Effect of comorbidity on length of hospital stay and in-hospital mortality among unintentionally injured patients

Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study

INTRODUCTION

Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults.

AIMS

i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma.

METHODS

A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019.

RESULTS

After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days.

CONCLUSION

Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.

Which Demographic and Clinical Characteristics Can Better Predict the Length of Hospital Stay among Traumatic Patients? A Retrospective Single-Center, Registry-Based Study

Background

Lengthy hospitalization may lead to an increased hospital-acquired patient complication, including infections, as well as increased costs for both healthcare systems and patients. A few studies evaluated the impact of various clinical and demographic variables on patients' length of stay (LOS). Hence, in this study, we aimed to investigate the impact of various variables on traumatic patients' LOS.

Methods

This is a retrospective single-center, registry-based study of traumatic patients admitted to Taleqani, a major trauma center in Kermanshah, Iran. A Minimal Dataset (MDS) was developed to retrieve traumatic data on demographic and clinical aspects. We used univariable and multiple quantile regression models to evaluate the association between independent variables, including ISS, GCS, and SBP, with LOS. LOS is practically defined as the time interval between hospital admission and discharge. The LOS durations have been presented as median (Q1 to Q3) hours. A p-value of <0.05 was considered statistically significant.

Results

A total of 2708 cases were included in this study, with 1989 (73.4%) of them being male. The median LOS was 87.00 (48.00 to 144.00) hours. When adjusted for systolic blood pressure (SBP), Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and cause of injury, the two characteristics of spine/back and multiple trauma were significantly associated with the higher LOS, with 43 (20.5 to 65.48) and 24 (10.39 to 37.60) hours more than extremities (P < 0.001 and P = 0.005). Besides, the patients admitted due to road traffic injuries (RTI) were discharged 16 and 41 hours later than falling and cutting/stabbing (P = 0.008 and < 0.001, respectively). Moreover, the patients with ISS≥16 and 9≤ISS≤15 had a median of 51 (21 to 80) and 34 (22 to 45) LOS hours more, compared to 1≤ISS≤8, respectively (P < 0.001). The trauma cases experiencing SBP ≤ 90 mmhg on admission had a median of 41 (20 to 62) hours more hospitalization period than those with SBP> 90 mmhg (P < 0.001). At last, the patients with GCS of 9 to 12 and GCS of 3 to 8 were hospitalized for 39 and 266 hours more than GCS of 13 to 15 (P < 0.001).

Conclusion

Determining independent determinants of prolonged LOS may lead to better identifying at-risk patients on admission. Trauma care providers should consider the following risk factors for increased LOS: higher ISS, Lower GCS, and SBP, multiple trauma or spine injury, and trauma resulting from falling or cutting/stabbing. As a result, the impact of extended LOS might be reduced by intervening in the related influencing factors.

Factors predicting oral and maxillofacial fractures after falling and factors predicting the duration of treatment

BACKGROUND/AIM

The first objective of this study was to identify predictive factors for oral and maxillofacial fractures at the initial response to the patient. The second objective was to determine the factors influencing the incidence of treatment duration of more than 1 month using the information shown in the medical record.

MATERIALS AND METHODS

Hospital records from 2011 to 2019 were reviewed to identify patients who had sustained oral and maxillofacial injuries by falling or falling from a height. Patterns and types of oral and maxillofacial injury, injury severity, and background of the injury were collected from the hospital records. The variables independently associated with a treatment duration of more than 1 month were determined by logistic regression analysis.

RESULTS

In total, 282 patients (150 men, 132 women; median age, 17.5 years) were selected for analysis. Maxillofacial fractures were observed in 20.9% of patients (59/282); among these, mandibular fractures were the most common (47/59). Logistic regression analysis showed that age (odds ratio [OR], 1.026), nighttime occurrence (OR, 2.192), and upper face injury (OR, 20.704) were independent predictive factors for having a maxillofacial fracture. Additionally, the number of injured teeth (OR, 1.515) and the use of intermaxillary fixation (OR, 16.091) were independent predictors of treatment duration of more than 1 month.

CONCLUSIONS

These results may be useful in the initial management of maxillofacial injuries in terms of better-informing patients injured by falling their expected treatment duration and managing the psychological impacts of a long treatment duration.

A nomogram for predicting risk of death during hospitalization in elderly patients with Alzheimer's disease at the time of admission

Background and objectives

Elderly patients with Alzheimer's disease (AD) often have multiple underlying disorders that lead to frequent hospital admissions and are associated with adverse outcomes such as in-hospital mortality. The aim of our study was to develop a nomogram to be used at hospital admission for predicting the risk of death in patients with AD during hospitalization.

Methods

We established a prediction model based on a dataset of 328 patients hospitalized with AD -who were admitted and discharged from January 2015 to December 2020. A multivariate logistic regression analysis method combined with a minimum absolute contraction and selection operator regression model was used to establish the prediction model. The identification, calibration, and clinical usefulness of the predictive model were evaluated using the C-index, calibration diagram, and decision curve analysis. Internal validation was evaluated using bootstrapping.

Results

The independent risk factors included in our nomogram were diabetes, coronary heart disease (CHD), heart failure, hypotension, chronic obstructive pulmonary disease (COPD), cerebral infarction, chronic kidney disease (CKD), anemia, activities of daily living (ADL) and systolic blood pressure (SBP). The C-index and AUC of the model were both 0.954 (95% CI: 0.929-0.978), suggesting that the model had accurate discrimination ability and calibration. Internal validation achieved a good C-index of 0.940.

Conclusion

The nomogram including the comorbidities (i.e., diabetes, CHD, heart failure, hypotension, COPD, cerebral infarction, anemia and CKD), ADL and SBP can be conveniently used to facilitate individualized identification of risk of death during hospitalization in patients with AD.

Impact of comorbidities on survival following major injury across different types of road users

BACKGROUND

While comorbidities and types of road users are known to influence survival in people hospitalised with injury, few studies have examined the association between comorbidities and survival in people injured in road traffic crashes. Further, few studies have examined outcomes across different types of road users with different types of pre-existing comorbidities. This study aims to examine differences in survival within 30 days of admission among different road user types with and without different pre-existing comorbidities.

METHOD

Retrospective cohort study using data for all major road trauma cases were extracted from the NSW Trauma Registry Minimum Dataset (1 January 2013 - 31 July 2019) and linked to the NSW Admitted Patient Data Collection, and the NSW Registry of Births, Deaths and Marriages - death dataset. Pre-existing comorbidities and road user types were identified by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and Charlson Comorbidity Index in the Trauma Registry, hospital admission, and death datasets. Logistic regression was used to assess the associations between six types of road users (pedestrian, pedal cycle, two- and three-wheel motorcycle, car and pick-up truck, heavy vehicle and bus, and other types of vehicle) and death within 30 days of hospital admission while controlling for comorbidities. All models used 'car and pick-up truck driver/passenger' as the road user reference group and adjusted for demographic variables, injury severity, and level of impaired consciousness.

RESULTS

Within 6253 traffic injury person-records (all aged ≥15 years old, ISS>12), and in final models, injured road users with major trauma who had a history of cardiovascular diseases (including stroke), diabetes mellitus, and higher Charlson Comorbidity Index score, were more likely to die, than those without pre-existing comorbidities. Furthermore, in final models, pedestrians were more likely to die than car occupants (OR: 1.68 - 1.77, 95CI%: 1.26 - 2.29 depending on comorbidity type).

CONCLUSIONS

This study highlights the need to prioritize enhanced management of trauma patients with comorbidities, given the increasing prevalence of chronic medical conditions globally, together with actions to prevent pedestrian crashes in strategies to reach Vision Zero.

Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning

Medical conditions can increase drowning risk. No prior study has systematically reviewed the published evidence globally regarding medical conditions and drowning risk for adults. MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest) and SPORTDiscus databases were searched for original research published between 1 January 2005 and 31 October 2021 that reported adult (≥15 years) fatal or non-fatal drowning of all intents and pre-existing medical conditions. Conditions were grouped into the relevant International Classifications of Diseases (ICD) codes. Eighty-three studies were included (85.5% high-income countries; 38.6% East Asia and Pacific region; 75.9% evidence level III-3). Diseases of the nervous system (n = 32 studies; 38.6%), mental and behavioural conditions (n = 31; 37.3%) and diseases of the circulatory system (n = 25; 30.1%) were the most common categories of conditions. Epilepsy was found to increase the relative risk of drowning by 3.8 to 82 times, with suggested preventive approaches regarding supervised bathing or showering. Drowning is a common suicide method for those with schizophrenia, psychotic disorders and dementia. Review findings indicate people with pre-existing medical conditions drown, yet relatively few studies have documented the risk. There is a need for further population-level research to more accurately quantify drowning risk for pre-existing medical conditions in adults, as well as implementing and evaluating population-level attributable risk and prevention strategies.

Clinical outcomes following major trauma for patients with a diagnosis of depression: a large UK database analysis

Background

More than a quarter of the UK population are affected by depression during their lifetime. For major trauma patients, postinjury depression can result in poorer long-term outcomes, but there is limited evidence regarding outcomes for patients with pre-existing depression. This study investigated the relationship between a diagnosis of depression prior to hospital admission and clinical outcomes after major trauma.

Methods

Trauma patients at a UK major trauma center were identified during a 6.5-year period using the Trauma Audit and Research Network database. Patients with Injury Severity Score >15 who did not die in the emergency department (ED) were included. Logistic regression models were used to compare in-hospital mortality (excluding ED), requirement for surgery, and length of stay (LOS) between those with depression and those without.

Results

There were 4602 patients included in the study and 6.45% had a diagnosis of depression. Depression was associated with a significant reduction in mortality (OR 0.54, 95% CI 0.30 to 0.91; p=0.026). However, patients with depression were more likely to have longer LOS (OR 124, 95% CI 8.5 to 1831; p<0.001) and intensive care unit LOS (OR 9.69, 95% CI 3.14 to 29.9; p<0.001). Patients with depression were also more likely to undergo surgery (OR 1.36, 95% CI 1.06 to 1.75; p=0.016).

Discussion

A pre-existing diagnosis of depression has complex association with clinical outcomes after major trauma, with reduced mortality but longer LOS and higher likelihood of surgical intervention. Further prospective investigations are warranted to inform optimal management strategies for major trauma patients with pre-existing depression.

Level of evidence

III.

Association of total pre-existing comorbidities with stroke risk: a large-scale community-based cohort study from China

Background

Comorbidities, any other coexisting diseases in patients with a particular index disease, are known to increase the mortality of a stroke. However, the association of pre-existing comorbidities with stroke risk has not been fully studied.

Methods

This study included 16,246 adults from a prospective community-based cohort with a baseline survey conducted in 2013 in China. Participants were followed up with hospitalization records and the Cause of Death Registry. The association of eight pre-existing comorbidities (coronary heart disease, hyperlipidemia, hypertension, diabetes, previous stroke, chronic obstructive pulmonary disease, nephropathy, and cancer) with stroke risk was analyzed using the Cox proportional hazard model in 2020.

Results

At a median follow-up of 5.5 years, a total of 449 participants (206 men and 243 women) developed a stroke. Four pre-existing comorbidities (hypertension, congenital heart disease, previous stroke, and diabetes) were independently and positively associated with the risk for all types of stroke. The adjusted hazard ratios for participants with only 1 and ≥ 2 pre-existing comorbidities compared with those without pre-existing conditions were 1.96 (95% CI: 1.44, 2.67; P < 0.001) and 2.87 (95% CI; 2.09, 3.94; P < 0.001) for total stroke, respectively. Moreover, male and female participants with a combination of increased age and a higher number of pre-existing comorbidities experienced the greatest risk of stroke.

Conclusions

The number of pre-existing comorbidities was independently associated with an increased risk of stroke. There was a synergic effect between increased age and a higher number of pre-existing comorbidities on stroke occurrence. Our novel findings emphasize the importance and potential application of pre-existing comorbidities as a risk indicator in stroke prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12002-1.

Data resource profile: the Korea National Hospital Discharge In-depth Injury Survey

The Korea National Hospital Discharge In-depth Injury Survey (KNHDIS), which was started in 2005, is a national probability survey of general hospitals in Korea with 100 or more beds conducted by the Korea Disease Control and Prevention Agency (KDCA). The KNHDIS captures approximately 9% of discharged cases from sampled hospitals using a 2-stage stratified cluster sampling scheme, among which 13% are injury related cases, defined as S00-T98 (injury, poisoning, and certain other consequences of external causes) using International Classification of Diseases, 10th revision codes. The KNHDIS collects information on characteristics of injury-related discharges in order to understand the scale of injuries, identify risk factors, and provide data supporting prevention policies and intervention strategies. The types of data captured include the hospitals’ information, detailed clinical information, and injury-related codes such as the mechanism, activities undertaken when injured (sports, leisure activities, work, treatment, and education), external causes of the injury, and location of the occurrence of the injury based on the International Classification of External Causes of Injuries. Furthermore, the means of transportation, risk factors for suicide, and toxic substances are recoreded. Annual reports of the KNHDIS are publicly accessible to browse via the KDCA website (http://www.kdca.go.kr) and microdata are available free of charge upon request via email (kcdcinjury@korea.kr).

Exploratory analysis on the association of mental health disorders with in-hospital postoperative complications and mortality in head and neck cancer surgery

BACKGROUND

The objective was to assess the association of mental health disorders with in-hospital complication and mortality rates in patients undergoing head and neck cancer surgery.

METHODS

In this exploratory retrospective study, the Nationwide Inpatient Sample was queried from 2003 to 2014 for all patients with a diagnosis of head and neck cancer who underwent surgery. Univariate cross-tabulation, logistic regression, and propensity score matching (PSM) were used to compare demographics, procedure-related variables, and in-hospital postoperative complications and mortality between patients with and without selected comorbid mental health disorders.

RESULTS

Of 39 600 included patients, 3390 (8.6%) had a selected comorbid mental health disorder diagnosis. After PSM, patients with selected mental health disorders had increased risk of overall medical complications on multivariable analysis (OR 1.28 [CI 1.12-1.46], P < 0.001) but not overall surgical complications or mortality.

CONCLUSIONS

Patients with a mental health disorder diagnosis have increased risk of in-hospital medical, certain surgical, and total complications.

Factors influencing the length of emergency room stay and hospital stay in non-fatal bicycle accidents: A retrospective analysis

PURPOSE

Lengthy hospitalization places a burden on patients and healthcare resources. However, the factors affecting the length of hospital stay (LHoS) and length of emergency room stay (LERS) in non-fatal bicycle accidents are currently unclear. We investigated these factors to inform efforts to minimize hospitalization.

METHODS

We performed a retrospective analysis of data from non-fatal injured bicyclists admitted to the Emergency and Critical Care Center at Kyoto Medical Center between January 2012 and December 2016. We measured LHoS, LERS, mechanism of injury, head injury prevalence, polytrauma, operations performed, injury severity score (ISS), abbreviated injury scale (AIS) score, maximum AIS score, and trauma and injury severity score probability of survival. We conducted multiple regression analysis to determine predictors of LHoS and LERS.

RESULTS

Within the study period, 82 victims met the inclusion and exclusion criteria and were included. Mean age was (46.0 ± 24.7) years. Overall mean LHoS was (16.8 ± 25.2) days, mean LERS was (10.6 ± 14.7) days, median ISS was 9 (interquartile range (IQR): 3-16), median maximum AIS was 3 (IQR: 1-4), and median trauma and injury severity score probability of survival was 98.0% (IQR: 95.5%-99.6%). Age, maximum AIS, ISS, and prevalence of surgery were significantly greater in long LHoS and LERS group compared with short LHoS and LERS group (p < 0.05). Performance of surgery independently explained LHoS (p = 0.0003) and ISS independently explained LERS (p = 0.0009).

CONCLUSION

Surgery was associated with long hospital stays and ISS was associated with long emergency room stays. To improve the quality life of the bicyclists, preventive measures for reducing injury severity or avoiding injuries needing operation are required.

Health care utilisation for treatment of injuries among immigrants in Norway: a nationwide register linkage study

Background

Previous research has generally found lower rates of injury incidence in immigrant populations than in native-born populations. Most of this literature relies on mortality statistics or hospital data, and we know less about injuries treated in primary health care. The aim of the present study was to assess use of primary and secondary care for treatment of injuries among immigrants in Norway according to geographic origin and type of injury.

Methods

We conducted a nationwide register-based cohort study of all individuals aged 25–64 years who resided in Norway as of January 1st 2008. This cohort was followed through 2014 by linking sociodemographic information and injury data from primary and secondary care. We grouped immigrants into six world regions of origin and identified immigrants from the ten most frequently represented countries of origin. Six categories of injury were defined: fractures, superficial injuries, open wounds, dislocations/sprains/strains, burns and poisoning. Poisson regression models were fitted to estimate incidence rate ratios separately for injuries treated in primary and secondary care according to immigrant status, geographic origin and type of injury, with adjustment for sex, age, county of residence, marital status and socioeconomic status.

Results

Immigrants had a 16% lower incidence of injury in primary care than non-immigrants (adjusted IRR = 0.84, 95% CI 0.83–0.84), and a 10% lower incidence of injury in secondary care (adjusted IRR = 0.90, 95% CI 0.90–0.91). Immigrants from Asia, Africa and European countries outside EU/EEA had lower rates than non-immigrants for injuries treated in both primary and secondary care. Rates were lower in immigrants for most injury types, and in particular for fractures and poisoning. For a subset of injuries treated in secondary care, we found that immigrants had lower rates than non-immigrants for treatment of self-harm, falls, sports injuries and home injuries, but higher rates for treatment of assault, traffic injuries and occupational injuries.

Conclusions

Health care utilisation for treatment of injuries in primary and secondary care in Norway was lower for immigrants compared to non-immigrants. Incidence rates were especially low for immigrants originating from Asia, Africa and European countries outside EU/EEA, and for treatment of fractures, poisoning, self-harm and sports injuries.

Non-psychiatric hospitalization length-of-stay for patients with psychotic disorders: A mixed methods study

OBJECTIVE

Patients with psychotic disorders experience higher rates of chronic and acute non-psychotic diseases and have frequent non-psychiatric hospitalizations which result in both longer and more varied length-of-stay (LoS) than other patients. This study seeks to use a patient-centered perspective to examine LoS.

METHODS

This article reports Phase Two of a mixed methods, exploratory sequential study on non-psychiatric hospitalizations for individuals with psychotic disorders. Patients' experiences were used to guide a quantitative analysis of LoS using a general linear model.

RESULTS

Medical comorbidities were the patient characteristics which had the largest effect on LoS. Certain processes of care highlighted by patients from Phase One were also associated with longer LoS, including: physical restraints (105%), psychiatric consults (20%) and continuous observation (133%). Only recent in-system outpatient appointments were associated with shorter LoS. Data integration highlighted that factors which were important to patients such as partner support, were not always quantitatively significant, while others like medical comorbidities and use of physical restraints were points of congruence.

CONCLUSIONS

Medical comorbidities were highly associated with LoS but processes relating to longer LoS are those that are used to manage symptoms of acute psychosis. Clinicians should develop policies and procedures that address psychosis symptoms effectively during non-psychiatric hospitalizations. Further research is needed to understand which patients with psychotic disorders are at highest risk of extended length-of-stay.

Frequency and predictors of 30-day readmission after an index hospitalization for generalized convulsive status epilepticus: A nationwide study

OBJECTIVE

The objective of the study was to assess the frequency and factors associated with all-cause 30-day readmission among patients hospitalized with generalized convulsive status epilepticus (GCSE) in a nationwide sample in the United States.

METHODS

We used The 2014 Nationwide Readmission Database (NRD) as the data source. We included adults (age ≥18 years) with a primary discharge diagnosis of GCSE, identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 345.3. We excluded patients who died during hospitalization and those who had missing information on the length of stay (LOS). We also excluded those discharged in December 2014. We computed the overall 30-day readmission rate and compared prespecified groups by their 30-day readmission status. We applied a multiple logistic regression analysis to identify independent predictors of all-cause 30-day readmission adjusting for potential confounders.

RESULTS

Among 14,562 (weighted 31,062) adults discharged with a diagnosis of GCSE, 2520 (17.3%) were readmitted within 30 days. In multivariate analysis, patients with comorbid conditions (odds ratio (OR) for Charlson Comorbidities Index (CCI) = 1 and ≥2 was 1.12, 95% confidence interval (CI): 1.0-1.36 and 1.32, 95% CI: 1.17-1.48, respectively), LOS >6 days (OR: 1.42; 95% CI: 1.05-192), discharged against medical advice (OR: 1.45; 95% CI: 1.09-1.92), or discharged to a short-term hospital (OR: 1.39; 95% CI: 1.0-1.88), had higher odds of 30-day readmission, while there was an inverse association for those aged ≥45 years or with high income. Seizures were the most common cause associated with readmission, followed by sepsis and cerebrovascular diseases, respectively.

SIGNIFICANCE

Little is known about the frequency and predictors of early readmission after GCSE. This study showed that more than one in six patients with GCSE was readmitted within 30 days after discharge. More considerable attention to high-risk subgroups may identify opportunities to ameliorate the clinical outcome and lessen the economic burden of early readmission after GCSE.

Comparison of the characteristics of work-related injuries between older workers and the workers of the conventional working-age in the Republic of Korea, 2010-2014

OBJECTIVE

With population ageing, the number of older workers is increasing and the number of work-related injuries in older people is also increasing. Occupational patterns and work-related injury patterns vary with age. This study aimed to compare the incidence and characteristics of work-related injuries in older and younger workers in Korea.

METHODS

We conducted a retrospective review of the characteristics of workers hospitalised with work-related injuries from January 2010 to December 2014, using data from the National Hospital Discharge In-Depth Injury Survey in South Korea. The analysis was stratified by age into older (aged ≥65 years) and younger (aged 20-64 years) workers.

RESULTS

The hospitalisation rate in older workers was double that of younger workers (2014 IRR: 2.06, 95% CI 1.53 to 2.76). Compared with workers of conventional working-age, a higher proportion of injured older workers were female (33.1% vs 13.6%, p<0.001), injured due to falls (40.8% vs 28.5%) and injured while working on a farm (46.5% vs 6.3%, p<0.001). In older workers, work-related injuries were seasonal and peaked during summer, but there was little seasonality in injuries among younger workers.

CONCLUSION

Older workers are more vulnerable to work-related injuries and have a different profile of work-related injuries from younger workers. Age-related differences in the injury profile need to be considered when developing workplace injury prevention policies and programmes, and the specific vulnerabilities of older workers need to be addressed.

The Incremental Hospitalization Cost of Significant Transport-Related Traumatic Brain Injury

AIM

This study aims to determine the incremental cost of acute hospitalization for traumatic brain injury (TBI) compared with matched controls. A second purpose is to identify the factors contributing to this hospital costs.

METHODOLOGY

Analyses were performed on administrative data for injured patients, hospitalized in Belgium between 2009 and 2011 following a road traffic accident. Cases were matched to a control with similar injuries but without TBI. The incremental hospitalization cost of TBI and the factors contributing to the hospital costs were determined using multivariable regression modeling with gamma distribution and log link.

RESULTS

A descriptive comparison of cases and controls shows clear differences in healthcare utilization and costs. The presence of a TBI increases the cost by a factor between 1.66 (95% confidence interval: 1.52-1.82) and 2.08 (95% confidence interval: 1.72-2.51). Regarding healthcare utilization, the most important determinants of hospital costs are surgical complexity, use of magnetic resonance imaging, intensive care unit admission, and mechanical ventilation.

DISCUSSION

To our knowledge, this is the first matched-control study calculating the incremental hospitalization cost of TBI. The insights provided by this study are relevant in the context of prospective payments and can be an incentive for investments in prevention policies and extramural care.

Risk factors for in-hospital mortality in patients with dementia

OBJECTIVE

To examine the in-hospital mortality rate, and its risk factors, for patients with dementia admitted to hospital.

STUDY DESIGN

We constructed an observational cohort study through data linkage of three Dutch national registers: the hospital discharge register (HDR), the population register (PR) and the national cause of death register. Patients with dementia in the HDR aged between 60 and 100 years registered between 1 January 2000 and 31 December 2010 were included.

MAIN OUTCOME MEASURES

Risk factors for in-hospital mortality were investigated using multivariable Cox proportional hazard regression models that included sex, age, marital status, ethnicity, somatic comorbidity, type of dementia and urgency of admission.

RESULTS

40,500 patients were included in the cohort. The overall in-hospital mortality rate was 11.1%. Factors that significantly increased the mortality risk were: male sex (adjusted hazard ratio (HR) 1.52, 95%-confidence interval (95%-CI) 1.43-1.63), higher age (adjusted HR 1.03, 95%-CI 1.03-1.04), living with a partner (adjusted HR 1.39, 95%-CI 1.30-1.49), acute admission (adjusted HR 2.16, 95%-CI 1.97-2.36) and Alzheimer's disease (adjusted HR 1.21, 95%-CI 1.13-1.29). Cardiovascular disease was the most common cause of in-hospital mortality.

CONCLUSIONS

This nationwide study found several independent risk factors for the in-hospital mortality of patients with dementia, including male sex, higher age, living with a partner, acute admission, and Alzheimer's disease. These risk factors should be taken into account by clinicians and caregivers as they will indicate whether patients are at risk of a more unfavourable outcome during hospital admission.

Incidence-Based versus Prevalence-Based Approaches on Measuring Disability-Adjusted Life Years for Injury

BACKGROUND

Injury represents an important aspect of disease that affects everyone at some point in their lives. To better understand and prevent these injuries, various analytical methods have been developed to assess both the magnitude and features of injury burden. In this study, we attempted to estimate the injury burden of Korea in 2014 by comparing the prevalence-based approach used by the Global Burden of Diseases (GBD) team and the World Health Organization against an alternative incidence-based approach, and to assess the different implications of these measurements.

METHODS

The 10th Korean National Hospital Discharge survey data and causes of death statistics in 2014 were used as data sources. Years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life years (DALYs) were calculated using both the incidence- and prevalence-based approaches. The Korean Classification of Diseases (KCD) version 5 diagnostic codes were used to classify the mechanism of injury.

RESULTS

The prevalence-based injury burden tended to be higher (1,670,229 DALYs) than the incidence-based injury burden (1,544,467 DALYs). The elderly population exhibited a higher prevalence-based YLD and DALY relative to incidence-based outcomes. In order of significance, the three most common causes of injury as calculated using an incidence-based approach were road injury, fall, and self-harm, compared with a prevalence-based method, which identified self-harm, road injury, and falls as the most common injuries.

CONCLUSION

An appropriate prevention program is needed for injuries with potential to cause long-lasting morbidity. Accordingly, a tailored injury-prevention strategy should be developed for each high-risk group.

Determinants and Variations of Hospital Costs in Patients With Lumbar Radiculopathy Hospitalized for Spinal Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to determine hospital costs related to surgery for lumbar radiculopathy and identify determinants of intramural costs based on minimal hospital and claims data.

SUMMARY OF BACKGROUND DATA

Costs related to the initial hospitalization of patients undergoing surgery for lumbar radiculopathy make up the major part of direct health care expenditure in this population. Identifying factors influencing intramural costs can be beneficial for health care policy makers, and clinicians working with patients with lumbar radiculopathy.

METHODS

The following data were collected from the University Hospital Brussels data warehouse for all patients undergoing surgery for lumbar radiculopathy in 2016 (n = 141): age, sex, primary diagnosis, secondary diagnoses, type of surgery, severity of illness (SOI), admission and discharge date, type of hospital admission, and all claims incurred for the particular hospital stay. Descriptive statistics for total hospital costs were performed. Univariate analyses were executed to explore associations between hospital costs and all other variables. Those showing a significant association (P < 0.05) were included in the multivariate general linear model analysis.

RESULTS

Mean total hospital costs were &OV0556; 5016 ± 188 per patient. Costs related to the actual residence (i.e., "hotel costs") comprised 53% of the total hospital costs, whereas 18% of the costs were claimed for the surgical procedure. Patients with moderate/major SOI had 44% higher hospital costs than minor SOI (P = 0.01). Presence of preadmission comorbidities incurred 46% higher costs (P = 0.03). Emergency procedures led to 72% higher costs than elective surgery (P < 0.001). Patients receiving spinal fusion had 211% higher hospital costs than patients not receiving this intervention (P < 0.001).

CONCLUSION

Hospital costs in patients receiving surgery for lumbar radiculopathy are influenced by SOI, the presence of preadmission comorbidities, type of hospital admission (emergency vs. elective), and type of surgical procedure.

LEVEL OF EVIDENCE

3.

[Changes in age distribution and frequency of comorbidities in patients in the occupational insurance association treatment process]

BACKGROUND

Due to the demographic development the proportion of older patients has increased. These show at least a higher rate of comorbidities, which affects the length of inpatient hospital stay. Until now no uniform recording exists for such comorbidities within the occupational insurance association system even if the clinical relevance is beyond dispute. Adaptations within the system with increased interdisciplinary treatment are necessary.

OBJECTIVE

The aim of this study was to analyze changes in the age distribution and the frequency of comorbidities in patients in the occupational insurance association system.

METHODS

The study was a retrospective analysis of age distribution and comorbidities of all operatively treated occupational insurance association patients in 2005 (n = 631), 2010 (n = 1180) and 2015/2016 (n = 2315). A comparison of the age groups ≤29 years, 30-49 years, 50-65 years and ≥66 years was performed.

RESULTS

The proportion of patients aged 50-65 years showed a significant increase: 2005 (26.5%), 2010 (30.5%) and 2015/2016 (37.3%) (p < 0.001) and an increased proportion of patients with at least 1 comorbidity: 2005 (38.7%), 2010 (52.5%) and 2015/2016 (52.9%) (p = 0.01). This was statistically significant (p < 0.001, p = 0.005) within the age group 30-49 years (2005: 31.1%, 2015/2016: 49.0%) and the age group 50-65 years (2005: 55.7%, 2015/2016: 67.1%). Significant changes were found for arterial hypertension, morbid obesity, thyroid and respiratory diseases. In addition, there was an increase in multimorbid patients.

DISCUSSION

A changing age distribution with a tendency to an increased number of older patients and an increased frequency of comorbidities could be determined. In the present documentation system of the occupational insurance association treatment procedure these comorbidities are insufficiently recorded and considered, even though their clinical relevance is indisputable. Adaptations with respect to intensified interdisciplinary cooperation are necessary.

Trend in Disability-Adjusted Life Years (DALYs) for Injuries in Korea: 2004-2012

BACKGROUND

Injury is a major public health problem and accounts for 10% of the global burden of disease. This study intends to present the temporal trend in the injury burden in Korea and to compare the burden size by injury mechanism and age group.

METHODS

This study was a nationwide population-based observational study. We used two data sets, the death certificates statistics and the Korean National Hospital Discharge Survey data (2004-2012). We calculated age-standardized disability-adjusted life year (DALY) from years of life lost (YLL) and years lived with disability (YLD) and trend analysis.

RESULTS

The DALYs of road injury decreased (P = 0.002), falls did not exhibit a trend (P = 0.108), and self-harm increased overall (P = 0.045). In the road injury, the YLLs decreased across all 4 age groups (0-14, 15-49, 50-79, ≥ 80) and the YLDs decreased in the 0-14-year-old group. In total, the DALYs of road injuries decreased in the 0-14-year-old group. In the fall injury, although the YLLs decreased in the over 80-year-old group, the YLDs increased in the 50-79-year-old group and the over 80-year-old group. The burden of self-harm injury was high in the age group 15 years and over, especially in the 15-49-year-old group.

CONCLUSION

The leading causes of the injury burden were road injuries, falls, and self-harm. The burden of road injury and self-harm have recently shown a gradual decreasing tendency. On the other hands, that of fall injuries are continually high in the age group over 50 years of age.

Socioeconomic disparities in the thoracic trauma population

BACKGROUND

Health-care disparities based on socioeconomic status have been well documented in the trauma literature; however, there is a paucity of data on how these factors affect outcomes in patients experiencing severe thoracic trauma. This study aims to identify the effect of insurance status and race on patient mortality and disposition after thoracic trauma.

METHODS

The National Trauma Data Bank was queried from 2007 to 2012 for patients with sternal fractures, rib fractures, and flailed chest. Demographics data were examined for the cohort based on insurance status. Univariate and multivariate logistic regression models were used, controlling for patient comorbidities, age, injury severity score, and associated injuries, to determine the impact of race and insurance status on length of stay, mortality, and discharge disposition.

RESULTS

A total of 152,655 thoracic traumas were included in our analysis. As compared to privately insured patients, uninsured patients with thoracic trauma were 1.9 times more likely to die (odds ratio [OR]: 1.91, confidence interval [CI]: 1.76-2.09) and 4.6 times more likely to leave against medical advice (OR: 4.61, CI: 3.14-6.79). When compared to Caucasians, Hispanics had slightly higher in-hospital mortality (OR: 1.14, CI: 1.02-1.27), but there was no survival difference seen in black patients (OR: 0.95, CI: 0.86-1.05).

CONCLUSIONS

Insurance status appears to have a more significant effect on thoracic trauma patient outcomes than race, but substantial socioeconomic disparities were seen in this patient population. Further studies are needed to show reproducibility of our findings and to investigate the impact of universal health care and expansion of insurance availability on thoracic trauma outcomes.

LEVEL OF EVIDENCE

Level 3, economic/decision.

Outcomes after traumatic injury in patients with preexisting psychiatric illness

BACKGROUND

Patients with psychiatric illness have been shown to experience higher rates of traumatic injury. Injury patterns, treatment decisions, and outcomes have not been well characterized in patients with psychiatric illness after injury, in particular those who undergo acute surgical intervention. The purpose of this analysis was to determine mortality, complications, and surgical intervention rates in patients with psychiatric illness after traumatic injury.

METHODS

This is a retrospective study of trauma patients ≥18 years old admitted to LAC + USC Medical Center between January 2008 and March 2015. Patients with psychiatric diagnoses were identified using ICD-9 diagnosis codes. Multivariate logistic regression analyses taking into account demographic and injury characteristics were used to identify associations between psychiatric comorbidity, injury mechanism, surgical interventions, and outcomes in patients after injury.

RESULTS

A total of 26,502 patients were analyzed. Of these, 3,040 (11.5%) had a documented psychiatric comorbidity (2.0% depressive disorder, 0.8% bipolar disorder, 1.3% schizophrenia, 0.5% anxiety disorder, 3.2% substance use disorder). Patients with psychiatric illness were significantly older (49.6 years vs. 42.0 years, p < 0.001), had a lower proportion of penetrating injuries (13.8% vs. 18.1%, p < 0.001), and had a higher incidence of self-inflicted injuries (11.6% vs. 0.72%, p < 0.001). No difference in gender distribution was observed (74.2% men vs. 74.4% men, p = 0.80). Overall mortality was similar in both groups (adjusted odds ratio [aOR], 0.73; p = 0.07). Patients with psychiatric illness were significantly less likely to undergo acute surgical intervention within 6 hours of emergency department admission (aOR, 0.64; p < 0.001). Time from ED arrival to consent for acute surgical intervention was similar in both groups (94.8 min vs. 93.0 min, p = 0.84). No significant difference in mortality after acute surgical intervention was observed (aOR, 0.26; p = 0.10). Psychiatric illness was associated with a significantly higher likelihood of developing complications (aOR, 1.90; p < 0.001) and longer hospital lengths of stay (10.6 days vs. 6.2 days, p < 0.001).

CONCLUSIONS

Trauma patients with comorbid psychiatric illness were observed to have lower rates of acute surgical interventions, higher complication rates, and longer hospital lengths of stay. Further studies are needed to better characterize the causative factors underlying these associations.

LEVEL OF EVIDENCE

Epidemiological, level III.

Variations in hospital costs after traffic injuries: The importance of sociodemographic aspects and comorbidities

OBJECTIVE

The impact of sociodemographic aspects and comorbidities on the inpatient hospital care costs of traffic victims are not clear. The main goal of this study is to provide insights into the sociodemographic characteristics and clinical conditions (including comorbidities) of the victims that result in higher hospital costs.

PARTICIPANTS

For the period 2009-2011, people admitted to a hospital as a result of a road traffic crash (N=64,304) were identified in the national Minimal Hospital Dataset, after which they were linked to their respective claims data from the sickness funds.

METHODS

A generalized linear model was used to analyse hospital costs controlling for roadway user categories, demographics (gender, age, individual socioeconomic status (SES)), and clinical factors (the nature, location, and severity of injury, and comorbidities).

RESULTS

The median hospital cost was € 2801 (IQR € 1510-€ 7175, 2015 Euros). There was no significant difference between gender. Low SES inpatients incurred 16% (95% CI: 14%-18%) higher hospital costs than inpatients of high SES. The presence of comorbidities was associated with an increased hospital cost, however with varying magnitude. For example traffic victims suffering from dementia incur significantly higher hospital costs than those who were not (49% higher, 95% CI: 44%-53%), whereas diabetes was associated with a smaller increase in costs compared to non-diabetics (13%, 95% CI: 10%-16%).

CONCLUSION

Comorbidities and low SES are associated with higher hospital costs for traffic victims, notwithstanding their age, and the nature and the severity of their injury. The broad variability of hospital costs among trauma inpatients should be accounted for when reconsidering financing models. Furthermore, the strong predictive value of some comorbidities and SES on hospital costs should be considered when projections of future health care utilisation in traffic safety scenarios are prepared.

Patterns of health care use of injured adults: A population-based matched cohort study

BACKGROUND

Healthcare use by traumatically injured individuals prior to and subsequent to their injury are not often explored for different types of injuries. This study aims to describe health care use 12 months preceding and 12 months following a traumatic injury by injury type and injury severity.

METHOD

Hospital and mortality data from three Australian states were linked in a population-based matched cohort study. Individuals ≥18 years who had an injury-related hospital admission in 2009 were identified as the injured cohort. A comparison cohort of non-injured people, matched 1:1 on age, gender and postcode of residence, was randomly selected from the electoral roll. Twelve-month pre- and post-index injury health service use was examined. Rates, adjusted rate ratios and attributable risk proportions were calculated by injury type and severity.

RESULTS

The injury cohort experienced higher 12-month pre- and post-injury hospital admissions than the non-injured group. By 6 to 7 months post-injury, the injury cohort had largely returned to their pre-injury health service use levels, except for injuries involving dislocations, sprains and strains and injury to nerves and spinal cord. Hip fracture (17.69 per 100 person-months) and poisoning (16.09 per 100 person-months) had the highest rates of post-injury hospitalisation in the injured cohort. The adjusted rate ratios (ARR) for post-injury hospitalisation were highest for poisoning (ARR: 3.77; 95% CI: 3.38-4.21) and injury to nerves and spinal cord (ARR: 2.73; 95% CI: 2.27-3.28). Poisoning also had the highest ARR for post-injury LOS (ARR: 5.31; 95% CI: 4.51-6.27).

CONCLUSIONS

After sustaining a traumatic injury, many individuals are readmitted to hospital and require ongoing care up to 12 months post-injury. That injured individuals post-injury largely return to their pre-index injury hospital use by 6 to 7 months could imply a return to pre-injury function and/or that other measures of health service use should be explored. Trauma services should consider long-term follow-up and support services for seriously injured patients post-hospital discharge.

Coagulation Profile as a Risk Factor for 30-Day Morbidity and Mortality Following Posterior Lumbar Fusion

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to identify associations between abnormal coagulation profile and postoperative morbidity and mortality in patients undergoing posterior lumbar fusion (PLF).

SUMMARY OF BACKGROUND DATA

The literature suggests that abnormal coagulation profile is associated with postoperative complications, notably the need for blood transfusion. However, there is little research that directly addresses the influence of coagulation profile on postoperative complications following PLF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP) was utilized to identify patients undergoing PLF between 2006 and 2013. Nine thousand two hundred ninety-five patients met inclusion criteria. Multivariate analysis was utilized to identify associations between abnormal coagulation profile and postoperative complications.

RESULTS

Low platelet count was an independent risk factor for organ space surgical site infections (SSIs) [odds ratio (OR) = 6.0, P < 0.001], ventilation >48 hours (OR = 4.5, P = 0.002), Acute renal failure (OR = 5.8, P = 0.007), transfusion (OR = 1.6, P < 0.001), sepsis (OR = 2.2, P = 0.037), reoperation (OR = 2.5, P = 0.001), and death (OR = 3.7, P = 0.049). High partial thromboplastin time (PTT) was an independent risk factor for ventilation >48 hours (OR = 5.6, P = 0.002), cerebrovascular accident (CVA)/stroke with neurological deficit (OR = 5.1, P = 0.011), cardiac arrest (OR = 5.4, P = 0.030), transfusion (OR = 1.5, P = 0.020), and death (OR = 4.5, P = 0.050). High International Normalized Ration (INR) was an independent risk factor for pneumonia (OR = 8.7, P = 0.001), pulmonary embolism (OR = 5.6, P = 0.021), deep venous thrombosis/Thrombophlebitis (OR = 4.8, P = 0.011), septic shock (OR = 8.4, P = 0.048), and death (OR = 9.8, P = 0.034). Bleeding disorder was an independent risk factor for organ space SSI (OR = 5.4, P = 0.01), pneumonia (OR = 3.0, P = 0.023), and sepsis (OR = 4.4, P < 0.001).

CONCLUSION

Abnormal coagulation profile was an independent predictor of morbidity and mortality in patients undergoing PLF. As such, it should be considered in preoperative optimization and risk stratification.

Higher mortality risk among injured individuals in a population-based matched cohort study

BACKGROUND

Improved understanding of long-term mortality attributable to injury is needed to accurately inform injury burden studies. This study aims to quantify and describe mortality attributable to injury 12 months after an injury-related hospitalisation in Australia.

METHOD

A population-based matched cohort study using linked hospital and mortality data from three Australian states during 2008-2010 was conducted. The injured cohort included individuals ≥18 years who had an injury-related hospital admission in 2009. A comparison cohort of non-injured people was obtain by randomly selecting from the electoral roll. This comparison group was matched 1:1 on age, gender and postcode of residence. Pre-index injury health service use and 12-month mortality were examined. Adjusted mortality rate ratios (MRR) and attributable risk were calculated. Cox proportional hazard regression was used to examine the effect of risk factors on survival.

RESULTS

Injured individuals were almost 3 times more likely to die within 12 months following an injury (MRR 2.90; 95% CI: 2.76-3.04). Individuals with a traumatic brain injury (MRR 7.58; 95% CI: 5.92-9.70) or injury to internal organs (MRR 7.38; 95% CI: 5.90-9.22) were 7 times more likely to die than the non-injured group. Injury was likely to be a contributory factor in 92% of mortality within 30 days and 66% of mortality at 12 months following the index injury hospital admission. Adjusted mortality rate ratios varied by type of cause-specific death, with MRR highest for injury-related deaths.

CONCLUSIONS

There are likely chronic consequences of sustaining a traumatic injury. Longer follow-up post-discharge is needed to consider deaths likely to be attributable to the injury. Better enumeration of long-term injury-related mortality will have the potential to improve estimates of injury burden.

Disability-Adjusted Life Years (DALYs) for Injuries Using Death Certificates and Hospital Discharge Survey by the Korean Burden of Disease Study 2012

A system for assessing the burdens imposed by disease and injury was developed to meet healthcare, priority setting, and policy planning needs. The first such system, the Global Burden of Disease (GBD), was implemented in 1990. However, problems associated with limited data and assumed disability weightings remain to be resolved. The purpose of the present study was to estimate national burdens of injuries in Korea using more reliable data and disability weightings. The incidences of injuries were estimated using the Korean National Hospital Discharge Survey and the mortality data from the Korean National Statistical Office in 2010. Additionally, durations of injuries and age at injury onset were used to calculate disability-adjusted life years (DALY) using disability weightings derived from the Korean Burden of Disease (KBD) study. Korea had 1,581,072 DALYs resulting from injuries (3,170 per 100,000), which was 22.9% higher than found by the GBD 2010 study. Males had almost twice as heavy an injury burden as females. Road injury, fall, and self-harm ranked 1st, 2nd, and 3rd in terms of burden of injury in 2010. Total injury burden peaked in the forties, while burden per person declined gradually from early adulthood. We hope that this study contributes to the reliable evaluation of injury burden and a better understanding of injury-related health status using nation-specific, dependable data.

The differential associations of preexisting conditions with trauma-related outcomes in the presence of competing risks

INTRODUCTION

Pre-existing chronic conditions (PECs) pose a unique problem for the care of aging trauma populations. However, the relationships between specific conditions and outcomes after injury are relatively unknown. Evaluation of trauma patients is further complicated by their discharge to care facilities, where mortality risk remains high. Traditional approaches for evaluating in-hospital mortality do not account for the discharge of at-risk patients, which constitutes a competing risk event to death. The objective of this study was to evaluate associations between 40 PECs and two clinical outcomes in the context of competing risks among older trauma patients.

METHODS

This retrospective study evaluated blunt-injured patients aged 55 years and older admitted to a level I trauma centre in 2006-2012. Outcomes were hospital length of stay (HLOS) and in-hospital mortality. Survivors were classified as discharges home or discharges to care facilities. Competing risks regression was used to evaluate each PEC with in-hospital mortality, accounting for discharges to care facilities as competing events. Competing risk estimates were compared to Cox model estimates, for which all survivors to discharge were non-events. Analyses were stratified using injury-based mortality risk at a 50% cutpoint (high versus low).

RESULTS

Among 4653 patients, 176 died in-hospital, 3059 were discharged home, and 1418 were discharged to a care facility. Most patients (98%) were classified with a low mortality risk. Only haemophilia and coagulopathy were consistently associated with longer HLOS. In the low-risk subgroup, in-hospital mortality was most strongly associated with liver diseases, haemophilia, and coagulopathy. In the high-risk group, Parkinson's disease, depression, and cancers showed the strongest associations. Accounting for the competing event altered estimates for 12 of 19 significant conditions.

CONCLUSIONS

Excess mortality among patients expected to survive their injuries may be attributable to complications resulting from PECs. Discharges to care facilities constitute a bias in the evaluation of in-hospital mortality and should be considered for the accurate calculation of risk. In conjunction with injury measures, consideration of PECs provides physicians with a foundation to plan clinical decisions in older trauma patients.