to their house. Age at baseline, housing damage by the disaster, deteriorating economic conditions, and worsened physical activity were used as confounders. Among the 1,098 participants who had not worn dentures before the GEJE, 495 were men (45.1%), with a mean ± SD age at baseline of 74.0 ± 6.9 y. During the 6-year follow-up, 372 (33.9%) participants initiated denture use. Compared to those who experienced a large increase in distance to dental clinics (>370.0-6,299.1 m), a large decrease in distance to dental clinics (>429.0-5,382.6 m) was associated with a marginally significantly higher initiation of denture use among disaster survivors (IRR = 1.28; 95% CI, 0.99-1.66). The experience of major housing damage was independently associated with higher initiation of denture use (IRR = 1.77; 95% CI, 1.47-2.14). Improved geographic access to dental clinics may increase dental visits of disaster survivors. Further studies in non-disaster-affected areas are needed to generalize these findings.
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Affiliation(s)
- T. Yamamoto
- Department of Health Promotion, National Institute of Public Health, Saitama, Japan
| | - M. Hanazato
- Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - H. Hikichi
- Division of Public Health, Kitasato University School of Medicine, Sagamihara, Japan
| | - K. Kondo
- Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
- Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Japan
| | - K. Osaka
- Department of International and Community Oral Health, Graduate School of Dentistry, Tohoku University, Sendai, Japan
| | - I. Kawachi
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - J. Aida
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Amato S, Benson JS, Stewart B, Sarathy A, Osler T, Hosmer D, An G, Cook A, Winchell RJ, Malhotra AK. Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study. J Trauma Acute Care Surg 2023; 94:755-764. [PMID: 36880704 PMCID: PMC10208642 DOI: 10.1097/ta.0000000000003940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality. METHODS A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality. RESULTS Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality. CONCLUSION Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Brenna E, Polistena B, Spandonaro F. Analysing outpatient care access for planning purposes: The Basilicata Region experience. EVALUATION AND PROGRAM PLANNING 2023; 99:102315. [PMID: 37210952 DOI: 10.1016/j.evalprogplan.2023.102315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/08/2023] [Accepted: 05/17/2023] [Indexed: 05/23/2023]
Abstract
The delivery of healthcare services at regional level should be modeled on population needs, stemming from patients' consumption pattern and trying to include unexpressed needs and exclude excesses of demand due to both moral hazard behaviors and inducements from the supply side. We propose a model able to estimate the frequency of access in outpatient care (OC) based on the characteristics of the population. According to empirical evidence, among the determinants of outpatient access we include variables addressing health, socioeconomic status and place of residence, plus variables related to the supply of services. We run generalized linear models for counting data of the Poisson family with the aim of both identifying the determinants of OC utilization and quantifying the related effects. We use the regional administrative database of Basilicata region, year 2019. Results are consistent with literature findings and provide new insights into the analysis of OC, suggesting that our model could easily be implemented by regional policymakers to plan the supply of ambulatory services on population needs.
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Affiliation(s)
- Elenka Brenna
- Department of Economics and Management, Università degli Studi di Pavia, Via San Felice al Monastero 5/7, 27100 Pavia, Italy.
| | | | - Federico Spandonaro
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Via di Val Cannuta n. 247, 00166 Roma, Italy
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HSUAN CHARLEEN, CARR BRENDANG, VANNESS DAVID, WANG YINAN, LESLIE DOUGLASL, DUNHAM ELEANOR, ROGOWSKI JEANNETTEA. A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks. Milbank Q 2023; 101:74-125. [PMID: 36919402 PMCID: PMC10037699 DOI: 10.1111/1468-0009.12609] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. CONTEXT Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. METHODS To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. FINDINGS The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. CONCLUSIONS The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.
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McCrum ML, Allen CM, Han J, Iantorno SE, Presson AP, Wan N. Greater spatial access to care is associated with lower mortality for emergency general surgery. J Trauma Acute Care Surg 2023; 94:264-272. [PMID: 36694335 PMCID: PMC10069479 DOI: 10.1097/ta.0000000000003837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) diseases are time-sensitive conditions that require urgent surgical evaluation, yet the effect of geographic access to care on outcomes remains unclear. We examined the association of spatial access with outcomes for common EGS conditions. METHODS A retrospective analysis of twelve 2014 State Inpatient Databases, identifying adults admitted with eight EGS conditions, was performed. We assessed spatial access using the spatial access ratio (SPAR)-an advanced spatial model that accounts for travel distance, hospital capacity, and population demand, normalized against the national mean. Multivariable regression models adjusting for patient and hospital factors were used to evaluate the association between SPAR with (a) in-hospital mortality and (b) major morbidity. RESULTS A total of 877,928 admissions, of which 104,332 (2.4%) were in the lowest-access category (SPAR, 0) and 578,947 (66%) were in the high-access category (SPAR, ≥1), were analyzed. Low-access patients were more likely to be White, male, and treated in nonteaching hospitals. Low-access patients also had higher incidence of complex EGS disease (low access, 31% vs. high access, 12%; p < 0.001) and in-hospital mortality (4.4% vs. 2.5%, p < 0.05). When adjusted for confounding factors, including presence of advanced hospital resources, increasing spatial access was protective against in-hospital mortality (adjusted odds ratio, 0.95; 95% confidence interval, 0.94-0.97; p < 0.001). Spatial access was not significantly associated with major morbidity. CONCLUSION This is the first study to demonstrate that geospatial access to surgical care is associated with incidence of complex EGS disease and that increasing spatial access to care is independently associated with lower in-hospital mortality. These results support the consideration of spatial access in the development of regional health systems for EGS care. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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Affiliation(s)
- Marta L McCrum
- From the Department of Surgery (M.L.M., S.E.I.), Surgical Population Analysis Research Core (M.L.M.), Statistical Design and Biostatistics Center (C.M.A., A.P.P.), and Department of Geography (J.H., N.W.), The University of Utah, Salt Lake City, Utah
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14
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Zou Y, Jia L, Chen S, Deng X, Chen Z, He Y, Wang Q, Xing D, Zhang Y. Spatial accessibility of emergency medical services in Chongqing, Southwest China. Front Public Health 2023; 10:959314. [PMID: 36684945 PMCID: PMC9853430 DOI: 10.3389/fpubh.2022.959314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/09/2022] [Indexed: 01/08/2023] Open
Abstract
Background Timely access to emergency medical services (EMS) can significantly reduce mortality. In China, the evidence of the accessibility of complete EMS which considers two related trips and involves large rural areas is insufficient. This study aimed to explore the accessibility of ambulance services and complete EMS in Chongqing and its regional differences, and to provide a reference for improving spatial accessibility of EMS in Chongqing and optimizing allocation of EMS resources. Methods The nearest neighbor method was used to measure spatial accessibility of ambulance services and complete EMS. Spatial aggregation patterns and influencing factors of spatial accessibility of complete EMS were analyzed using Moran's I index, Pearson correlation and multiple linear regression. Results The medians of shortest travel time for ambulance, monitoring ambulance, primary EMS and advanced EMS in Chongqing were 7.0, 18.6, 36.2, and 47.8 min. The shortest travel time for complete EMS showed significant spatial aggregation characteristics. The Low-Low types that referred to cluster of short EMS travel time mainly distributed in city proper. The High-High types that referred to cluster of long EMS travel time mainly distributed in northeast and southeast of Chongqing. Urbanization rate was a negative influencing factor on shortest travel time for primary EMS, while average elevation and the number of settlements were positive influencing factors. GDP per capita and urbanization rate were negative influencing factors on shortest travel time for advanced EMS, while the number of settlements was a positive influencing factor. Conclusion This study evaluated the accessibility of EMS which considers two related trips in Chongqing. Although the accessibility of ambulances in Chongqing was relatively high, the accessibility of monitoring ambulance was relatively low. Regional and urban-rural differences in the accessibility of complete EMS integrating two related trips were obvious. It was recommended to increase financial investment in economic backward areas, increase high-quality EMS resources, enhance EMS capacity of central township health centers, strengthen road construction in mountainous areas, and provide reasonable planning of rural settlements for improving the spatial accessibility of EMS, narrowing the urban-rural gap and improving equity in getting EMS for all the people.
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Affiliation(s)
- Yang Zou
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
| | - Ling Jia
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
| | - Saijuan Chen
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
| | - Xinyi Deng
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
| | - Zhiyi Chen
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
| | - Ying He
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
| | - Qiuting Wang
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
| | - Dianguo Xing
- Office of Health Emergency, Chongqing Municipal Health Commission, Chongqing, China
| | - Yan Zhang
- School of Public Health, Research Center for Medicine and Social Development, Innovation Center for Social Risk Governance in Health, Research Center for Public Health Security, Chongqing Medical University, Chongqing, China
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Rahman R, Xu AL, Dhanjani SA, Zhang B, Nayar SK, Humbyrd CJ, LaPorte D. Does Time to Imaging and Surgery for Distal Radius Fractures Vary based on Geographic Socioeconomic Disadvantage? Hand (N Y) 2022; 17:95S-102S. [PMID: 35189731 PMCID: PMC9793622 DOI: 10.1177/15589447221075669] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND While disparities in aspects of distal radius fracture (DRF) management and orthopedics at large have been studied, disparities in time to DRF evaluation and treatment are unknown. We sought to determine if geographic socioeconomic disadvantage is associated with time to imaging in the emergency department (ED) and time to surgery for DRFs. METHODS We performed a time-to-event analysis of 105 patients undergoing DRF surgery after ED triage within our hospital system between January 1, 2015, and January 1, 2020. Area Deprivation Index (ADI) national percentile was used as the metric of geographic socioeconomic disadvantage for each patient's ZIP code of residence. We performed Cox regression analysis to determine hazard ratios to undergo DRF imaging and surgery for patients in each ADI group, adjusting for potential confounders, α = 0.05. RESULTS There was no association between geographic socioeconomic disadvantage and time to DRF imaging, after adjusting for confounders. However, compared to patients from the least disadvantaged areas, patients from the most disadvantaged areas (ADI Quartiles 3 and 4) had an adjusted hazard ratio for surgery of 0.55 [0.32, 0.94] (P = .03), and were thus 45% [6%, 68%] less likely to undergo surgery for DRF at any time following ED triage. CONCLUSIONS Operative patients from more socioeconomically disadvantaged neighborhoods see disparities in time to surgery for DRF. Equitable access to timely surgical care is needed and may be improved with increased access to orthopedic surgeons, patient education, support in navigating the health system, and improved continuity of fracture care. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rafa Rahman
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Amy L. Xu
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | | | - Bo Zhang
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Suresh K. Nayar
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | | | - Dawn LaPorte
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
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Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review. Healthcare (Basel) 2022; 10:healthcare10122391. [PMID: 36553915 PMCID: PMC9778378 DOI: 10.3390/healthcare10122391] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 12/05/2022] Open
Abstract
The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.
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Chung M, Robinson B, Fukuda M, Dunbar JA, Ulangca RA, Khazaeni LM. Access to Pediatric Eye Care Following Vision Screening. J Pediatr Ophthalmol Strabismus 2022; 59:369-374. [PMID: 35275779 DOI: 10.3928/01913913-20220210-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To quantify the accessibility of eye care providers from photoscreening centers within the vision screening region in relation to population density and median household income. METHODS Driving times between vision screening locations and eye care centers were mapped and analyzed using OpenStreetMap software (Open Street Map Foundation). U.S. Census Bureau data of population density and median household income were linked with screening centers using ArcGIS Online (Esri) to determine correlations with driving times. RESULTS A total of 290 driving times for 145 photo-screening centers, 147 optometrists, and 7 pediatric ophthalmologists were calculated and mapped. Median driving times from a photoscreening center to the nearest optometrist and ophthalmologist were 4.74 and 25.10 minutes, respectively, with 90% of the screening centers residing within 12.46 and 67.19 minutes of the nearest optometrist and ophthalmologist, respectively. Driving times to optometrists are far less than times to pediatric ophthalmologists due to the greater number of optometrists. Decreasing driving times with increasing population and median household income indicate the concentration of optometrists and pediatric ophthalmologists within urbanized areas. CONCLUSIONS Most photoscreening centers reside within 5 and 70 minutes of the nearest optometrist and pediatric ophthalmologist, respectively. Driving times indicate the region's greater accessibility to optometrists than to pediatric ophthalmologists. Eye care centers tend to be localized within urbanized areas with higher population densities and higher median household incomes. [J Pediatr Ophthalmol Strabismus. 2022;59(6):369-374.].
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Geographic disparities in access to immunotherapy clinical trials for metastatic melanoma. Arch Dermatol Res 2022; 315:1033-1036. [PMID: 36305959 DOI: 10.1007/s00403-022-02433-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/13/2022] [Indexed: 11/02/2022]
Abstract
Survival outcomes for metastatic melanoma have drastically improved with the advent of immunotherapy. Access to ongoing immunotherapy clinical trials has become increasingly important to patients with advanced disease. We sought to quantify geographic disparities in access to these trials by U.S. division, region, urban/rural status, and median income. We searched ClinicalTrials.gov for interventional immunotherapy trials for metastatic melanoma from 2015 to 2021 and identified U.S. zip codes for each participating trial site. ArcGIS was used to calculate the one-way driving time from each zip code to the nearest treatment center. Melanoma burden in each zip code outside a 60 min driving radius was calculated by multiplying population by the corresponding state's cancer-specific mortality rate. χ2 tests were used to test for significance between census regions, divisions, and urban vs. rural zip codes, while logistic regression was used to quantify risk of poor access with median income. Across 148 trials, 4844 treatment centers were located in 1102 unique zip codes. 9010 zip codes were located greater than one-hour driving time from the nearest clinical trial. Southern regions were most likely to have poor access of all regions (p < 0.001), and rural status also significantly correlated with poor access (p < 0.001). For every $10,000 increase in median income, the likelihood of a zip code being within 60 min from a trial increased by 1.315. While immunotherapy continue to improve survival outcomes for metastatic melanoma, geographic access to clinical trials investigating these therapies remains a challenge for a significant proportion of the U.S. population.
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A Geographical Analysis of Access to Trauma Centers from US National Parks in 2018. Prehosp Disaster Med 2022; 37:794-799. [PMID: 36263736 DOI: 10.1017/s1049023x22001431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Millions of people visit US national parks annually to engage in recreational wilderness activities, which can occasionally result in traumatic injuries that require timely, high-level care. However, no study to date has specifically examined timely access to trauma centers from national parks. This study aimed to examine the accessibility of trauma care from national parks by calculating the travel time by ground and air from each park to its nearest trauma center. Using these calculations, the percentage of parks by census region with timely access to a trauma center was determined. METHODS This was a cross-sectional study analyzing travel times by ground and air transport between national parks and their closest adult advanced trauma center (ATC) in 2018. A list of parks was compiled from the National Parks Service (NPS) website, and the location of trauma centers from the 2018 National Emergency Department Inventory (NEDI)-USA database. Ground and air transport times were calculated using Google Maps and ArcGIS, with medians and interquartile ranges reported by US census region. Percentage of parks by region with timely trauma center access-defined as access within 60 minutes of travel time-were determined based on these calculated travel times. RESULTS In 2018, 83% of national parks had access to an adult ATC within 60 minutes of air travel, while only 26% had timely access by ground. Trauma center access varied by region, with median travel times highest in the West for both air and ground transport. At a national level, national parks were unequally distributed, with the West housing the most parks of all regions. CONCLUSION While most national parks had timely access to a trauma center by air travel, significant gaps in access remain for ground, the extent of which varies greatly by region. To improve the accessibility of trauma center expertise from national parks, the study highlights the potential that increased implementation of trauma telehealth in emergency departments (EDs) may have in bridging these gaps.
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McCrum ML, Wan N, Han J, Lizotte SL, Horns JJ. Disparities in Spatial Access to Emergency Surgical Services in the US. JAMA HEALTH FORUM 2022; 3:e223633. [PMID: 36239953 PMCID: PMC9568808 DOI: 10.1001/jamahealthforum.2022.3633] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Importance Hospitals with emergency surgical services provide essential care for a wide range of time-sensitive diseases. Commonly used measures of spatial access, such as distance or travel time, have been shown to underestimate disparities compared with more comprehensive metrics. Objective To examine population-level differences in spatial access to hospitals with emergency surgical capability across the US using enhanced 2-step floating catchment (E2SFCA) methods. Design, Setting, and Participants A cross-sectional study using the 2015 American Community Survey data. National census block group (CBG) data on community characteristics were paired with geographic coordinates of hospitals with emergency departments and inpatient surgical services, and hospitals with advanced clinical resources were identified. Spatial access was measured using the spatial access ratio (SPAR), an E2SFCA method that captures distance to hospital, population demand, and hospital capacity. Small area analyses were conducted to assess both the population with low access to care and community characteristics associated with low spatial access. Data analysis occurred from February 2021 to July 2022. Main Outcomes and Measures Low spatial access was defined by SPAR greater than 1.0 SD below the national mean (SPAR <0.3). Results In the 217 663 CBGs (median [IQR] age for CBGs, 39.7 [33.7-46.3] years), there were 3853 hospitals with emergency surgical capabilities and 1066 (27.7%) with advanced clinical resources. Of 320 million residents, 30.8 million (9.6%) experienced low access to any hospital with emergency surgical services, and 82.6 million (25.8%) to advanced-resource centers. Insurance status was associated with low access to care across all settings (public insurance: adjusted rate ratio [aRR], 1.21; 95% CI, 1.12-1.25; uninsured aRR, 1.58; 95% CI, 1.52-1.64). In micropolitan and rural areas, high-share (>75th percentile) Hispanic and other (Asian; American Indian, Alaska Native, or Pacific Islander; and 2 or more racial and ethnic minority groups) communities were also associated with low access. Similar patterns were seen in access to advanced-resource hospitals, but with more pronounced racial and ethnic disparities. Conclusions and Relevance In this cross-sectional study of access to surgical care, nearly 1 in 10 US residents experienced low spatial access to any hospital with emergency surgical services, and 1 in 4 had low access to hospitals with advanced clinical resources. Communities with high rates of uninsured or publicly insured residents and racial and ethnic minority communities in micropolitan and rural areas experienced the greatest risk of limited access to emergency surgical care. These findings support the use of E2SFCA models in identifying areas with low spatial access to surgical care and in guiding health system development.
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Affiliation(s)
- Marta L. McCrum
- Division of General Surgery, University of Utah, Salt Lake City
| | - Neng Wan
- Department of Geography, University of Utah, Salt Lake City
| | - Jiuying Han
- Department of Geography, University of Utah, Salt Lake City
| | | | - Joshua J. Horns
- Surgical Population Analysis Research Core, Department of Surgery, University of Utah, Salt Lake City
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21
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Rosenthal JL, Haynes SC, Bonilla B, Rominger K, Williams J, Sanders A, Orqueza Dizon RA, Grether-Jones KL, Marcin JP, Hamline MY. Enhancing the Implementation of the Virtual Pediatric Trauma Center Using Practical, Robust, Implementation and Sustainability Model: A Mixed-Methods Study. TELEMEDICINE REPORTS 2022; 3:137-148. [PMID: 36185467 PMCID: PMC9518803 DOI: 10.1089/tmr.2022.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND This article describes factors related to adoption, implementation, and effectiveness of the Virtual Pediatric Trauma Center intervention, which uses telehealth for trauma specialist consultations for seriously injured children. We aimed at (1) measuring RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation outcomes and (2) identifying PRISM (Practical, Robust, Implementation, and Sustainability Model) contextual factors that influenced the implementation outcomes. METHODS This interim implementation evaluation of our telehealth trial used a convergent mixed-methods design. The quantitative component was a cross-sectional analysis of pediatric trauma encounters using electronic health records. The qualitative component was a thematic analysis of written and verbal feedback from providers and family advisory board meetings. We compared the quantitative and qualitative data by synthesizing them in a joint display table, organized by RE-AIM dimensions. We categorized these key findings into the PRISM domains. RESULTS During the first 10 months of this trial, 246 subjects were randomized, with 177 assigned to standard care and 69 assigned to telehealth. Four referring sites transitioned from standard care into their intervention period. PRISM contextual factors that influenced RE-AIM implementation outcomes included the following findings: Providers struggle to remember, interpret, and navigate intervention workflows; providers have preconceived ideas about the intervention purpose; the intervention mitigates parents' anxieties about the transfer process. DISCUSSION This study revealed implementation challenges that influence the overall success of this telehealth trial. Early identification of these challenges allows our team the opportunity to address them now to optimize the intervention reach, adoption, and implementation. This early action will ultimately enhance the success of our trial and the ability of our intervention to achieve broad impact.
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Affiliation(s)
- Jennifer L. Rosenthal
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Sarah C. Haynes
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Bethney Bonilla
- Center for Healthcare Policy and Research, University of California Davis, Sacramento, California, USA
| | - Katherine Rominger
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Jacob Williams
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - April Sanders
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | | | - Kendra L. Grether-Jones
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - James P. Marcin
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
| | - Michelle Y. Hamline
- Department of Pediatrics, University of California Davis, Sacramento, California, USA
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Tolpadi A, Elliott MN, Waxman D, Becker K, Flow-Delwiche E, Lehrman WG, Stark D, Parast L. National travel distances for emergency care. BMC Health Serv Res 2022; 22:388. [PMID: 35331209 PMCID: PMC8944092 DOI: 10.1186/s12913-022-07743-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Most emergency department (ED) patients arrive by their own transport and, for various reasons, may not choose the nearest ED. How far patients travel for ED treatment may reflect both patients’ access to care and severity of illness. In this study, we aimed to examine the travel distance and travel time between a patient’s home and ED they visited and investigate how these distances/times vary by patient and hospital characteristics. Methods We randomly sampled and collected data from 14,812 patients discharged to the community (DTC) between January and March 2016 from 50 hospital-based EDs nationwide. We geocoded and calculated the distance and travel time between patient and hospital-based ED addresses, examined the travel distances/ times between patients’ home and the ED they visited, and used mixed-effects regression models to investigate how these distances/times vary by patient and hospital characteristics. Results Patients travelled an average of 8.0 (SD = 10.9) miles and 17.3 (SD = 18.0) driving minutes to the ED. Patients travelled significantly farther to avoid EDs in lower performing hospitals (p < 0.01) and in the West (p < 0.05) and Midwest (p < 0.05). Patients travelled farther when visiting EDs in rural areas. Younger patients travelled farther than older patients. Conclusions Understanding how far patients are willing to travel is indicative of whether patient populations have adequate access to ED services. By showing that patients travel farther to avoid a low-performing hospital, we provide evidence that DTC patients likely do exercise some choice among EDs, indicating some market incentives for higher-quality care, even for some ED admissions. Understanding these issues will help policymakers better define access to ED care and assist in directing quality improvement efforts. To our knowledge, our study is the most comprehensive nationwide characterization of patient travel for ED treatment to date. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07743-7.
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Affiliation(s)
- Anagha Tolpadi
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA.
| | - Marc N Elliott
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA
| | - Daniel Waxman
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA
| | - Kirsten Becker
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA
| | | | | | - Debra Stark
- Centers for Medicare & Medicaid Services, Baltimore, MD, 21244, USA
| | - Layla Parast
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA
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Hassler J, Ceccato V. Socio-spatial disparities in access to emergency health care-A Scandinavian case study. PLoS One 2021; 16:e0261319. [PMID: 34890436 PMCID: PMC8664193 DOI: 10.1371/journal.pone.0261319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
Having timely access to emergency health care (EHC) depends largely on where you live. In this Scandinavian case study, we investigate how accessibility to EHC varies spatially in order to reveal potential socio-spatial disparities in access. Distinct measures of EHC accessibility were calculated for southern Sweden in a network analysis using a Geographical Information System (GIS) based on data from 2018. An ANOVA test was carried out to investigate how accessibility vary for different measures between urban and rural areas, and negative binominal regression modelling was then carried out to assess potential disparities in accessibility between socioeconomic and demographic groups. Areas with high shares of older adults show poor access to EHC, especially those in the most remote, rural areas. However, rurality alone does not preclude poor access to EHC. Education, income and proximity to ambulance stations were also associated with EHC accessibility, but not always in expected ways. Despite indications of a well-functioning EHC, with most areas served within one hour, socio-spatial disparities in access to EHC were detected both between places and population groups.
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Affiliation(s)
- Jacob Hassler
- Department of Urban Planning and Environment, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Vania Ceccato
- Department of Urban Planning and Environment, KTH Royal Institute of Technology, Stockholm, Sweden
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Lasky T, Richmond BK, Samanta D, Annie F. A 10-Year Review of Spatio-Temporal Patterns of Firearm Injury in a Rural Setting. Am Surg 2021; 88:834-839. [PMID: 34866416 DOI: 10.1177/00031348211054559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION West Virginia (WV) had the ninth highest rate of firearm mortality of all states in the United States according to the CDC in 2018. Gun violence in WV has been a steady problem over the last decade. The rural population is more vulnerable to unintentional firearm injuries and suicides. Previously published literature from urban settings has demonstrated a link between firearm injuries and modifiable situational variables such as crime, unemployment, low income, and low education. There are very few studies that have utilized geospatial analytic techniques as a tool for injury mapping, surveillance, and primary prevention in rural and frontier zones of the United States. METHODS We performed a 10-year retrospective single-institution review of firearm injuries at a rural WV level 1 trauma center between January 2010 and December 2019. The AIS World Geocoding Service was then used to identify specific areas of emerging firearm-related injuries within the service area. RESULTS Specific hot spots of emerging firearm injury were identified in both intentional and unintentional populations. These were located in geographically distinct areas of the WV unincorporated rural and frontier population. These rural WV hotspots were associated with the modifiable variables of crime, unemployment, lower income, and lower education level. CONCLUSIONS Emerging hot spots of firearm injury in rural and frontier locations were associated with modifiable social determinants. These areas represent an opportunity for targeted injury prevention efforts addressing these disparities. Further prospective study of these findings is warranted.
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Affiliation(s)
- Tiffany Lasky
- West Virginia University School of Medicine-Charleston Division, Department of Surgery, 37297Charleston Area Medical Center, Charleston, WV, USA
| | - Bryan K Richmond
- West Virginia University School of Medicine-Charleston Division, Department of Surgery, 37297Charleston Area Medical Center, Charleston, WV, USA
| | - Damayanti Samanta
- Center for Health Services and Outcomes Research, 20205Charleston Area Medical Center Institute for Academic Medicine, Charleston, WV, USA
| | - Frank Annie
- Center for Health Services and Outcomes Research, 20205Charleston Area Medical Center Institute for Academic Medicine, Charleston, WV, USA
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Metzger GA, Asti L, Quinn JP, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level. J Am Coll Surg 2021; 233:776-793.e16. [PMID: 34656739 PMCID: PMC8627499 DOI: 10.1016/j.jamcollsurg.2021.08.694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/21/2021] [Accepted: 08/25/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income. STUDY DESIGN Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years. RESULTS Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points). CONCLUSIONS The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.
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Affiliation(s)
- Gregory A Metzger
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - John P Quinn
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Medical Student Research Program, College of Medicine, The Ohio State University, Columbus, OH
| | - Deena J Chisolm
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - Henry Xiang
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH.
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Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis. J Craniofac Surg 2021; 33:997-1002. [PMID: 34690320 DOI: 10.1097/scs.0000000000008306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
ABSTRACT It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x[Combining Tilde] = 2330.6 PMP), 28,004 surgeons (x[Combining Tilde] = 83.5 PMP), and 746 training positions (x[Combining Tilde] = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P < 0.01), surgeon (70.8 versus 98.8, P < 0.01), training positions (0 versus 3.4, P < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density (P < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP (P < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.
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Abstract
OBJECTIVES Population density can limit the level of care that can be provided in local facilities in Ontario, and as such, patients with severe illnesses often require interfacility transfers to access specialized care. This study aimed to identify causes of delay in interfacility transport by air ambulance in Ontario. METHODS Causes of delay were identified by manual review of electronic patient care records (ePCRs). All emergent interfacility transfers conducted by Ornge, the sole provider of air-based medical transport in Ontario, between January 1, 2016 and December 31, 2016 were included. The ePCRs were reviewed if they met one or more of the following: (1) contained a standardized delay code; (2) contained free text including "delay", "wait", or "duty-out"; (3) were above the 75th percentile in total transport time; or (4) were above the 90th percentile in time to bedside, time at the sending hospital, or time to receiving facility. RESULTS Our search strategy identified 1,220 ePCRs for manual review, which identified a total of 872 delays. Common delays cited included aircraft refueling (234 delays), waiting for land emergency medical service (EMS) escort (146), and staffing- or dispatch-related issues (124). Other delays included weather/environmental hazards (43); mechanical issues (36); and procedures, imaging, or stabilization (80). CONCLUSIONS Some common causes of interfacility delay are potentially modifiable: better trip planning around refueling and improved coordination with local EMS, could reduce delays experienced during interfacility trips. To better understand causes of delay, we would benefit from improved documentation and record availability which limited the results in this study.
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Maish G, Horst M, Ting Brown C, Morgan M, Bradburn E, Cook A, Rogers FB. A comprehensive analysis of undertriage in a mature trauma system using geospatial mapping. J Trauma Acute Care Surg 2021; 91:77-83. [PMID: 33605697 DOI: 10.1097/ta.0000000000003113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The correct triage of trauma patients to trauma centers (TCs) is essential. We sought to determine the percentage of patients who were undertriaged within the Pennsylvania (PA) trauma system and spatially analyze areas of undertriage (UTR) in PA for all age groups: pediatric, adult, and geriatric. We hypothesized that there would be certain areas that had high UTR for all age groups. METHODS From 2003 to 2015, all admissions from the Pennsylvania Trauma Systems Foundation registry and those meeting trauma criteria (International Classification of Diseases, Ninth Diseases: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Admissions were divided into age groups: pediatric (<15 years), adult (15-64 years), and geriatric (≥65 years). All pediatric trauma cases were included from the Pennsylvania Trauma Systems Foundation and PHC4 registry, while only cases with Injury Severity Score of >9 were included in adult and geriatric age groups. Undertriage was defined as patients not admitted to level I/II adult TCs (n = 24), pediatric (n = 3), or adult and pediatric combined facility (n = 3) divided by the total number of patients from the PHC4 database. ArcGIS Desktop (version 10.7; ESRI, Redlands, CA) and GeoDa (version 1.14.0; CSDS, Chicago, IL) open source license were used for geospatial mapping of UTR with a spatial empirical Bayesian smoothed UTR by zip code tabulation area (ZCTA) and Stata (version 16.1; Stata Corp., College Station, TX) for statistical analyses. RESULTS There were significant percentages of UTR for all age groups. One area of high UTR for all age groups had TCs and large nontrauma centers in close proximity. There were high rates of UTR for all ages in rural areas, specifically in the upper central regions of PA, with limited access to TCs. CONCLUSION It appears there are two patterns leading to UTR. The first is in areas where TCs are in close proximity to large competing nontrauma centers, which may lead to inappropriate triage. The second has to do with lack of access to TCs. Geospatial mapping is a valuable tool that can be used to ascertain where trauma systems should focus scarce resources to decrease UTR. LEVEL OF EVIDENCE Epidemiological, level III; Care management, level III.
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Affiliation(s)
- George Maish
- From the Trauma and Acute Care Surgery (G.M., M.H., C.T.B., M.M., E.B., F.B.R.), Penn Medicine Lancaster General Health, Lancaster, Pennsylvania; and Department of Surgery, University of Texas Health Science Center at Tyler (A.C.), UT Health East Texas, Tyler, Texas
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Jarman MP, Weaver MJ, Haider AH, Salim A, Harris MB. Geographic Distribution of Orthopaedic Trauma Resources and Service Use in the United States: A Cross Sectional Analysis. J Surg Res 2021; 267:328-335. [PMID: 34186309 DOI: 10.1016/j.jss.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/15/2021] [Accepted: 05/26/2021] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; College of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Salim
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Ellison P, Cifarelli D, Pearce A, Moore L, Parrish D, Ellison M, Fazi A, Vanek T, Meltzer H, Knight J. Incidence, Prevalence, and Outcomes of Pediatric Trauma in Rural Appalachia (West Virginia) From 2017 to 2019. Cureus 2021; 13:e14245. [PMID: 33824845 PMCID: PMC8016142 DOI: 10.7759/cureus.14245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Appalachian rural pediatric trauma has its unique incidence, presentation, and distribution due to the mechanisms of injury, geographic location, access to care, and social issues. Purpose To review, analyze, and understand pediatric trauma in West Virginia during the period 2017-2019. Materials and methods After institutional review board approval, the statewide trauma database was queried and analyzed in a retrospective cohort study for all pediatric trauma ages zero to 18 from 2017-2019 in the Appalachian regions one through four in West Virginia. The following were analyzed: gender, injury mechanism, Glasgow Coma Scale Score (GCS) at admission, injury severity score (ISS), toxicology screen results, hospital length of stay, duration of ventilatory support, number of procedures performed during admission, presence of non-accidental trauma, cardiac arrest, patient discharge disposition, and mortality. Results One-thousand eighty-two (1182) patients between the ages of zero to 18 were admitted to the trauma center. An average of 37% was female and 63% male. In the 11-18 age group, 24% were female and 76% were male. Most injuries were due to blunt force (89%), followed by penetrating injuries (7.2%) and burns (1.4%). The majority had minor or moderate injuries with 95% receiving a Glasgow Coma Scale (GCS) >13 and 72% listed as minor on the injury severity score (ISS). Children in ages 0-2 years had the highest proportion of poor (0-8) GCS scores, high ISS (>14) scores, most hospital admission days, most days on a ventilator, highest mortality, most pre-hospital cardiac arrests, child abuse, burns, and placement with child protective services. An average of 31% of children tested, and 17% in the age group of 0-2 had a positive toxicology screen. There were 3670 procedures done in total and the most common procedure performed was an ultrasound of the abdomen. Procedures were performed in 90% of the patients. Conclusions and relevance Based on our study, the zero to two-year-old pediatric trauma patients are most vulnerable to poor outcomes and may need targeted preventative interventions. Toxicology screens may need to be more widely implemented in pediatric trauma in the Appalachian region. Rural trauma in Appalachia has endemic issues related to substance abuse, poverty, and a lower degree of social support as compared to urban areas. Although the distribution of injury may follow a national distribution, mechanism, management, and outcomes can vary.
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Affiliation(s)
- Pavithra Ellison
- Anesthesiology, West Virginia University School of Medicine, Morgantown, USA
| | - Daniel Cifarelli
- Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Alexandra Pearce
- Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Lucas Moore
- Biostatistics and Epidemiology, West Virginia University School of Medicine, Morgantown, USA
| | - Dan Parrish
- Surgery, West Virginia University School of Medicine, Morgantown, USA
| | - Matthew Ellison
- Anesthesiology, West Virginia University School of Medicine, Morgantown, USA
| | - Alyssa Fazi
- Anesthesiology, West Virginia University School of Medicine, Morgantown, USA
| | - Trey Vanek
- Anesthesiology, West Virginia University School of Medicine, Morgantown, USA
| | - Hal Meltzer
- Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
| | - Jennifer Knight
- Surgical Trauma and Critical Care, West Virginia University School of Medicine, Morgantown, USA
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Effect of Distance to Trauma Centre, Trauma Centre Level, and Trauma Centre Region on Fatal Injuries among Motorcyclists in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18062998. [PMID: 33803979 PMCID: PMC7999330 DOI: 10.3390/ijerph18062998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022]
Abstract
Background: Studies have suggested that trauma centre-related risk factors, such as distance to the nearest trauma hospital, are strong predictors of fatal injuries among motorists. Few studies have used a national dataset to study the effect of trauma centre-related risk factors on fatal injuries among motorists and motorcyclists in a country where traffic is dominated by motorcycles. This study investigated the effect of distance from the nearest trauma hospital on fatal injuries from two-vehicle crashes in Taiwan from 2017 to 2019. Methods: A crash dataset and hospital location dataset were combined. The crash dataset was extracted from the National Taiwan Traffic Crash Dataset from 1 January 2017 through 31 December 2019. The primary exposure in this study was distance to the nearest trauma hospital. This study performed a multiple logistic regression to calculate the adjusted odds ratios (AORs) for fatal injuries. Results: The multivariate logistic regression models indicated that motorcyclists involved in crashes located ≥5 km from the nearest trauma hospital and in Eastern Taiwan were approximately five times more likely to sustain fatal injuries (AOR = 5.26; 95% CI: 3.69–7.49). Conclusions: Distance to, level of, and region of the nearest trauma centre are critical risk factors for fatal injuries among motorcyclists but not motorists. To reduce the mortality rate of trauma cases among motorcyclists, interventions should focus on improving access to trauma hospitals.
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Rosenbaum K, Grigorian A, Yeates E, Kuza C, Kim D, Inaba K, Dolich M, Nahmias J. A national analysis of pediatric firearm violence and the effects of race and insurance status on risk of mortality. Am J Surg 2021; 222:654-658. [PMID: 33451675 DOI: 10.1016/j.amjsurg.2020.12.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 11/29/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To perform a national analysis of pediatric firearm violence (PFV), hypothesizing that black and uninsured patients would have higher risk of mortality. METHODS The Trauma Quality Improvement Program (2014-2016) was queried for PFV patients ≤16 years-old. Multivariable logistic regression models on all patients and a subset excluding severe brain injuries were performed. RESULTS The PFV mortality rate was 11.2%. 66.5% of PFV patients were black (p < 0.001). Deceased patients were more likely to be uninsured (14.5% vs. 5.3%, p < 0.001). Black race was an associated risk factor for mortality in patients without severe brain injury (OR 5.26, CI 1.00-27.47, p = 0.049) but not for the overall population (OR 1.32, CI 0.68-2.56, p = 0.39). CONCLUSION Nearly two-thirds of PFV patients were black. Contrary to previous studies, black and uninsured pediatric patients did not have an increased risk of mortality overall. However, in a subset of patients without severe brain injury, black race was associated with increased mortality risk. SUMMARY Between 2014 and 2016 the mortality rate for pediatric firearm violence (PFV) in children 16 years and younger was 11.2%. Although two-thirds of PFV patients were black, black race and lack of insurance were not risk factors of mortality for the overall population. Once patients with severe brain injury were excluded, black race and became associated with an increased risk of mortality.
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Affiliation(s)
- Kathryn Rosenbaum
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Areg Grigorian
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Eric Yeates
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Catherine Kuza
- University of Southern California, Department of Anesthesiology, Los Angeles, CA, USA
| | - Dennis Kim
- University of California, Los Angeles-Harbor, Department of Surgery, Torrance, CA, USA
| | - Kenji Inaba
- University of Southern California, Department of Surgery, Los Angeles, CA, USA
| | - Matthew Dolich
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA
| | - Jeffry Nahmias
- University of California, Irvine, Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, Orange, CA, USA.
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Alber DA, Dalton MK, Uribe-Leitz T, Ortega G, Salim A, Haider AH, Jarman MP. A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care. J Surg Res 2021; 257:486-492. [PMID: 32916501 DOI: 10.1016/j.jss.2020.08.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 06/01/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Daniel A Alber
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; The College of Brown University, Providence, Rhode Island
| | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Tarsicio Uribe-Leitz
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Gezzer Ortega
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ali Salim
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.
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Ratliff H, Korst G, Moth J, Jupiter D. Geographical Variation in Traumatic Brain Injury Mortality by Proximity to the Nearest Neurosurgeon. J Surg Res 2020; 259:480-486. [PMID: 33070997 DOI: 10.1016/j.jss.2020.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/07/2020] [Accepted: 09/22/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Trauma mortality disproportionately affects populations farther from potentially lifesaving trauma care, and traumatic brain injury (TBI) is no exception. Previous examinations have examined proximity to trauma centers as an explanation for trauma mortality, but little is known about the relationship between proximity to neurosurgeons specifically in TBI mortality. MATERIALS AND METHODS In this cross-sectional study, county-level TBI mortality rates from 2008 to 2014 were examined in relation to the distance to the nearest neurosurgeon and trauma facility. The locations of practicing neurosurgeons and trauma facilities in the United States were determined by geocoding data from the 2017 Medicare Physician and Other Supplier and Provider of Services files (respectively). The association between TBI mortality and the distance from the population-weighted centroid of the county to a closest neurosurgeon and trauma facility was examined using multivariate negative binomial regression. RESULTS A total of 761 of the 3108 counties (24.5%) in the continental United States were excluded from the analysis because they had 20 or fewer TBI deaths during this time, producing unstable estimates. Excluded counties accounted for 1.67% of the US population. Multivariate analysis revealed a county's mortality increased 10% for every 25 miles from the nearest neurosurgeon (adjusted incident rate ratio: 1.10 [95% confidence interval: 1.08-1.12]; P < 0.001). The distance to the nearest trauma facility was not found to be significantly associated with mortality (adjusted incident rate ratio: 1.01 [95% confidence interval: 0.99-1.03]; P = 0.36). CONCLUSIONS These findings suggest that proximity to neurosurgeons may influence county-level TBI mortality. Further research into this topic with more granular data may help to allocate scarce public health resources.
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Affiliation(s)
- Hunter Ratliff
- School of Medicine, University of Texas Medical Branch, Galveston, Texas.
| | - Genevieve Korst
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - John Moth
- School of Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Daniel Jupiter
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas
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Farley BJ, Shear BM, Lu V, Walworth K, Gray K, Kirsch M, Clements JM. Rural, urban, and teaching hospital differences in hip fracture mortality. J Orthop 2020; 21:453-458. [PMID: 32982100 DOI: 10.1016/j.jor.2020.08.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/29/2020] [Accepted: 08/31/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Hip fractures remain one of the most prevalent and deadly conditions afflicting those 65 years and older. For other health conditions (e.g. myocardial infarction), hospital location is associated with poorer health outcomes. To our knowledge, no study has investigated the relationship between hip fracture morality rate in the United States between urban and rural hospital settings. Methods A retrospective cohort study was conducted to examine differences in in-hospital mortality between groups treated in rural, urban-teaching, and urban-non-teaching hospitals, as well as public and private hospitals. Mortality rates were also compared for variances between surgical treatment, sex, insurance, patient location, race, and income. Discharge data was collected for 256,240 inpatient stays from the 2012 National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Results Odds of mortality were 14.6% greater in rural hospital hip fracture patients compared to Urban/Non-Teaching centers (p < 0.05). Conclusions Results from this study lend support to necessitate further research investigating prospective barriers to care of those in rural settings. This may point to limitations in resources and trained medical and surgical specialists in rural hospitals and need for continued research to mitigate such findings.
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Affiliation(s)
- Brendan J Farley
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Brian M Shear
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Vivian Lu
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Kyla Walworth
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Kevin Gray
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - Matt Kirsch
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
| | - John M Clements
- Central Michigan University, College of Medicine, Mt. Pleasant, MI, USA
- Michigan State University, College of Human Medicine, Division of Public Health, Flint, MI, USA
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The geriatric trauma patient: A neglected individual in a mature trauma system. J Trauma Acute Care Surg 2020; 89:192-198. [PMID: 32118822 DOI: 10.1097/ta.0000000000002646] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Those older than 65 years represent the fastest growing demographic in the United States. As such, their care has been emphasized by trauma entities such as the American College of Surgeons Committee on Trauma. Unfortunately, much of that focus has been of their care once they reach the hospital with little attention on the access of geriatric trauma patients to trauma centers (TCs). We sought to determine the rate of geriatric undertriage (UT) to TCs within a mature trauma system and hypothesized that there would be variation and clustering of the geriatric undertriage rate (UTR) within a mature trauma system because of the admission of geriatric trauma patient to nontrauma centers (NTCs). METHODS From 2003 to 2015, all geriatric (age >65 years) admissions with an Injury Severity Score of greater than 9 from the Pennsylvania Trauma Systems Foundation (PTSF) registry and those meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Undertriage rate was defined as patients not admitted to TCs (n = 27) divided by the total number of patients as from the PHC4 database. The PHC4 contains all inpatient admissions within Pennsylvania (PA), while PTSF reports admissions to PA TCs. The zip code of residence was used to aggregate calculations of UTR as well as other aggregate patient and census demographics, and UTR was categorized into lower, middle box, and upper quartiles. ArcGIS Desktop: Version 10.7, ESRI, Redlands, CA and GeoDa: Version 1.14.0, Open source license were used for geospatial mapping of UT with a spatial empirical Bayesian smoothed UTR, and Stata: Version 16.1, Stata Corp., College Station TX was used for statistical analyses. RESULTS Pennsylvania Trauma Systems Foundation had 58,336 cases, while PHC4 had 111,626 that met the inclusion criteria, resulting in a median (Q1-Q3) smoothed UTR of 50.5% (38.2-60.1%) across PA zip code tabulation areas. Geospatial mapping reveals significant clusters of UT regions with high UTR in some of the rural regions with limited access to a TC. The lowest quartile UTR regions tended to have higher population density relative to the middle or upper quartile UTR regions. At the patient level, the lowest UTR regions had more racial and ethnic diversity, a higher injury severity, and higher rates of treatment at a TC. Undertriage rate regions that were closer to NTCs had a higher odds of being in the upper UTR quartile; 4.48 (2.52-7.99) for NTC with less than 200 beds and 8.53 (4.70-15.47) for NTC with 200 beds or greater compared with zip code tabulation areas with a TC as the closest hospital. CONCLUSION There are significant clusters of geriatric UT within a mature trauma system. Increased emphasis needs to focus prehospital on identifying the severely injured geriatric patient including specific geriatric triage protocols. LEVEL OF EVIDENCE Epidemiological, Level III.
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An analysis of pediatric trauma center undertriage in a mature trauma system. J Trauma Acute Care Surg 2020; 87:800-807. [PMID: 30889142 DOI: 10.1097/ta.0000000000002265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Improved mortality as a result of appropriate triage has been well established in adult trauma and may be generalizable to the pediatric trauma population as well. We sought to determine the overall undertriage rate (UTR) in the pediatric trauma population within Pennsylvania (PA). We hypothesized that a significant portion of pediatric trauma population would be undertriaged. METHODS All pediatric (age younger than 15) admissions meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database and the Pennsylvania Trauma Systems Foundation (PTSF) registry. Undertriage was defined as patients not admitted to PTSF-verified pediatric trauma centers (n = 6). The PHC4 contains inpatient admissions within PA, while PTSF only reports admissions to PA trauma centers. ArcGIS Desktop was used for geospatial mapping of undertriage. RESULTS A total of 37,607 cases in PTSF and 63,954 cases in PHC4 met criteria, suggesting UTR of 45.8% across PA. Geospatial mapping reveals significant clusters of undertriage regions with high UTR in the eastern half of the state compared to low UTR in the western half. High UTR seems to be centered around nonpediatric facilities. The UTR for patients with a probability of death 1% or less was 39.2%. CONCLUSION Undertriage is clustered in eastern PA, with most areas of high undertriage located around existing trauma centers in high-density population areas. This pattern may suggest pediatric undertriage is related to a system issue as opposed to inadequate access. LEVEL OF EVIDENCE Retrospective study, without negative criteria, Level III.
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Leung M, Chow CB, Ip PKP, Yip SFP. Geographical accessibility of community social services and incidence of self-harm. Spat Spatiotemporal Epidemiol 2020; 33:100334. [PMID: 32370942 DOI: 10.1016/j.sste.2020.100334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 11/17/2019] [Accepted: 12/27/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The study aimed to explore the association between area-based coverage of community services and the incidence of self-harm, which will provide an evaluation framework for the support of self-harm. METHODS Enhanced two-Step floating catchment area method was used to estimate the centersto- population ratio and geographical accessibility adjusted by a distance-decay function. Spearman's rank coefficient was used to examine the association between the self-harm rate and adjusted accessibility index. RESULTS There was a significant negative correlation between the accessibility index and selfharm rate in youth (rho = -0.87, P < 0.01) and older adults (rho = -0.87, P < 0.01). The survival curves showed no relationship between self-harm repetition and service accessibility in youth or older adults. CONCLUSIONS The uneven spatial accessibility of community social service centers and the independence between spatial accessibility and self-harm highlights the need to explore personal barriers to community service utilization.
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Affiliation(s)
- Ming Leung
- Princess Margaret Hospital, A&E Office, 1/F, Block H, Lai King Hill Road, Kwai Chung, NT, Hong Kong; Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong.
| | - Chun Bong Chow
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong; Hospital Authority Infectious Disease Centre and Paediatrics & Adolescent Medicine, Princess Margaret Hospital, Hong Kong; University of Hong Kong - ShenZhen Hospital, ShenZhen.
| | - Pak-Keung Patrick Ip
- Department of Paediatrics and Adolescent Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong.
| | - Siu-Fai Paul Yip
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong; Faculty of Social Sciences, Director of HK Jockey Club Center of Suicide Research and Prevention, Hong Kong.
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Stellflug SM, Lowe NK. Development of the Pediatric Advanced Life Support Skills Self-Efficacy Inventory to Assess Rural Healthcare Providers. J Nurs Meas 2020; 28:JNM-D-18-00076. [PMID: 32179726 DOI: 10.1891/jnm-d-18-00076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Rural healthcare provider's willingness to implement pediatric resuscitation may be impeded by comfort level. The purpose of this study was to evaluate the psychometric properties of the Pediatric Advanced Life Support Skill Self-Efficacy Inventory (PALS-SSEI). METHODS A 19-item inventory was created based on PALS skills. The PALS-SSEI was completed by 94 participants in a study to test the effects of simulation training on PALS knowledge and skill. RESULTS Six clinical content experts rated the content validity of the PALS-SSEI as high. Item and factor analysis supported the tool's construct validity. A Cronbach's alpha coefficient of 0.88 supported the internal consistency of the tool. CONCLUSIONS The PALS-SSEI demonstrated good initial psychometric properties. The tool can be used to assess self-efficacy for PALS skills among healthcare providers.
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Russell C, Neufeld M, Sabioni P, Varatharajan T, Ali F, Miles S, Henderson J, Fischer B, Rehm J. Assessing service and treatment needs and barriers of youth who use illicit and non-medical prescription drugs in Northern Ontario, Canada. PLoS One 2019; 14:e0225548. [PMID: 31805082 PMCID: PMC6894813 DOI: 10.1371/journal.pone.0225548] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/06/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Illicit drug use rates are high among Canadian youth, and are particularly pronounced in Northern Ontario. The availability and accessibility of effective substance use-related treatments and services are required to address this problem, especially among rural and remote Northern communities. In order to assess specific service and treatment needs, as well as barriers and deterrents to accessing and utilizing services and treatments for youth who use illicit drugs in Northern Ontario, we conducted the present study. METHODS This study utilized a mixed-methods design and incorporated a community-based participatory research approach. Questionnaires were administered in conjunction with audio-recorded semi-structured interviews and/or focus groups with youth (aged 14-25) who live in Northern Ontario and use illicit drugs. Interviews with 'key informants' who work with the youth in each community were also conducted. Between August and December 2017, the research team traveled to Northern Ontario communities and carried out data collection procedures. RESULTS A total of 102 youth and 35 key informants from eleven different Northern Ontario communities were interviewed. The most commonly used drugs were prescription opioids, cocaine and crack-cocaine. Most participants experienced problems related to their drug use, and reported 'fair' mental and physical health status. Qualitative analyses highlighted an overall lack of services; barriers to accessing treatment and services included lack of motivation, stigmatization, long wait-lists and transportation/mobility issues. Articulated needs revolved around the necessity of harm reduction-based services, low-threshold programs, specialized programming, and peer-based counselling. CONCLUSIONS Although each community varied in terms of drug use behaviors and available services, an overall need for youth-specific, low-threshold services was identified. Information gathered from this study can be used to help inform rural and remote communities towards improving treatment and service system performance and provision.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Maria Neufeld
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Dresden, Germany
| | - Pamela Sabioni
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Translational Addiction Research Lab, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Thepikaa Varatharajan
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Sarah Miles
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Joanna Henderson
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- The Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Benedikt Fischer
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Psychiatry, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Dresden, Germany
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science (IMS), University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
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Probst J, Zahnd W, Breneman C. Declines In Pediatric Mortality Fall Short For Rural US Children. Health Aff (Millwood) 2019; 38:2069-2076. [DOI: 10.1377/hlthaff.2019.00892] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Janice Probst
- Janice Probst is a distinguished professor emerita in the Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, in Columbia
| | - Whitney Zahnd
- Whitney Zahnd is a research assistant professor in the Rural and Minority Health Research Center of the University of South Carolina
| | - Charity Breneman
- Charity Breneman was a postdoctoral fellow in the Rural and Minority Health Research Center of the University of South Carolina at the time the study was performed
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Dodson BK, Braswell M, David AP, Young JS, Riccio LM, Kim Y, Calland JF. Adult and elderly population access to trauma centers: an ecological analysis evaluating the relationship between injury-related mortality and geographic proximity in the United States in 2010. J Public Health (Oxf) 2019; 40:848-857. [PMID: 29190373 PMCID: PMC6306086 DOI: 10.1093/pubmed/fdx156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
Abstract
Background Ongoing development and expansion of trauma centers in the United States necessitates empirical analysis of the effect of investment in such resources on population-level health outcomes. Methods Multiple linear regressions were performed to predict state-level trauma-related mortality among adults and the elderly across 50 US states in 2010. The number of trauma centers per capita in each state and the percentage of each state’s population living within 45-min of a trauma center served as the key independent variables and injury-related mortality served as the dependent variable. All analyses were stratified by age (adult versus elderly; elderly ≥ 65 years old) and were performed in SPSS. Results The proportion of a population with geographic proximity to a trauma center demonstrates a consistent inverse linear relationship to injury-related mortality. The relationship reliably retains its significance in models including demographic covariates. Interestingly, access to Levels I and II trauma centers demonstrates a stronger correlation with mortality than was observed with Level III centers. Conclusion Trauma center access is associated with reduced trauma-related mortality among both adults and the elderly as measured by state reported mortality rates. Ongoing efforts to designate and verify new trauma centers, particularly in poorly-served ‘trauma deserts’, could lead to lower mortality for large populations.
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Affiliation(s)
- B K Dodson
- Eastern Virginia Medical School, School of Medicine, Norfolk, VA, USA
| | - M Braswell
- Institute for Advanced Studies in Culture, Charlottesville, VA, USA
| | - A P David
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - J S Young
- School of Medicine, Department of Surgery- Division of Acute Care Surgery and Outcomes Research, University of Virginia, Charlottesville, VA, USA
| | - L M Riccio
- Winchester Medical Center, Acute Care Emergency Surgery Services, Winchester, VA, USA
| | - Y Kim
- School of Medicine, Department of Surgery- Division of Acute Care Surgery and Outcomes Research, University of Virginia, Charlottesville, VA, USA
| | - J F Calland
- School of Medicine, Department of Surgery- Division of Acute Care Surgery and Outcomes Research, University of Virginia, Charlottesville, VA, USA
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Jarman MP, Curriero FC, Haut ER, Pollack Porter K, Castillo RC. Associations of Distance to Trauma Care, Community Income, and Neighborhood Median Age With Rates of Injury Mortality. JAMA Surg 2019; 153:535-543. [PMID: 29417146 DOI: 10.1001/jamasurg.2017.6133] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Importance Rural, low-income, and historically underrepresented minority communities face substantial barriers to trauma care and experience high injury incidence and mortality rates. Characteristics of injury incident locations may contribute to poor injury outcomes. Objective To examine the association of injury scene characteristics with injury mortality. Design, Setting, and Participants In this cross-sectional study, data from trauma center and emergency medical services provided by emergency medical services companies and designated trauma centers in the state of Maryland from January 1, 2015, to December 31, 2015, were geocoded by injury incident locations and linked with injury scene characteristics. Participants included adults who experienced traumatic injury in Maryland and were transported to a designated trauma center or died while in emergency medical services care at the incident scene or in transit. Exposures The primary exposures of interest were geographic characteristics of injury incident locations, including distance to the nearest trauma center, designation level and ownership status of the nearest trauma center, and land use, as well as community-level characteristics such as median age and per capita income. Main Outcomes and Measures Odds of death were estimated with multilevel logistic regression, controlling for individual demographic measures and measures of injury and health. Results Of the 16 082 patients included in this study, 8716 (52.4%) were white, and 5838 (36.3%) were African American. Most patients were male (10 582; 65.8%) and younger than 65 years (12 383; 77.0%). Odds of death increased by 8.0% for every 5-mile increase in distance to the nearest trauma center (OR, 1.08; 95% CI, 1.01-1.15; P = .03). Compared with privately owned level 1 or 2 centers, odds of death increased by 49.9% when the nearest trauma center was level 3 (OR, 1.50; 95% CI, 1.06-2.11; P = .02), and by 80.7% when the nearest trauma center was publicly owned (OR, 1.81; 95% CI, 1.39-2.34; P < .001). At the zip code tabulation area level, odds of death increased by 16.0% for every 5-year increase in median age (OR, 1.16; 95% CI, 1.03-1.30; P = .02), and decreased by 26.6% when the per capita income was greater than $25 000 (OR, 0.73; 95% CI, 0.54-0.99; P = .05). Conclusions and Relevance Injury scene characteristics are associated with injury mortality. Odds of death are highest for patients injured in communities with higher median age or lower per capita income and at locations farthest from level 1 or 2 trauma centers.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Frank C Curriero
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Keshia Pollack Porter
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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Lilley R, de Graaf B, Kool B, Davie G, Reid P, Dicker B, Civil I, Ameratunga S, Branas C. Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand: a cross-sectional study. BMJ Open 2019; 9:e026026. [PMID: 31350239 PMCID: PMC6661642 DOI: 10.1136/bmjopen-2018-026026] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 06/20/2019] [Accepted: 07/04/2019] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Rapid access to advanced emergency medical and trauma care has been shown to significantly reduce mortality and disability. This study aims to systematically examine geographical access to prehospital care provided by emergency medical services (EMS) and advanced-level hospital care, for the smallest geographical units used in New Zealand and explores national disparities in geographical access to these services. DESIGN Observational study involving geospatial analysis estimating population access to EMS and advanced-level hospital care. SETTING Population access to advanced-level hospital care via road and air EMS across New Zealand. PARTICIPANTS New Zealand population usually resident within geographical census meshblocks. PRIMARY AND SECONDARY OUTCOME MEASURES The proportion of the resident population with calculated EMS access to advanced-level hospital care within 60 min was examined by age, sex, ethnicity, level of deprivation and population density to identify disparities in geographical access. RESULTS An estimated 16% of the New Zealand population does not have timely EMS access to advanced-level hospital care via road or air. The 700 000 New Zealanders without timely access lived mostly in areas of low-moderate population density. Indigenous Māori, New Zealand European and older New Zealanders were less likely to have timely access. CONCLUSIONS These findings suggest that in New Zealand, geographically marginalised groups which tend to be rural and remote communities with disproportionately more indigenous Māori and older adults have poorer EMS access to advanced-level hospitals. Addressing these inequities in rapid access to medical care may lead to improvements in survival that have been documented for people who experience medical or surgical emergencies.
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Affiliation(s)
- Rebbecca Lilley
- Department of Preventive and Social Medicine, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Brandon de Graaf
- Department of Preventive and Social Medicine, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Bridget Kool
- Section of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Gabrielle Davie
- Department of Preventive and Social Medicine, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, The University of Auckland, Auckland, New Zealand
| | - Bridget Dicker
- Department of Paramedicine, Auckland University of Technology, Auckland, New Zealand
- St Johns, Auckland, New Zealand
| | - Ian Civil
- Department of Surgery, The University of Auckland, Auckland, New Zealand
- Trauma and Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Shanthi Ameratunga
- Section of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Charles Branas
- Department of Epidemiology, Columbia University, New York city, New York, USA
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Shen YC, Chen G, Hsia RY. Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017. JAMA Netw Open 2019; 2:e197855. [PMID: 31348507 PMCID: PMC6661722 DOI: 10.1001/jamanetworkopen.2019.7855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. OBJECTIVE To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. MAIN OUTCOMES AND MEASURES Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. RESULTS The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). CONCLUSIONS AND RELEVANCE This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
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Abstract
BACKGROUND Geographic distribution of trauma system resources including trauma centers and helicopter bases correlate with outcomes. However, ground emergency medical services (EMS) coverage is dynamic and more difficult to quantify. Our objective was to evaluate measures that describe ground EMS coverage in trauma systems and correlate with outcome. METHODS Trauma system resources in Pennsylvania were mapped. Primary outcome was county age-adjusted transportation injury fatality rate. Measures of county EMS coverage included average distance to the nearest trauma center, number of basic life support and advanced life support units/100 square miles, distance differential between the nearest trauma center and nearest helicopter base, and nearest neighbor ratio (dispersed or clustered geographic pattern of agencies). Spatial-lag regression determined association between fatality rates and these measures, adjusted for prehospital time, Injury Severity Score, and socioeconomic factors. Relative importance of these measures was determined by assessing the loss in R value from the full model by removing each measure. A Geographic Emergency Medical Services Index (GEMSI) was created based on these measures for each county. RESULTS Median fatality rate was higher in counties with fewer trauma system resources. Decreasing distance to nearest trauma center, increasing advanced life support units/100 square miles, greater distance reduction due to helicopter bases, and dispersed geographic pattern of county EMS agencies were associated with lower fatality rates. The GEMSI ranged from -6.6 to 16.4 and accounted for 49% of variation in fatality rates. Adding an EMS agency to a single county that produced a dispersed pattern of EMS coverage reduced predicted fatality rate by 6%, while moving a helicopter base into the same county reduced predicted fatality rate by 22%. CONCLUSION The GEMSI uses several measures of ground EMS coverage and correlates with outcome. This tool may be used to describe and compare ground EMS coverage across trauma system geographies, as well as help optimize the geographic distribution of trauma system resources. LEVEL OF EVIDENCE Ecological study, level IV.
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Mapping areas with concentrated risk of trauma mortality: A first step toward mitigating geographic and socioeconomic disparities in trauma. J Trauma Acute Care Surg 2019. [PMID: 29538227 DOI: 10.1097/ta.0000000000001883] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many rural, low-income, and historically underrepresented minority communities lack access to trauma center services, including surgical care and injury prevention efforts. Along with features of the built and social environment at injury incident locations, geographic barriers to trauma center services may contribute to injury disparities. This study sought to classify injury event locations based on features of the built and social environment at the injury scene, and to examine patterns in individual patient demographics, injury characteristics, and mortality by location class. METHODS Data from the 2015 Maryland Adult Trauma Registry and associated prehospital records (n = 16,082) were used in a latent class analysis of characteristics of injury event locations, including trauma center distance, trauma center characteristics, land use, community-level per capita income, and community-level median age. Mortality effects of location class were estimated with logistic regression, with and without adjustment for individual patient demographics and injury characteristics. RESULTS Eight classes were identified: rural, exurban, young suburban, aging suburban, inner suburban, urban fringe, high-income urban core, and low-income urban core. Patient characteristics and odds of death varied across classes. Compared with inner suburban locations, adjusted odds of death were highest at rural (odds ratio [OR], 1.98; 95% confidence interval [CI], 1.36-2.88), young suburb (OR, 1.57; 95% CI, 1.14-2.17), aging suburb (OR, 1.36; 95% CI, 1.04-1.78), and low-income urban core (OR, 1.38; 95% CI, 1.04-1.83) locations. CONCLUSION Injury incident locations can be categorized into distinguishable classes with varying mortality risk. Identification of location classes may be useful for targeted primary prevention and treatment interventions, both by identifying geographic areas with the highest risk of injury mortality and by identifying patterns of individual risk within location classes. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.
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Undertriage in trauma: Does an organized trauma network capture the major trauma victim? A statewide analysis. J Trauma Acute Care Surg 2019; 84:497-504. [PMID: 29283966 DOI: 10.1097/ta.0000000000001781] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-TCs (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. METHODS All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9, 800-959; Injury Severity Score [ISS], > 9 or > 15) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on ISSs throughout the state. RESULTS For ISS > 9, 173,022 cases were identified from 2003 to 2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS > 15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to TCs comprise the highest proportion of undertriaged trauma patients. CONCLUSION Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and health care system imperatives. LEVEL OF EVIDENCE Epidemiological study, level III; Therapeutic, level IV.
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Anderson ES, Greenwood-Ericksen M, Wang NE, Dworkis DA. Closing the gap: Improving access to trauma care in New Mexico (2007-2017). Am J Emerg Med 2019; 37:2028-2034. [PMID: 30824273 DOI: 10.1016/j.ajem.2019.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Trauma is a major cause of death and disability in the United States, and significant disparities exist in access to care, especially in non-urban settings. From 2007 to 2017 New Mexico expanded its trauma system by focusing on building capacity at the hospital level. METHODS We conducted a geospatial analysis at the census block level of access to a trauma center in New Mexico within 1 h by ground or air transportation for the years 2007 and 2017. We then examined the characteristics of the population with access to care. A multiple logistic regression model assessed for remaining disparities in access to trauma centers in 2017. RESULTS The proportion of the population in New Mexico with access to a trauma center within 1 h increased from 73.8% in 2007 to 94.8% in 2017. The largest increases in access to trauma care within 1 h were found among American Indian/Alaska Native populations (AI/AN) (35.2%) and people living in suburban areas (62.9%). In 2017, the most rural communities (aOR 58.0), communities on an AI/AN reservation (aOR 25.6), communities with a high proportion of Hispanic/Latino persons (aOR 8.4), and a high proportion of elderly persons (aOR 3.2) were more likely to lack access to a trauma center within 1 h. CONCLUSION The New Mexico trauma system expansion significantly increased access to trauma care within 1 h for most of New Mexico, but some notable disparities remain. Barriers persist for very rural parts of the state and for its sizable American Indian community.
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Affiliation(s)
- Erik S Anderson
- Alameda Health System - Highland Hospital, Department of Emergency Medicine, United States of America.
| | | | - Nancy Ewen Wang
- Stanford University, Department of Emergency Medicine, United States of America
| | - Daniel A Dworkis
- University of Southern California, Los Angeles County Hospital, Department of Emergency Medicine, United States of America
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Differences in hospital outcomes following traumatic injury for patients experiencing immediate transfer to a level I trauma facility versus resuscitation at a critical access hospital (CAH). Am J Surg 2018; 217:643-647. [PMID: 30473224 DOI: 10.1016/j.amjsurg.2018.10.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/02/2018] [Accepted: 10/16/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Critical access hospitals (CAH) serve a key role in providing medical care to rural patients. The purpose of this study was to assess effectiveness of CAHs in initial care of trauma patients. METHODS A 5-year retrospective review was conducted of all adult trauma patients who were transported directly to a level I trauma facility or were transported to a CAH then transferred to a level I trauma facility after initial resuscitation. RESULTS Of 1478 patients studied, 1084 were transferred from a CAH with 394 transported directly to the level I facility. Patients transported directly to the level I hospital were younger and more severely injured. After controlling for injury severity score, age, GCS, and shock, the odds of mortality did not differ between CAH transfer patients and patients transported directly to a level I facility (OR 0.70, P = 0.20). Transfer from CAH was associated with decreased ICU and hospital days, but not associated with increased ventilator days. CONCLUSION This study demonstrates that use of a CAH for initial trauma care in rural areas is effective.
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