Association between race and age in survival after trauma

Impact of trauma center designation level on survival in trauma during pregnancy: Observational study across US trauma centers

BACKGROUND

Trauma is the leading non obstetric cause of death in pregnant women. Pregnancy above 20 weeks falls under special considerations group in the Center for Disease Control and Prevention (CDC) field triage criteria. Trauma centers' designation level in the United States is based on available resources for care.

AIM

In this study, we examine the association between trauma center designation level and survival of pregnant patients presenting to the Emergency Department (ED) after a traumatic injury.

METHODS

This retrospective observational study included all pregnant women of reproductive age (16 years and above) who experienced any form of trauma and were registered in the National Trauma Data Bank 2020 dataset. Descriptive analysis was carried out. All variables were stratified by the trauma designation levels. Firth logistic regression was conducted to examine the association between trauma designation levels and survival to hospital discharge after controlling for all potential confounding factors.

RESULTS

A total of 1612 patients were included in this study. The average age was 27.2 (±6.9 years). Most patients were taken to level I (58.3 %) and II (33.9 %) centers. Overall survival of patients after pregnancy trauma was 97.2 %. After adjusting for confounders, patients taken to level II and III trauma centers had similar survival to hospital discharge compared with those taken to level I centers [OR = 2.561, 95 % CI: 0.644-10.182 and OR = 4.886, 95 % CI: 0.584-40.862 respectively].

CONCLUSION

In this study, trauma center designation level did not impact survival of pregnant patients sustaining injuries. This provides further evidence that the CDC's field triage guidelines, including their specific considerations for pregnant patients are accurate and that the current practice seems to be effective.

Predictors of healthy days at home: Benchmarking long-term outcomes in geriatric trauma

BACKGROUND

Quality benchmarking has recently evolved from a historical focus on short-term morbidity and mortality as the key metrics to assessing long-term outcomes. Long-term quality metrics have been shown to provide a more complete assessment of geriatric trauma care. Among these metrics, patients' average number of healthy days at home (HDAH) proports to be a useful administrative claims-based marker of patient functional status. Our goal was to determine the predictors of HDAH among injured older adults.

METHODS

Medicare inpatient claims (2014-2015) were used to identify all geriatric trauma patients. Patients' number of HDAH was measured from the date of discharge and calculated as the total sum of patients' time during that period less any time spent in the hospital or emergency department, step-down/rehabilitation/nursing care, home health, or after death within a 365-period after index admission. Controlling for demographic, injury severity, and hospital-level characteristics, multivariable regression analyses were performed to identify the factors associated with increased HDAH.

RESULTS

We included 772,109 geriatric trauma patients. The mean age was 82.15 years (SD, 8.49 years), 68.3% were female, and 91.6% were White. The median HDAH was 351 days (interquartile range, 351-355 days). After adjusted analysis, age, Black race, Charlson Comorbidity Index (CCI), and care at a level 3/nontrauma center were associated with fewer HDAH within 365 days after discharge.

CONCLUSION

This study suggests that higher level trauma centers provide more HDAH after index admission for injured older adults. Future studies should focus on correlating HDAH with more granular but less readily accessible quality of life metrics.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; III.

Age-related disparities in older adults in trauma

As the population of older adults (≥65 years of age) continues to grow, the incidence of traumatic injuries in this demographic is also increasing nationwide. It has been well established that older adults experience worse outcomes, that is, an increased morbidity and mortality, when compared to younger adults. Moreover, survivors often experience accelerated cognitive and functional decline, loss of independence, and recurring injuries and hospitalizations. This manuscript examines the multifaceted challenges and disparities faced by older adults in trauma care. Factors such as age-related physiological changes, racial disparities, access to health care, and structural ageism that contribute to poor outcomes in geriatric patients who experience trauma. This is exacerbated by the sparsity of geriatric-specific practice management guidelines, thier poor implementation, and the critical under-representation of older adults in trauma research. However, significant efforts are being made to improve the care of older adults, including geriatric patients who experience trauma, through age-friendly systems, and initiatives aimed at promoting inclusive and effective care. These endeavors hold promise for a future where trauma care for older adults is comprehensive and equitable.

Analysis of the diversity pipeline for the orthopedic trauma surgeon workforce in the United States

INTRODUCTION

There is a lack of research on the state of racial, ethnic, and gender diversity in the emerging orthopedic trauma workforce. The purpose of this study was to analyze the training pathway for diverse candidates in orthopedic trauma as it relates to race, ethnicity, and sex.

METHODS

Self-reported demographic data were compared among allopathic medical students, orthopedic surgery residents, orthopedic trauma fellows, and the general population in the United States (2013-2022). Race categories consisted of White, Asian, Black, and Native American/Alaskan Native (NA/AN), and Native Hawaiian/Pacific Islander (NH/PI). Ethnicity categories were Hispanic/Latino or non-Hispanic/Latino. Sex categories were male and female. Representation was calculated at each stage of accredited training. Participation-to-prevalence ratios (PPRs) quantified the equitable representation of demographic groups in the emerging orthopedic trauma workforce relative to the US population. PPR thresholds were used to classify representation as overrepresented (PPR > 1.2), equitable (PPR = 0.8-1.2), and underrepresented (PPR < 0.8).

RESULTS

Relative to medical school and orthopedic surgery residency, fewer female (48.5 % vs 16.7 % vs 18.7 %, P < 0.001), Hispanic (6.1 % vs 4.5 % vs 2.6 %, P < 0.001), Black (6.9 % vs 5.0 % vs 3.1 %, P < 0.001), and Asian (24.0 % vs 14.3 % vs 12.2 %, P < 0.001) trainees existed in orthopedic trauma fellowship training. In contrast, more male (51.5 % vs 83.3 % vs 81.3 %, P < 0.001) and White (62.8 % vs 79.1 % vs 84.0 %, P < 0.001) trainees existed in orthopedic trauma fellowship relative to earlier training stages. There were zero NA/AN or NH/PI trainees in orthopedic trauma (PPR = 0). Relative to the US population, Hispanic (PPR = 0.14), Black (PPR = 0.25), and female (PPR = 0.37) trainees were underrepresented in orthopedic trauma. In contrast, Asian (PPR = 2.04), male (PPR = 1.64), and White (PPR = 1.36) trainees were overrepresented in orthopedic trauma.

CONCLUSION

Women, racial, and ethnic minorities are underrepresented in the emerging orthopedic trauma workforce relative to the US population, and earlier stages of training. Targeted recruitment and guided mentorship of these groups may lead to greater interest, engagement, and diversity in orthopedic trauma.

Area deprivation index and social vulnerability index in Milwaukee County: Impact on hospital outcomes after traumatic injuries

BACKGROUND

Predisposing factors for traumatic injuries are complex and variable. Neighborhood environments may influence injury mechanism or outcomes. The Social Vulnerability Index (SVI) identifies areas at risk for emergencies; Area Deprivation Index (ADI) measures socioeconomic disadvantage. The objective was to assess the impact of SVI or ADI on hospital length of stay (LOS) and mortality for injured patients to determine whether SVI or ADI indicated areas where injury prevention may be most impactful.

METHODS

Adult patients who resided in Milwaukee County and were treated for injuries from 2015 to 2022 at a level I trauma center were included. Patients' addresses were geocoded and merged with 2020 state-level SVI and ADI measures. SVI ranks census tracts 0-100 from least to most vulnerable. ADI ranks census block groups 1-10 from least to most disadvantaged. ADI and SVI rankings were converted to deciles. Statistical analyses included descriptive statistics, chi-square tests, and regression models for LOS and in-hospital mortality, adjusted for either SVI or ADI within separate models, age, sex, race or ethnicity, mechanism of injury (MOI), injury severity score (ISS).

RESULTS

14,542 patients were included; 63 % were male. Mean total hospital LOS was 6.4 ± 9.8 days, and in-hospital mortalities occurred in 5.2 % of patients. Based on SVI and ADI, 5,280 (36 %) patients resided in high vulnerability areas and 5,576 (39 %) lived in highly disadvantaged areas, respectively. After adjusting for patient factors, SVI deciles #6, 9, 10 were associated with increased hospital LOS, and SVI decile #5 was associated with in-hospital mortality (OR = 2.22, 95 %CI:1.06-4.63; p = 0.034). When adjusted for ADI, the 7th-10th deciles were associated with increased hospital LOS. Greater age and ISS were associated with increased hospital LOS and mortality when adjusted for SVI and ADI.

CONCLUSIONS

SVI and ADI identified a similar proportion of patients in high vulnerability or disadvantaged areas. Higher SVI and ADI deciles were associated with longer hospital LOS, and only the 5th SVI decile was associated with in-hospital mortality. Highly disadvantaged or vulnerable areas may have a longer LOS, but SVI and ADI have limited influence on trauma mortality. Continued research on neighborhood and community factors and trauma outcomes is needed.

Impact of neoadjuvant chemotherapy on short-term outcomes after simple and complex minimally invasive minor hepatectomy for colorectal liver metastases: A propensity-score matched and coarsened exact matched study

BACKGROUND

In the last three decades, minimally invasive liver resection has been replacing conventional open approach in liver surgery. More recently, developments in neoadjuvant chemotherapy have led to increased multidisciplinary management of colorectal liver metastases with both medical and surgical treatment modalities. However, the impact of neoadjuvant chemotherapy on the surgical outcomes of minimally invasive liver resections remains poorly understood.

METHODS

A multicenter, international, database of 4998 minimally invasive minor hepatectomy for colorectal liver metastases was used to compare surgical outcomes in patients who received neoadjuvant chemotherapy with surgery alone. To correct for baseline imbalance, propensity score matching, coarsened exact matching and inverse probability treatment weighting were performed.

RESULTS

2546 patients met the inclusion criteria. After propensity score matching there were 759 patients in both groups and 383 patients in both groups after coarsened exact matching. Baseline characteristics were equal after both matching strategies. Neoadjuvant chemotherapy was not associated with statistically significant worse surgical outcomes of minimally invasive minor hepatectomy.

CONCLUSION

Neoadjuvant chemotherapy had no statistically significant impact on short-term surgical outcomes after simple and complex minimally invasive minor hepatectomy for colorectal liver metastases.

Societal Burden of Trauma and Disparities in Trauma Care

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.

The role of race and insurance in trauma patients' mortality: A cross-sectional analysis based on a nationwide sample

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.

Is ethnicity a risk factor for mortality in major trauma? A single-centred cohort study

INTRODUCTION

Many studies have found varying health outcomes in patients from different minority ethnic groups. There has been limited research into the outcomes in major trauma dependent on ethnicity. The aim was to analyse whether ethnicity was an independent risk factor for 30-day mortality in patients presenting to a major trauma centre when adjusting for confounders.

METHODS

This was a retrospective review of all patients presenting to a single major trauma centre from 2010 to 2020. Data were collected on patient demographics and variables including mechanism and injury severity score. Logistic regression was used to determine significant predictors of mortality.

RESULTS

There were 10,668 data sets with ethnicity data; of these 9,098 were of White ethnicity, 1,143 were Asian and 427 were classified as Black. The 30-day mortality rate was 7.76% for White ethnicities, 6.91% for Asian ethnicity and 5.15% for people of Black ethnicity. On multivariate logistic regression, ethnicity (p = 0.076) was not associated with 30-day mortality. Age, Injury Severity Score (ISS), Probability of Survival (PS) score, shock and Glasgow Coma Scale (GCS; p < 0.001) were associated with 30-day mortality. White ethnicity had an odds ratio (OR) of mortality of 1.16 (95% confidence interval [CI] 0.658-2.040) (p = 0.609) compared with Black ethnicity and an OR of 0.74 (95% CI 0.546-1.001) (p = 0.050) compared with Asian patients. Black patients had an OR of mortality of 0.65 (95% CI 0.351-1.193) (p = 0.164) compared with the Asian population.

CONCLUSION

Ethnicity is not a significant risk factor for 30-day mortality in trauma patients.

Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality

Importance

Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used.

Objective

To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors.

Design, Setting, and Participants

This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022.

Exposures

Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI.

Main Outcomes and Measures

Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression.

Results

A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05).

Conclusions and Relevance

The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.

Development of a Machine Learning-Based Prescriptive Tool to Address Racial Disparities in Access to Care After Penetrating Trauma

Importance

The use of artificial intelligence (AI) in clinical medicine risks perpetuating existing bias in care, such as disparities in access to postinjury rehabilitation services.

Objective

To leverage a novel, interpretable AI-based technology to uncover racial disparities in access to postinjury rehabilitation care and create an AI-based prescriptive tool to address these disparities.

Design, Setting, and Participants

This cohort study used data from the 2010-2016 American College of Surgeons Trauma Quality Improvement Program database for Black and White patients with a penetrating mechanism of injury. An interpretable AI methodology called optimal classification trees (OCTs) was applied in an 80:20 derivation/validation split to predict discharge disposition (home vs postacute care [PAC]). The interpretable nature of OCTs allowed for examination of the AI logic to identify racial disparities. A prescriptive mixed-integer optimization model using age, injury, and gender data was allowed to "fairness-flip" the recommended discharge destination for a subset of patients while minimizing the ratio of imbalance between Black and White patients. Three OCTs were developed to predict discharge disposition: the first 2 trees used unadjusted data (one without and one with the race variable), and the third tree used fairness-adjusted data.

Main Outcomes and Measures

Disparities and the discriminative performance (C statistic) were compared among fairness-adjusted and unadjusted OCTs.

Results

A total of 52 468 patients were included; the median (IQR) age was 29 (22-40) years, 46 189 patients (88.0%) were male, 31 470 (60.0%) were Black, and 20 998 (40.0%) were White. A total of 3800 Black patients (12.1%) were discharged to PAC, compared with 4504 White patients (21.5%; P < .001). Examining the AI logic uncovered significant disparities in PAC discharge destination access, with race playing the second most important role. The prescriptive fairness adjustment recommended flipping the discharge destination of 4.5% of the patients, with the performance of the adjusted model increasing from a C statistic of 0.79 to 0.87. After fairness adjustment, disparities disappeared, and a similar percentage of Black and White patients (15.8% vs 15.8%; P = .87) had a recommended discharge to PAC.

Conclusions and Relevance

In this study, we developed an accurate, machine learning-based, fairness-adjusted model that can identify barriers to discharge to postacute care. Instead of accidentally encoding bias, interpretable AI methodologies are powerful tools to diagnose and remedy system-related bias in care, such as disparities in access to postinjury rehabilitation care.

Unmet Social Health Needs as a Driver of Inequitable Outcomes After Surgery: A Cross-sectional Analysis of the National Health Interview Survey

OBJECTIVE

This study aims to identify opportunities to improve surgical equity by evaluating unmet social health needs by race, ethnicity, and insurance type.

BACKGROUND

Although inequities in surgical care and outcomes based on race, ethnicity, and insurance have been well documented for decades, underlying drivers remain poorly understood.

METHODS

We used the 2008-2018 National Health Interview Survey to identify adults age 18 years and older who reported surgery in the past year. Outcomes included poor health status (self-reported), socioeconomic status (income, education, employment), and unmet social health needs (food, housing, transportation). We used logistic regression models to progressively adjust for the impact of patient demographics, socioeconomic status, and unmet social health needs on health status.

RESULTS

Among a weighted sample of 14,471,501 surgical patients, 30% reported at least 1 unmet social health need. Compared with non-Hispanic White patients, non-Hispanic Black, and Hispanic patients reported higher rates of unmet social health needs. Compared with private insurance, those with Medicaid or no insurance reported higher rates of unmet social health needs. In fully adjusted models, poor health status was independently associated with unmet social health needs: food insecurity [adjusted odds ratio (aOR)=2.14; 95% confidence interval (CI): 1.89-2.41], housing instability (aOR=1.69; 95% CI: 1.51-1.89), delayed care due to lack of transportation (aOR=2.58; 95% CI: 2.02-3.31).

CONCLUSIONS

Unmet social health needs vary significantly by race, ethnicity, and insurance, and are independently associated with poor health among surgical populations. As providers and policymakers prioritize improving surgical equity, unmet social health needs are potential modifiable targets.

The unexpected paradox of geriatric traumatic brain injury outcomes: Uncovering racial and ethnic disparities

BACKGROUND

Healthcare disparities have always challenged surgical care in the US. We aimed to assess the influence of disparities on cerebral monitor placement and outcomes of geriatric TBI patients.

METHODS

Analysis of 2017-2019 ACS-TQIP. Included severe TBI patients ≥65 years. Patients who died within 24 h were excluded. Outcomes included mortality, cerebral monitors use, complications, and discharge disposition.

RESULTS

We included 208,495 patients (White = 175,941; Black = 12,194) (Hispanic = 195,769; Non-Hispanic = 12,258). On multivariable regression, White race was associated with higher mortality (aOR = 1.26; p < 0.001) and SNF/rehab discharge (aOR = 1.11; p < 0.001) and less likely to be discharged home (aOR = 0.90; p < 0.001) or to undergo cerebral monitoring (aOR = 0.77; p < 0.001) compared to Black. Non-Hispanics had higher mortality (aOR = 1.15; p = 0.013), complications (aOR = 1.26; p < 0.001), and SNF/Rehab discharge (aOR = 1.43; p < 0.001) and less likely to be discharged home (aOR = 0.69; p < 0.001) or to undergo cerebral monitoring (aOR = 0.84; p = 0.018) compared to Hispanics. Uninsured Hispanics had the lowest odds of SNF/rehab discharge (aOR = 0.18; p < 0.001).

CONCLUSIONS

This study highlights the significant racial and ethnic disparities in the outcomes of geriatric TBI patients. Further studies are needed to address the reason behind these disparities and identify potentially modifiable risk factors in the geriatric trauma population.

Factors associated with survival in adult trauma patients undergoing angiography with and without embolization across trauma centers in the United States

INTRODUCTION

Interventional angiography is increasingly utilized in trauma management for various injuries. Despite published guidelines by the Eastern Association for the Surgery of Trauma on the use of angiography, limited data exist on factors associated with outcomes in angiography procedures. This study examines factors associated with survival to hospital discharge in trauma patients undergoing angiography with or without embolization across US trauma centers.

MATERIALS AND METHODS

This retrospective observational study used the National Trauma Data Bank 2017 dataset and included adult trauma patients who underwent conventional angiography with or without embolization. A bivariate analysis was done to compare patients' characteristics by outcome (survived/died), followed by a multivariable logistic regression analysis to determine factors associated with survival to hospital discharge after adjusting for important confounders.

RESULTS

In the included sample of 4242 patients, median age was 41 years and male gender was predominant (72.6%). Overall mean time to angiography was 263.77 ± 750.19 min. Factors positively associated with survival included treatment at large facilities with over 401 beds (OR = 2.170; 95% CI, [1.277-3.685]), helicopter ambulance/fixed-wing transport (OR = 1.736; 95% CI, [1.325-2.275]), mild Glasgow Coma Scale (OR = 7.621; 95% CI, [5.868-9.898]) and moderate Glasgow Coma Scale (OR = 3.127; 95% CI, [2.080-4.701]), SBP ≥ 90 (OR = 1.516; 95% CI [1.199-1.916]), and spleen as embolization site (OR = 1.647; 95% CI [1.119-2.423]).

CONCLUSION

This nationwide study identified variables associated with survival in trauma patients who underwent angiography. These variables can serve in creating standardized risk stratification tools that could be incorporated into evidence-based guidelines for angiography candidates.

Comparison Between Minimally Invasive Right Anterior and Right Posterior Sectionectomy vs Right Hepatectomy: An International Multicenter Propensity Score-Matched and Coarsened-Exact-Matched Analysis of 1,100 Patients

BACKGROUND

The role of minimally invasive right anterior and right posterior sectionectomy (MI-RAS/MI-RPS) for right-sided liver lesions remains debatable. Although technically more demanding, these procedures might result in faster recovery and lower postoperative morbidity compared with minimally invasive right hemihepatectomy.

STUDY DESIGN

This is an international multicenter retrospective analysis of 1,114 patients undergoing minimally invasive right hemihepatectomy, MI-RAS, and MI-RPS at 21 centers between 2006 and 2019. Minimally invasive surgery included pure laparoscopic, robotic, hand-assisted, or a hybrid approach. A propensity-matched and coarsened-exact-matched analysis was performed.

RESULTS

A total of 1,100 cases met study criteria, of whom 759 underwent laparoscopic, 283 robotic, 11 hand-assisted, and 47 laparoscopic-assisted (hybrid) surgery. There were 632 right hemihepatectomies, 373 right posterior sectionectomies, and 95 right anterior sectionectomies. There were no differences in baseline characteristics after matching. In the MI-RAS/MI-RPS group, median blood loss was higher (400 vs 300 mL, p = 0.001) as well as intraoperative blood transfusion rate (19.6% vs 10.7%, p = 0.004). However, the overall morbidity rate was lower including major morbidity (7.1% vs 14.3%, p = 0.007) and reoperation rate (1.4% vs 4.6%, p = 0.029). The rate of close/involved margins was higher in the MI-RAS/MI-RPS group (23.4% vs 8.9%, p < 0.001). These findings were consistent after both propensity and coarsened-exact matching.

CONCLUSIONS

Although technically more demanding, MI-RAS/MI-RPS is a valuable alternative for minimally invasive right hemihepatectomy in right-sided liver lesions with lower postoperative morbidity, possibly due to the preservation of parenchyma. However, the rate of close/involved margins is higher in these procedures. These findings might guide surgeons in preoperative counselling and in selecting the appropriate procedure for their patients.

Limited liver resections in the posterosuperior segments: international multicentre propensity score-matched and coarsened exact-matched analysis comparing the laparoscopic and robotic approaches

Background

Limited liver resections (LLRs) for tumours located in the posterosuperior segments of the liver are technically demanding procedures. This study compared outcomes of robotic (R) and laparoscopic (L) LLR for tumours located in the posterosuperior liver segments (IV, VII, and VIII).

Methods

This was an international multicentre retrospective analysis of patients who underwent R-LLR or L-LLR at 24 centres between 2010 and 2019. Patient demographics, perioperative parameters, and postoperative outcomes were analysed; 1 : 3 propensity score matching (PSM) and 1 : 1 coarsened exact matching (CEM) were performed.

Results

Of 1566 patients undergoing R-LLR and L-LLR, 983 met the study inclusion criteria. Before matching, 159 R-LLRs and 824 L-LLRs were included. After 1 : 3 PSM of 127 R-LLRs and 381 L-LLRs, comparison of perioperative outcomes showed that median blood loss (100 (i.q.r. 40–200) versus 200 (100–500) ml; P = 0.003), blood loss of at least 500 ml (9 (7.4 per cent) versus 94 (27.6 per cent); P &lt; 0.001), intraoperative blood transfusion rate (4 (3.1 per cent) versus 38 (10.0 per cent); P = 0.025), rate of conversion to open surgery (1 (0.8 per cent) versus 30 (7.9 per cent); P = 0.022), median duration of Pringle manoeuvre when applied (30 (20–46) versus 40 (25–58) min; P = 0.012), and median duration of operation (175 (130–255) versus 224 (155–300); P &lt; 0.001) were lower in the R-LLR group compared with the L-LLR group. After 1 : 1 CEM of 104 R-LLRs with 104 L-LLRs, R-LLR was similarly associated with significantly reduced blood loss and a lower rate of conversion to open surgery.

Conclusion

Based on a matched analysis of well selected patients, both robotic and laparoscopic access could be undertaken safely with good outcomes for tumours in the posterosuperior liver segments.

Interventional angiography utilization for adult trauma patients in Trauma Centers across the United States: An observational study using the National Trauma Data Bank

Angiography and embolization are part of trauma management protocols for various injuries. This study examines the use of angiography and embolization use in trauma care across Trauma Centers in the United States. We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients (≥16 years) who underwent conventional angiography with or without embolization were included. A univariate analysis was carried out to describe patients' demographic and injury characteristics as well as the time to angiography, angiography details, complications, and outcome (survival to hospital discharge: yes/no). One-year period prevalence proportion of angiography procedure was determined. A total of 4242 patients were included. The 1-year period prevalence proportion of angiography procedure with or without embolization was 0.53% (95% confidence intervals: 0.527-0.529). The median age was 41 years (interquartile range: 27-58) with most patients being in the age group 16 to 64 (83.8%) and males (72.6%). Over half of the patients, 55.4% had an embolization procedure performed in addition to angiography. The mean time to angiography was 263.77 ± 750.19 minutes. The most common embolization sites were the pelvis (24.9%), spleen (11.8%), and liver (9%). This study described angiography and embolization utilization in adult trauma patients in Trauma Centers in the US. Its findings provide the basis for future studies to examine more closely angiography/embolization utilization in specific subpopulations, and to create standardized risk stratification tools for trauma patients who are candidates for this procedure.

A biosocial return to race? A cautionary view for the postgenomic era

Recent studies demonstrating epigenetic and developmental sensitivity to early environments, as exemplified by fields like the Developmental Origins of Health and Disease (DOHaD) and environmental epigenetics, are bringing new data and models to bear on debates about race, genetics, and society. Here, we first survey the historical prominence of models of environmental determinism in early formulations of racial thinking to illustrate how notions of direct environmental effects on bodies have been used to naturalize racial hierarchy and inequalities in the past. Next, we conduct a scoping review of postgenomic work in environmental epigenetics and DOHaD that looks at the role of race/ethnicity in human health (2000-2021). Although there is substantial heterogeneity in how race is conceptualized and interpreted across studies, we observe practices that may unwittingly encourage typological thinking, including: using DNA methylation as a novel marker of racial classification; neglect of variation and reversibility within supposedly homogenous racial groups; and a tendency to label and reify whole groups as pathologized or impaired. Even in the very different politico-economic and epistemic context of contemporary postgenomic science, these trends echo deeply held beliefs in Western thinking which claimed that different environments shape different bodies and then used this logic to argue for essential differences between Europeans and non-Europeans. We conclude with a series of suggestions on interpreting and reporting findings in these fields that we feel will help researchers harness this work to benefit disadvantaged groups while avoiding the inadvertent dissemination of new and old forms of stigma or prejudice.

Race and trauma mortality: The effect of hospital-level Black-White patient race distribution

BACKGROUND

Race-related health disparities have been well documented in the United States. In some settings, Black patients have better outcomes in hospitals that serve high proportions of Black patients. We hypothesized that Black trauma patients would have lower mortality in high Black-serving (H-BS) hospitals.

METHODS

We identified all adult patients with Black or White race and with an Injury Severity Score of ≥4 from the 2017 National Inpatient Sample. We collected hospital identifier, mechanism, age, sex, comorbidities, urban-rural location, insurance, zip code income quartile, and injury severity calculated from International Classification of Diseases, Tenth Revision, codes. We used a previously published method to group hospitals by proportion of Black patients served: HB-S (top 5%), medium Black serving (5-25%), and low Black serving (L-BS; bottom 75%). Adjusted logistic regression using an interaction variable between race and hospital service rank (reference: White patients in H-BS) was used to identify factors associated with mortality.

RESULTS

We analyzed 184,080 trauma patients (median age, 72 years [interquartile range, 55-84 years]; Injury Severity Score, 9 [4-10]), of whom 11.7% were Black. Overall mortality was 4%. Of 2,376 hospitals, 126 (5.3%) were H-BS and 469 (19.7%) were medium Black serving. Furthermore, 29.8% of Black and 3.6% of White patients were treated at H-BS hospitals, while 71.7% of White and 23.6% of Black patients were treated at L-BS hospitals (p < 0.001). Black patients had the lowest mortality at H-BS hospitals (odds ratio [OR], 0.76 [0.64-0.92]) and the highest mortality (OR, 1.43 [1.13-1.80]) at L-BS hospitals. White patients had the lowest mortality at L-BS hospitals (OR, 0.76 [0.64-0.92]).

CONCLUSION

After adjusting for patient and hospital factors, disparities exist such that Black and White patients have the best outcomes in hospitals that treat those patients most frequently, suggesting potential for racial bias at the institutional level. Further efforts must be made to promote equitable treatment at all hospitals and reduce these disparities.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level IV.

Evaluating the complex association between Social Vulnerability Index and trauma mortality

INTRODUCTION

Social determinants of health are known to impact patient-level outcomes, but they are often difficult to measure. The Social Vulnerability Index was created by the Centers for Disease Control to identify vulnerable communities using population-based measures. However, the relationship between SVI and trauma outcomes is poorly understood.

METHODS

In this retrospective study, we merged SVI data with a statewide trauma registry and used three analytic models to evaluate the association between SVI quartile and inpatient trauma mortality: (1) an unadjusted model, (2) a claims-based model using only covariates available to claims datasets, and (3) a registry-based model incorporating robust clinical variables collected in accordance with the National Trauma Data Standard.

RESULTS

We identified 83,607 adult trauma admissions from January 1, 2017, to September 30, 2020. Higher SVI was associated with worse mortality in the unadjusted model (odds ratio, 1.72 [95% confidence interval, 1.30-2.29] for highest vs. lowest SVI quintile). A weaker association between SVI and mortality was identified after adjusting for covariates common to claims data. Finally, there was no significant association between SVI and inpatient mortality after adjusting for covariates common to robust trauma registries (adjusted odds ratio, 1.10 [95% confidence interval, 0.80-1.53] for highest vs. lowest SVI quintile). Higher SVI was also associated with a higher likelihood of presenting with penetrating injuries, a shock index of >0.9, any Abbreviated Injury Scale score of >5, or in need of a blood transfusion (p < 0.05 for all).

CONCLUSION

Patients living in communities with greater social vulnerability are more likely to die after trauma admission. However, after risk adjustment with robust clinical covariates, this association was no longer significant. Our findings suggest that the inequitable burden of trauma mortality is not driven by variation in quality of treatment, but rather in the lethality of injuries. As such, improving trauma survival among high-risk communities will require interventions and policies that target social and structural inequities upstream of trauma center admission.

LEVEL OF EVIDENCE

Prognostic / Epidemiologic, Level IV.

Developing a measure of overall intensity of injury care: A latent class analysis

BACKGROUND

While injury is a leading cause of death and debility in older adults, the relationship between intensity of care and trauma remains unknown. The focus of this analysis is to measure the overall intensity of care delivered to injured older adults during hospitalization.

METHODS

We used Centers for Medicare and Medicaid Services Medicare fee-for-service claims data (2013-2014), to identify emergency department-based claims for moderate and severe blunt trauma in age-eligible beneficiaries. Medical procedures associated with care intensity were identified using a modified Delphi method. A latent class model was estimated using the identified procedures, intensive care unit length of stay, demographics, and injury characteristics. Clinical phenotypes for each class were explored.

RESULTS

A total of 683,398 cases were classified as low- (73%), moderate- (23%), and high-intensity care (4%). Greater age and reduced injury severity were indicators of lower intensity, while males, non-Whites, and nonfall mechanisms were more common with high intensity. Intubation/mechanical ventilation was an indicator of high intensity and often occurred with at least one other procedure or an extended intensive care unit stay.

CONCLUSION

This work demonstrates that, although heterogeneous, care for blunt trauma can be evaluated using a single novel measure.

LEVEL OF EVIDENCE

For prognostic/epidemiological studies, level III.

Impact of Trauma Center Designation Level on the Survival of Trauma Patients Transported by Police in the United States

Background: Police involvement in trauma management and transport is increasing in the US. Little is known about prehospital triage criteria and transport patterns used by Police Officers. In this study, we examined the impact of trauma designation level on the survival of trauma patients transported to trauma centers by police.Methods: We used the National Trauma Data Bank (NTDB) 2017 dataset in this retrospective observational study. Adult trauma patients transported by Police to Level I, II and III trauma centers were included. We performed a univariate analysis followed by a bivariate analysis. Finally, we carried out a multivariable logistic regression analysis adjusting for confounders to assess the impact of trauma level designation on outcomes of patients transported by Police.Results: A total of 2,788 patients were included. The majority of the patients were males (84.6%) between the ages of 16 and 55 with half of them being African American. Most had a mild GCS (13-15) (89.5%) and only 17.4% were recorded to have severe traumatic injuries with ISS ≥ 16. The most common trauma type was blunt trauma (61.4%) followed by penetrating injuries (32.2%) and burns (1.5%). Around half of injuries were the result of assault (49.4%) and 43.0% were unintentional. Head and neck injuries were most common (40.8%) followed by extremities (27.4%) and torso injuries (25.0%). Approximately half of the patients were admitted to floor bed/observation unit/step-down unit (50.7%) while 18.9% and 19.8% went to the Operating Room or Intensive Care Unit respectively. Overall survival to hospital discharge was 93.2%. Survival was 91.6% in Level I, 98.2% in level II and 98.7% in Level III centers. After adjusting for significant confounders, survival to hospital discharge was similar for patients transported by police to level II and III trauma centers in comparison to those transported to level I (OR = 0.866 95%CI (0.321-2.333); p = 0.776).Conclusion: Transport of trauma patients by police to trauma centers of different designation levels was not associated with survival in this study. Survival was also similar to other trauma studies. As such, trauma patients may be safely transported by Police to closest trauma designated center without affecting outcomes.

Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease.

METHODS

We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups.

RESULTS

We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I² = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I² = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I² = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I² = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates.

CONCLUSIONS

Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Factors associated with survival in adult patients with traumatic arrest: a retrospective cohort study from US trauma centers

Background

Traumatic arrests increasingly affect young adults worldwide with low reported survival rates. This study examines factors associated with survival (to hospital discharge) in traumatic arrests transported to US trauma centers.

Methods

This retrospective cohort study used the US National Trauma Databank 2015 dataset and included patients who presented to trauma centers with “no signs of life”. Univariate and bivariate analyses were done. Factors associated with survival were identified using multivariate regression analyses.

Results

The study included 5980 patients with traumatic arrests. Only 664 patients (11.1%) survived to hospital discharge. Patients were predominantly in age group 16–64 (84.6%), were mostly males (77.8%) and white (55.1%). Most were admitted to Level I (55.5%) or Level II trauma centers (31.6%). Injuries were mostly blunt (56.7%) or penetrating (39.3%). The median of the injury severity score (ISS) was 19 (interquartile range [IQR]: 9–30). Factors associated with decreased survival included: Age group ≥ 65 (Ref: 16–24), male gender, self-inflicted and other or undetermined types of injuries (Ref: assault), injuries to head and neck, injuries to torso and ISS ≥ 16 (Ref: < 16) and ED thoracotomy. While factors associated with increased survival included: All injury mechanisms (with the exception of motor vehicle transportation) (Ref: firearm), injuries to extremities or spine and back and all methods of coverage (Ref: self-pay).

Conclusion

Patients with traumatic arrests have poor outcomes with only 11.1% surviving to hospital discharge. Factors associated with survival in traumatic arrests were identified. These findings are important for devising injury prevention strategies and help guide trauma management protocols to improve outcomes in traumatic arrests.

Level of evidence

Level III.

Comparison between short and long-term outcomes after minimally invasive versus open primary liver resections for hepatocellular carcinoma: A 1:1 matched analysis

BACKGROUND

This study aims to compare the short- and long-term outcomes of patients undergoing minimally invasive liver resection (MILR) versus open liver resection (OLR) for nonrecurrent hepatocellular carcinoma (HCC).

METHODS

Review of 204 MILR and 755 OLR without previous LR performed between 2005 and 2018. 1:1 coarsened exact matching (CEM) and 1:1 propensity-score matching (PSM) were performed.

RESULTS

Overall, 190 MILR were well-matched with 190 OLR by PSM and 86 MILR with 86 OLR by CEM according to patient baseline characteristics. After PSM and CEM, MILR was associated with a significantly longer operation time [230 min (interquartile range [IQR], 145-330) vs. 160 min (IQR, 125-210), p < .001] [215 min (IQR, 135-295) vs. 153.5 min (120-180), p < .001], shorter postoperative stay [4 days (IQR, 3-6) vs. 6 days (IQR, 5-8), p = .001)] [4 days (IQR, 3-5) vs. 6 days (IQR, 5-7), p = .004] and lower postoperative morbidity [40 (21%) vs. 67 (35.5%), p = .003] [16 (18.6%) vs. 27 (31.4%), p = .036] compared to OLR. MILR was also associated with a significantly longer median time to recurrence (70 vs. 40.3 months, p = .014) compared to OLR after PSM but not CEM. There was no significant difference in terms of overall survival and recurrence-free survival.

CONCLUSION

MILR is associated with superior short-term postoperative outcomes and with at least equivalent long-term oncological outcomes compared to OLR for HCC.

Racial and Ethnic Disparities in Frail Geriatric Trauma Patients

Background

Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients.

Methods

We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay.

Results

We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2–2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1–1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1–1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1–1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics.

Conclusion

Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.

Patterns and Predictors of Firearm-related Spinal Cord Injuries in Adult Trauma Patients

INTRODUCTION

Firearm-related spinal cord injuries are commonly missed in the initial assessment as they are often obscured by concomitant injuries and emergent trauma management. These injuries, however, have a significant health and financial impact. The objective of this study was to examine firearm-related spinal cord injuries and identify predictors of presence of such injuries in adult trauma patients.

METHODS

This retrospective cohort study examined adult trauma patients (≥16 years) with injuries from firearms included in the 2015 United States National Trauma Data Bank. We performed descriptive and bivariate analyses and compared two groups: patients with no spinal cord injury (SCI) or vertebral column injury (VCI); and patients with SCI and/or VCI. Predictors of SCI and/or VCI in patients with firearm-related injuries were identified using a multivariate logistic regression analysis.

RESULTS

There were 34,898 patients who sustained a firearm-induced injury. SCI and/or VCI were present in 2768 (7.9%) patients. Patients with SCI and/or VCI had more frequently severe injuries, higher Injury Severity Score (ISS), lower mean systolic blood pressure, and lower Glasgow Coma Scale (GCS). The mortality rate was not significantly different between the two groups (14.7%, N = 407 in SCI and/or VCI vs 15.0%, N = 4,811 in no SCI or VCI group). Significant general positive predictors of presence of SCI and/or VCI were as follows: university hospital; assault; public or unspecified location of injury; drug use; air medical transport; and Medicaid coverage. Significant clinical positive predictors included fractures, torso injuries, blood vessel or internal organ injuries, open wounds, mild (13-15) and moderate GCS scores (9 - 12), and ISS ≥ 16.

CONCLUSION

Firearm-induced SCI and/or VCI injuries have a high burden on affected victims. The identified predictors for the presence of SCI and/or VCI injuries can help with early detection, avoiding management delays, and improving outcomes. Further studies defining the impact of each predictor are needed.

Racial and Sex Disparities in Trauma Outcomes Based on Geographical Region

OBJECTIVES

Disparities in outcomes among trauma patients have been shown to be associated with race and sex. The purpose of this study was to analyze racial and sex mortality disparities in different regions of the United States, hypothesizing that the risk of mortality among black and Asian trauma patients, compared to white trauma patients, will be similar within all regions in the United States.

METHODS

The Trauma Quality Improvement Program (2010-2016) was queried for adult trauma patients, separating by U.S. Census regions. Multivariable logistic regression analyses were performed for each region, controlling for known predictors of morbidity and mortality in trauma.

RESULTS

Most trauma patients were treated in the South (n = 522 388, 40.7%). After risk adjustment, black trauma patients had a higher associated risk of death in all regions, except the Northeast, compared to white trauma patients. The highest associated risk of death for blacks (vs. whites) was in the Midwest (odds ratio [OR] 1.30, P < .001). Asian trauma patients only had a higher associated risk of death in the West (OR 1.39, P < .001). Male trauma patients, compared to women, had an increased associated risk of mortality in all four regions.

DISCUSSION

This study found major differences in outcomes among different races within different regions of the United States. There was also both an increased rate and associated risk of mortality for male patients in all regions. Future prospective studies are needed to identify what regional differences in trauma systems including population density, transport times, hospital access, and other trauma resources explain these findings.

Racial Disparities in Surgery: A Cross-Specialty Matched Comparison Between Black and White Patients

Objective

To determine if Black race is associated with worse short-term postoperative morbidity and mortality when compared to White race in a contemporary, cross-specialty-matched cohort.

Background

Growing evidence suggests poorer outcomes for Black patients undergoing surgery.

Methods

A retrospective analysis was conducted comprising of all patients undergoing surgery in the National Surgical Quality Improvement Program dataset between 2012 and 2018. One-to-one coarsened exact matching was conducted between Black and White patients. Primary outcome was rate of 30-day morbidity and mortality.

Results

After 1:1 matching, 615,118 patients were identified. Black race was associated with increased rate of all-cause morbidity (odds ratio [OR] = 1.10, 95% confidence interval [CI] 1.08-1.13, P < 0.001) and mortality (OR = 1.15, 95% CI 1.01-1.31, P = 0.039). Black race was associated with increased risk of re-intubation (OR = 1.33, 95% CI 1.21-1.48, P < 0.001), pulmonary embolism (OR = 1.55, 95% CI 1.40-1.71, P < 0.001), failure to wean from ventilator for >48 hours (OR = 1.14, 95% CI 1.02-1.29, P < 0.001), progressive renal insufficiency (OR = 1.63, 95% CI 1.43-1.86, P < 0.001), acute renal failure (OR = 1.39, 95% CI 1.16-1.66, P < 0.001), cardiac arrest (OR = 1.47, 95% CI 1.24-1.76 P < 0.001), bleeding requiring transfusion (OR = 1.39, 95% CI 1.34-1.43, P < 0.001), DVT/thrombophlebitis (OR = 1.24, 95% CI 1.14-1.35, P < 0.001), and sepsis/septic shock (OR = 1.09, 95% CI 1.03-1.15, P < 0.001). Black patients were also more likely to have a readmission (OR = 1.12, 95% CI 1.10-1.16, P < 0.001), discharge to a rehabilitation center (OR = 1.73, 95% CI 1.66-1.80, P < 0.001) or facility other than home (OR = 1.20, 95% CI 1.16-1.23, P < 0.001).

Conclusion and Relevance

This contemporary matched analysis demonstrates an association with increased morbidity, mortality, and readmissions for Black patients across surgical procedures and specialties.

Racial And Socioeconomic Differences Affect Outcomes in Elderly Burn Patients

BACKGROUND

Race and socioeconomic status influence outcomes for adult and pediatric burn patients, yet the impact of these factors on elderly patients (Medicare eligible, 65 years of age) remains unknown.

METHODS

Data pooled from three verified burn centers from 2004 to 2014 were reviewed retrospectively. Age, race, gender, percent total body surface area (%TBSA) burn, mortality, length of stay (LOS), LOS per %TBSA burn, and zip code which provided Census data on race, poverty, and education levels within a community were collected. Data were analyzed using logistic and generalized linear models in SAS version 9.4 (SAS Institute, Cary, NC, USA).

RESULTS

Our population was mainly Caucasian (63%), African American (18%), Hispanic (7.6%), and Asian (3.5%). Mean age was 76.3 ± 8.3 years, 52.5% were male. Mean %TBSA was 9 ± 13.8%; 15% of the patients sustained an inhalation injury. The mortality rate was 14.4%. Inhalation injury was significantly associated with mortality and discharge to a skilled nursing facility (SNF) (p < 0.05). Race was significantly associated with socioeconomic disparities and affected LOS/TBSA, but not discharge to SNF or mortality on univariate analysis. Poverty level, education level, and insurance status (others vs. public) independently predicted SNF discharge, while median income and insurance type independently predicted LOS/TBSA.

CONCLUSION

In this elderly cohort, race did not predict standard markers of burn outcome (mortality and discharge to SNF). Socioeconomic status independently predicted LOS and discharge to SNF, suggesting a relationship between socioeconomic status and recovery from a burn injury. Better understanding of racial and socioeconomic disparities is necessary to provide equitable treatment of all patients.

Youth injury and parents' unemployment-the importance of socio-economic status and ethnicity context

BACKGROUND

Youth whose parents are unemployed have poorer health and well-being, including more injuries that result in hospitalization. The current study examined the possibility of an association of parents' employment status with youth injury and the interaction of this status with other socio-economic factors and ethnicity.

METHODS

We distributed to adolescents aged 11-15 years, in class, the Israel Health Behavior in School-Aged Children Survey. We distinguished between any injury and severe injury, defining the latter as one necessitating the use of a cast, stitches and crutches or overnight hospitalization.

RESULTS

Of 13 705 respondents, 6224 (45%) had an injury in the past year that required medical treatment and 1827 pupils (13.5%) reported severe injuries. The odds of any injury were 1.86 for boys as against girls (95% confidence interval [CI] 1.73-1.99), 0.80 for school grade (95% CI 0.78-0.82), 1.56 for Arabs vs. Jews (95% CI 1.43-1.70) and 1.10 for high Family Affluence Scale (FAS) vs. medium FAS (95% CI 1.01-1.21). Only in the low FAS group, when two parents were unemployed, the odds for severe injury was 1.36 (95% CI 1.03-1.78); when one or two parents were employed, the odds of severe child injury were the same (OR 1.13 and 95% CI 0.92-1.40).

CONCLUSION

Factors that were found to increase the risk of injury among youth were parental unemployment, low socio-economic status and Arab ethnicity. The home environment was the most common place for injury.

Impact of liver cirrhosis on the difficulty of minimally-invasive liver resections: a 1:1 coarsened exact-matched controlled study

INTRODUCTION

The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process.

METHODS

Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients.

RESULTS

Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%, p = 0.03), operation time (261 vs 238 min, p  < 0.001), blood loss (607 vs 314 mls, p  = 0.002), transfusion rate (22% vs 9%, p  = 0.001), need for application of Pringles maneuver (51% vs 34%, p  = 0.010), postoperative stay (6 vs 4.5 days, p  = 0.004) and postoperative morbidity (26% vs 13%, p  = 0.029).

CONCLUSION

The presence of liver cirrhosis affected both the intraoperative technical difficulty and postoperative outcomes of MILR and hence should be considered an important parameter to be included in future difficulty scoring systems for MILR.

Racial inequality in the trauma of women: A disproportionate decade

BACKGROUND

Historically, women have been largely underrepresented in the body of medical research. Given the paucity of data regarding race and trauma in women, we aimed to evaluate the most common types of traumas incurred by women and analyze temporal racial differences.

METHODS

A 10-year review (2007-2016) of the National Trauma Data Bank was conducted to identify common mechanisms of injuries among women. Trends of race, intent of injury, and firearm-related assaults were assessed using the Cochran-Armitage Trend test. Multivariable multinomial logistic regressions were utilized to examine the association between race and trauma subtypes.

RESULTS

Of the 2,082,768 women identified as a trauma during this study period, the majority presented due to an unintentional intent (94.5%), whereas fewer presented secondary to an assault (4.4%) or self-inflicted injury (1.1%). While racioethnic minority women encompassed a small percentage of total traumas (19%), they accounted for roughly three fifths of assault-related traumas (p < 0.001). Though total assaults decreased by 20.8% during the study period, black and Hispanic women saw a disproportionately smaller decrease of 15.1% and 15.8%, respectively. On regression analysis, compared with white women, black women had more than four times the odds of being an assault-related trauma compared with unintentional trauma (odds ratio, 4.48; 95% confidence interval, 4.41-4.55). On subset analysis, firearm-related assault was 17.3 times more prevalent among black women (white, 0.3% vs. black: 5.2%; p < 0.001). In fact, history of alcohol abuse was found to be an effect modifier of the association of race/ethnicity and firearm-related trauma.

CONCLUSION

Compelling data highlight a disproportionate trend in the assault-related trauma of minority women. Specifically, minority women, especially those with a history of alcohol abuse, were at increased risk of being involved in a firearm assault. Further studies are essential to help mitigate disparities and subsequently develop preventative services for this diverse population.

LEVEL OF EVIDENCE

Epidemiological, Level III.

Patient Race and Insurance Status Do Not Impact the Treatment of Simple Mandibular Fractures

INTRODUCTION

Health-care disparities have been reported throughout medical literature for decades. While blatant explicit bias is not prevalent, a substantial body of research has been published suggesting that systemic biases related to sex, race, income, and insurance status likely exist. To our knowledge, no study has assessed the impact of patient race and insurance status on clinical decision-making in facial fracture repair in the United States. Thus, the objective of this project was to assess if race and insurance status impacted whether patients obtained open or closed treatment of simple mandibular fractures.

METHODS

Patients who had either open or closed treatment of mandibular fractures were extracted from the 2012 and 2013 National Inpatient Sample and analyzed. Patients who had a length of stay longer than 3 days or died during their inpatient stay were excluded. These exclusion criteria were used to control for patients with polytrauma as well as complicated fractures. Univariate analysis was undertaken to elucidate different variable associations with the type of reduction performed. All covariates were then entered into a multivariable logistic regression model to test the variables simultaneously.

RESULTS

Patients with simple condylar, alveolar border, and closed mandibular fractures were more likely to undergo closed reduction (CR) on univariate analysis, as were patients with female gender and a fall mechanism (P value < .05). African Americans, Hispanics, and patients without insurance were more likely to undergo open reduction on univariate analysis (P value < .05). Multivariate analysis demonstrated that patients with simple condylar, subcondylar, alveolar border, or closed mandibular fractures were more likely to undergo a CR, as were patients with female gender and a firearm or fall mechanism (P < .05). However, neither race nor insurance status demonstrated a statistically significant association with closed or open reduction.

CONCLUSION

Anatomic location and mechanism of injury were the variables found to be significantly associated with patients undergoing open reduction versus CR of simple mandibular fractures-not race or insurance status.

Progress in research of enhanced recovery after surgery and surgery related differences

Enhanced recovery after surgery (ERAS) refers to the use of standardized, multimodal perioperative strategies to reduce physiological stress and organ dysfunction caused by surgery. Since the ERAS concept was put forward, it has been widely respected in the surgical field. Its benefits in the surgical field for the vast majority of patients, medical staff and healthcare systems are obvious. However, for some specific people undergoing surgery, the benefits are not certain, which is the so-called surgery-related differences. This article analyzes recent studies of different surgical fields related to surgical-related differences in different ethnic groups, reviews a large number of positive effects of the implementation of ERAS on surgical-related differences, and elaborates its possible mechanism. It is finally concluded that ERAS, a standardized model for resolving surgical-related differences, should become the gold standard for surgical perioperative management.

Impact of trauma designation levels on survival of drowning victims: An observational study from trauma centers in the United States

Drowning causes significant morbidity and mortality. Healthcare regionalization aims at improving patient outcomes. This study examines the impact of trauma center level designation on survival of drowning victims.Retrospective cohort study utilizing the National Trauma Data Bank (NTDB) 2015. Descriptive, bivariate and multivariate analyses were conducted.The 212 patients were included. Mean age was 33.58 (±20.02) years with 69.3% (n = 147) males. Patients were mostly taken to Level I (n = 107, 50.5%) and II (n = 81, 32.8%) centers, requiring admission (43.5% (n = 96), 23.1% (n = 49) and 8.5% (n = 18) to Intensive Care, floor, and Operating Room, respectively). Overall hospital discharge survival was 83.5% (n = 177). After adjusting for confounders, there was no significant difference in survival of patients taken to Level I compared to Level II and III centers.This study did not identify a survival benefit for patients with drowning related injuries when taken to Level I compared to Level II or III Trauma centers. Further outcome studies are needed in organized trauma systems to improve field triage criteria for specific injury mechanisms.

Racial/Ethnic Disparities in Longer-term Outcomes Among Emergency General Surgery Patients: The Unique Experience of Universally Insured Older Adults

OBJECTIVES

To determine whether racial/ethnic disparities in 30/90/180-day mortality, major morbidity, and unplanned readmissions exist among universally insured older adult (≥65 years) emergency general surgery patients; vary by diagnostic category; and can be explained by variations in geography, teaching status, age-cohort, and a hospital's percentage of minority patients.

SUMMARY OF BACKGROUND DATA

As the US population ages and discussions surrounding the optimal method of insurance provision increasingly enter into national debate, longer-term outcomes are of paramount concern. It remains unclear the extent to which insurance changes disparities throughout patients' postacute recovery period among older adults.

METHODS

Survival analysis of 2008 to 2014 Medicare data using risk-adjusted Cox proportional-hazards models.

RESULTS

A total of 6,779,649 older adults were included, of whom 82.8% identified as non-Hispanic white (NHW), 9.2% non-Hispanic black (NHB), 5.6% Hispanic, and 1.5% non-Hispanic Asian (NHA). Relative to NHW patients, each group of minority patients was significantly less likely to die [30-day NHB vs NHW hazard ratio (95% confidence interval): 0.88 (0.86-0.89)]. Differences became less apparent as outcomes approached 180 days [180-day NHB vs NHW: 1.00 (0.98-1.02)]. For major morbidity and unplanned readmission, differences among NHW, Hispanic, and NHA patients were comparable. NHB patients did consistently worse. Efforts to explain the occurrence found similar trends across diagnostic categories, but significant differences in disparities attributable to geography and the other included factors that combined accounted for up to 50% of readmission differences between racial/ethnic groups.

CONCLUSION

The study found an inversion of racial/ethnic mortality differences and mitigation of non-NHB morbidity/readmission differences among universally insured older adults that decreased with time. Persistent disparities among nonagenarian patients and hospitals managing a regionally large share of minority patients warrant particular concern.

Impact of trauma level designation on survival of patients arriving with no signs of life to US trauma centers

BACKGROUND

Trauma level designation and verification are examples of healthcare regionalization aiming at improving patient outcomes. This study examines impact of Trauma Levels on survival of patients arriving with "no signs of life" to US trauma centers.

METHODS

This retrospective study used the US National Trauma Data Bank (NTDB) 2015 dataset. A descriptive followed by a bivariate analysis was done comparing variables by the trauma designation levels. A multivariate analysis assessed the effect of the trauma designation on survival to hospital discharge after controlling for potential confounding factors.

RESULTS

6160 patients without signs of life were included. The average age was 40.66 years (±19.96) with male predominance (77.3%). Most patients were transported using ground ambulance (83.5%) and were taken to Level I (57%) and Level II (32.4%) centers. Blunt injuries were the most common (56.9%). Motor Vehicle Collision (MVC) (38.5%) and firearm (33.8%) were the most common mechanisms of injury. Survival to hospital discharge among patients with no signs of life ranged from 13.7% at Level I to 27.9% at Level III. After adjusting for confounders, including Injury Severity Score (ISS), higher survival was noted at Level II trauma centers compared to Level I.

CONCLUSIONS

Patients presenting without signs of life to Level II trauma centers had higher survival to hospital discharge compared to Level I and Level III centers. These findings can guide future prehospital triage criteria of trauma patients in organized Emergency Medical Services (EMS) systems and highlight the need for more outcome research on trauma systems.

Dehydroepiandrosterone: a potential therapeutic agent in the treatment and rehabilitation of the traumatically injured patient

Severe injuries are the major cause of death in those aged under 40, mainly due to road traffic collisions. Endocrine, metabolic and immune pathways respond to limit the tissue damage sustained and initiate wound healing, repair and regeneration mechanisms. However, depending on age and sex, the response to injury and patient prognosis differ significantly. Glucocorticoids are catabolic and immunosuppressive and are produced as part of the stress response to injury leading to an intra-adrenal shift in steroid biosynthesis at the expense of the anabolic and immune enhancing steroid hormone dehydroepiandrosterone (DHEA) and its sulphated metabolite dehydroepiandrosterone sulphate (DHEAS). The balance of these steroids after injury appears to influence outcomes in injured humans, with high cortisol: DHEAS ratio associated with increased morbidity and mortality. Animal models of trauma, sepsis, wound healing, neuroprotection and burns have all shown a reduction in pro-inflammatory cytokines, improved survival and increased resistance to pathological challenges with DHEA supplementation. Human supplementation studies, which have focused on post-menopausal females, older adults, or adrenal insufficiency have shown that restoring the cortisol: DHEAS ratio improves wound healing, mood, bone remodelling and psychological well-being. Currently, there are no DHEA or DHEAS supplementation studies in trauma patients, but we review here the evidence for this potential therapeutic agent in the treatment and rehabilitation of the severely injured patient.

Long-term outcomes among injured older adults transported by emergency medical services

INTRODUCTION/OBJECTIVE

Little is known about the long-term outcomes of injured older adults cared for in trauma systems. We sought to describe mortality and causes of death over time, and the independent association of injury severity, comorbidities, and other factors on 12-month mortality among injured older adults transported by emergency medical services (EMS).

MATERIALS AND METHODS

This was a population-based cohort study of injured adults ≥ 65 years in the United States transported by 44 EMS agencies to 51 hospitals from January 1, 2011 to December 31, 2011, with 12-month follow-up through December 31, 2012. The primary outcomes were time to death and causes of death. We used descriptive statistics and Cox proportional hazards models to generate adjusted hazard ratios (HR).

RESULTS

15,649 injured older adults were transported by EMS, frequently after a fall (84.5%). Serious injuries (Injury Severity Score [ISS] ≥ 16) occurred in 3.5%, with serious extremity injury (Abbreviated Injury Scale score ≥ 3) being most common (17.8%). Mortality rates were: 1.6% in-hospital, 5.1% at 30 days, 9.4% at 90 days and 20.3% at 1 year. The adjusted HR for patients in the highest comorbidity quartile was 2.20 (versus lowest quartile, 95% CI 1.97-2.46, p <  .001), while the HR for ISS ≥ 25 was 2.69 (versus ISS 0-8, 95% CI 1.60-4.51, p =  .001). Cardiovascular etiologies (53.3%) and dementia (32.7%) were the most common causes of death, with injury listed in 12.8% of death certificates.

CONCLUSIONS

Injury requiring EMS transport is a sentinel event among older adults, with death typically occurring months later, often due to cardiovascular causes and dementia. A heavy comorbidity burden had an adjusted mortality risk comparable to severe injury.

Racial and Ethnic Differences in Limiting Life-Sustaining Treatment in Trauma Patients

Introduction:

Differences in health care between racial and ethnic groups exist. The literature suggests that African Americans and Hispanics prefer more aggressive treatment at the end of life. The aim of this study is to assess racial and ethnic differences in limiting life-sustaining treatment (LLST) after trauma.

Study Design:

We performed a 2-year (2013-2014) retrospective analysis of Trauma Quality Improvement Program database. Patients with age ≥16 and Injury Severity Score (ISS) ≥ 16 were included. Outcome measures were the incidence and the predictors of LLST. Multivariable logistic regression was performed to control for confounding variables.

Results:

A total of 97 024 patients were identified. Mean age was 49 (21) years, 68% were male, 68% were white, and 14% were Hispanic. The overall incidence of LLST was 7.2%. Based on race, LLST was selected as consistent with goals of care more often in white when compared to African American individuals who experience serious traumatic injury (8.0% vs 4.5%; P < .001). Based on ethnicity, LLST was more often selected in non-Hispanics (7.5% vs 5.2%, P < .001) when compared to Hispanics. On regression analysis, the independent predictors of LLST were white race (odds ratio [OR]: 2.7 [1.6–4.4], P = .02), non-Hispanic ethnicity (OR: 1.9 [1.4-4.6]; P = .03), severe head injury (OR: 1.7 [1.1-3.2]; P = .04), and ISS (OR: 3.1 [2.4-5.1]; P < .01).

Conclusions:

Differences exist in selecting LLST between different racial and ethnic groups in severe trauma. African Americans and Hispanics are less likely to select LLST when compared to whites and non-Hispanics. Further studies are required to analyze the factors associated with selecting LLST in African Americans and Hispanics.

Racial disparities in post-discharge healthcare utilization after trauma

BACKGROUND

Racial disparities in trauma outcomes have been documented, but little is known about racial differences in post-discharge healthcare utilization. This study compares the utilization of post-discharge healthcare services by African-American and Caucasian trauma patients.

METHODS

Trauma patients with an Injury Severity Score (ISS)≥9 from three Level-I trauma centers were contacted between 6 and 12 months post-injury. Utilization of trauma-related healthcare services was asked. Coarsened exact matching (CEM) was used to match African-American and Caucasian patients. Conditional logistic regression then compared matched patients in terms of post-discharge healthcare utilization.

RESULTS

182 African-American and 1,117 Caucasian patients were followed. Of these, 141 African-Americans were matched to 628 Caucasians. After CEM, we found that African-American patients were less likely to use rehabilitation services [OR:0.64 (95% CI:0.43-0.95)] and had fewer injury-related outpatient visits [OR:0.59 (95% CI:0.40-0.86)] after discharge.

CONCLUSIONS

This study shows the existence of racial disparities in post-discharge healthcare utilization after trauma for otherwise similarly injured, matched patients.

Achieving ethnic equality in the Israel trauma healthcare system: the case of the elderly population

Objective

To determine if ethnic disparities exist with regard to the risk of injury and injury outcomes among elderly hospitalized casualties in Israel.

Methods

A retrospective study based on data from the Israeli National Trauma Registry between 2008 and 2017. Data included demographic, injury and hospitalization characteristics. Descriptive statistics and adjusted logistic regression were used to examine the differences between Jewish and Arab casualties, aged 65 and older.

Result

The study included 96,795 casualties. The proportion of elderly hospitalized casualties was 2.8 times greater than their proportion in the population (3.1 times greater among Jews and 2.1 times among Arabs). In comparison to Arabs, Jews suffered from a greater percentage of head injuries (10.5 and 8.9%, respectively for Jews and Arabs p < .001), but fewer extremity injuries (46.7% vs. 48.0% respectively for Jews and Arabs p < .05). Among severe/critical casualties and among casualties with severe head injuries, Arabs were more likely to be transported to the hospital in a private car (27% vs. 21% respectively for Arabs and Jews p < .001; 30.5% vs. 23.3% respectively for Arabs and Jews p < .001). Logistic regression analysis, adjusted for age, gender, injury severity, type of injury, type of trauma center and year of admission, shows that Jews, relative to Arabs, were more likely to be hospitalized for more than seven days, admitted to the intensive care unit (ICU) and to be discharged to a rehabilitation center (OR: 1.3, 1.3 and 2.4 respectively). No differences regarding surgery (OR: 0.95) or in-hospital mortality (OR: 0.99) were found.

Conclusions

Ethnic disparities between Jewish and Arab hospitalized casualties were observed with regard to hospital stay, ICU admission and rehabilitation transfer. However, no differences were found with regard to mortality and surgery. While the reported disparities may be due in part by cultural differences and accessibility, health policy decision makers should aim to reduce the gaps by optimizing the accessibility of ambulance and rehabilitation services as well as increasing awareness regarding the availability of these medical services among the Arab population.

Dialysis is an independent risk factor for perioperative adverse events, readmission, reoperation, and mortality for patients undergoing elective spine surgery

BACKGROUND CONTEXT

The prevalence of dialysis-dependent patients in the United States is growing. Prior studies evaluating the risk of perioperative adverse events for dialysis-dependent patients are either institutional cohort studies limited by patient numbers or administrative database studies limited to inpatient data.

PURPOSE

The present study uses a large, national sample with 30-day follow-up to investigate dialysis as risk factor for perioperative complications independent of patient demographics or comorbidities.

STUDY DESIGN/SETTING

This is a retrospective cohort study.

PATIENT SAMPLE

Patients undergoing elective spine surgery with or without dialysis from the 2005-2015 National Surgical Quality Improvement Program (NSQIP) database were included in the study.

OUTCOME MEASURES

Postoperative complications within 30 days and binomial reoperation, readmission, and mortality within 30 days were determined.

METHODS

The 2005-2015 NSQIP databases were queried for adult dialysis-dependent and dialysis-independent patients undergoing elective spinal surgery. Differences in 30-day outcomes were compared using risk-adjusted multivariate regression and coarsened exact matching analysis for adverse events, unplanned readmission, reoperation, and mortality. The percentage of complications occurring before versus after hospital discharge was also assessed. The authors have no financial disclosures related to the present study.

RESULTS

A total of 467 dialysis and 173,311 non-dialysis patients met the inclusion criteria. Controlling for age, gender, body mass index, functional status, and American Society of Anesthesiologists (ASA) class, dialysis patients were found to be at significantly greater odds of any adverse event (odds ratio [OR]=2.52 before, 2.17 after matching, p=<.001), major adverse event (OR=2.90 before, 2.52 after matching, p=<.001), and minor adverse event (OR=1.50 before matching, p=<.025, but not significantly different after matching). Further, dialysis patients were significantly more likely to return to the operating room (OR=2.77 before, 2.50 after matching, p=<.001), have unplanned readmissions (OR=2.73 before, 2.37 after matching, p=<.001), and die within 30 days (OR=3.77 before, 2.71 after matching, p=<.001). Adverse events occurred after discharge for 51.78% of non-dialysis patients and for 43.80% of dialysis patients.

CONCLUSIONS

Dialysis patients undergoing elective spine surgery are at significantly higher risk of aggregated adverse outcomes, return to the operating room, readmission, and death than non-dialysis patients, even after controlling for patient demographics and overall health (as indicated by ASA class). These differences need to be considered when determining treatment options. Additionally, with bundled payments expected in spine surgery, physicians and hospitals need to account for increased costs and liabilities when working with dialysis patients.

Dialysis Patients Undergoing Total Knee Arthroplasty Have Significantly Increased Odds of Perioperative Adverse Events Independent of Demographic and Comorbidity Factors

BACKGROUND

The prevalence of dialysis-dependent patients is growing, and an increasing number of these patients are being considered for total knee arthroplasty (TKA). Studies assessing the preoperative risk associated with TKA in this population are limited to institutional cohorts with small sample sizes or national inpatient databases that lack follow-up data.

METHODS

The 2006-2015 National Surgical Quality Improvement Program databases were queried for adult patients undergoing elective TKA. Differences in 30-day any/severe/minor adverse event, need for reoperation, readmission, and mortality were compared for dialysis-dependent and nondialysis TKA patients using risk-adjusted logistic regression. To account for the smaller number of dialysis patients and variations in study populations, coarsened exact matching was used. The proportion of adverse events that occurred before vs after discharge was also assessed.

RESULTS

In total, 250 dialysis-dependent patients and 163,560 nondialysis patients met inclusion criteria. After controlling for patient demographics (age, sex, body mass index, functional status) and overall health (American Society of Anesthesiologists class), matched analysis revealed dialysis-dependent patients to be significantly more likely to experience any adverse event (odds ratio = 2.01; 95% confidence interval [CI], 1.34-3.02; P = .001), severe adverse event (odds ratio = 2.49; 95% CI, 1.61-3.84; P < .001), reoperation (odds ratio = 2.38; 95% CI, 1.19-4.75; P = .014), readmission (odds ratio = 2.32; 95% CI, 1.47-3.66; P = .001), and mortality (odds ratio = 6.71; 95% CI, 2.99-22.50; P = .002). The majority of adverse outcomes occurred postdischarge.

CONCLUSION

Independent of patient demographics and overall health (American Society of Anesthesiologists), patients undergoing dialysis before TKA are significantly more likely to experience 30-day adverse outcomes than matched nondialysis cohorts. Preoperative evaluation of bone health status and management of medical treatment are warranted in this fragile population. Cautious surgical planning, patient counseling, and heightened surveillance are necessitated throughout their perioperative period and postoperative recovery plans may need to be different from nondialysis counterparts. Furthermore, hospitals and physicians must take these increased risks into account when working on bundle payment reimbursement strategies and resource allocation.

LEVEL OF EVIDENCE

3.