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Atkins K, Cairns B, Schneider A, Charles A. An evaluation of the "Obesity Paradox" in isolated blunt abdominal trauma in the United States. Injury 2024; 55:111612. [PMID: 38759489 PMCID: PMC11179957 DOI: 10.1016/j.injury.2024.111612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/23/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND The obesity paradox theorizes a survival benefit in trauma patients secondary to the cushioning effect of adiposity. We aim to evaluate the impact of body mass index (BMI) on abdominal injury severity, morbidity, and mortality in adults with isolated, blunt abdominal trauma in the United States. METHODS We reviewed the National Trauma Data Bank (2013-2021) for adults sustaining isolated, blunt abdominal trauma stratified by BMI. We performed a doubly robust, augmented inverse-propensity weighted multivariable logistic regression to estimate the average treatment effect (ATE) of BMI on mortality and the presence of abdominal organ injury. RESULTS 36,350 patients met the inclusion criteria. In our study, 41.4 % of patients were normal-weight (BMI 18.5-24.9), 20.6 % were obese (BMI 30-39.9), and 4.7 % were severely obese (BMI≥40). In these cohorts, the abdominal abbreviated injury scale (AIS) was 2 (2 -3). Obese and severely obese patients had significantly reduced presence of pancreas, spleen, liver, kidney, and small bowel injuries. The predicted probability of abdominal AIS severity decreased significantly with increasing BMI. Crude mortality was significantly higher in obese (1.3 %) and severely obese patients (1.3 %) compared to normal-weight patients (0.7 %). Obese and severely obese patients demonstrated non-statistically significant changes in the mortality of +26.4 % (ATE 0.264, 95 %CI -0.108-0.637, p = 0.164) and +55.5 % (ATE 0.555, 95 %CI -0.284-1.394, p = 0.195) respectively, compared to normal weight patients. CONCLUSION BMI may protect against abdominal injury in adults with isolated, blunt abdominal trauma. Mortality did not decrease in association with increasing BMI, as this may be offset by the increase in co-morbidities in this population.
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Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, USA.
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Liu XY, Qin YM, Tian SF, Zhou JH, Wu Q, Gao W, Bai X, Li Z, Xie WM. Performance of trauma scoring systems in predicting mortality in geriatric trauma patients: comparison of the ISS, TRISS, and GTOS based on a systemic review and meta-analysis. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02467-1. [PMID: 38363328 DOI: 10.1007/s00068-024-02467-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/22/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE This meta-analysis aimed to evaluate the performance of the Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), and the Geriatric Trauma Outcome Score (GTOS) in predicting mortality in geriatric trauma patients. METHODS The MEDLINE, Web of Science, and EMBASE databases were searched for studies published from January 2008 to October 2023. Studies assessing the performance of the ISS, TRISS, or GTOS in predicting mortality in geriatric trauma patients (over 60 years old) and reporting data for the analysis of the pooled area under the receiver operating characteristic curve (AUROC) and the hierarchical summary receiver operating characteristic curve (HSROC) were included. Studies that were not conducted in a group of geriatric patients, did not consider mortality as the outcome variable, or had incomplete data were excluded. The Critical Appraisal Skills Programme (CASP) Clinical Prediction Rule Checklist was utilized to assess the risk of bias in included studies. STATA 16.0. was used for the AUROC analysis and HSROC analysis. RESULTS Nineteen studies involving 118,761 geriatric trauma patients were included. The pooled AUROC of the TRISS (AUC = 0.82, 95% CI: 0.77-0.87) was higher than ISS (AUC = 0.74, 95% CI: 0.71-0.79) and GTOS (AUC = 0.80, 95%CI: 0.77-0.83). The diagnostic odds ratio (DOR) calculated from HSROC curves also suggested that the TRISS (DOR = 21.5) had a better performance in predicting mortality in geriatric trauma patients than the ISS (DOR = 6.27) and GTOS (DOR = 4.76). CONCLUSION This meta-analysis suggested that the TRISS showed better accuracy and performance in predicting mortality in geriatric trauma patients than the ISS and GTOS.
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Affiliation(s)
- Xin-Yu Liu
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yu-Meng Qin
- Department of Neurosurgery, Xianning Central Hospital, The First Affiliated Hospital of Hubei University of Science and Technology, Xianning, 437000, China
| | - Shu-Fang Tian
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jun-Hao Zhou
- School of Laboratory Medicine, Hubei University of Chinese Medicine, Wuhan, 430065, China
| | - Qiqi Wu
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wei Gao
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiangjun Bai
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhanfei Li
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Wei-Ming Xie
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
- Division of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430034, China.
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Atkins K, Schneider A, Charles A. Negative laparotomy rates and outcomes following blunt traumatic injury in the United States. Injury 2023; 54:110894. [PMID: 37330406 PMCID: PMC10526723 DOI: 10.1016/j.injury.2023.110894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 05/19/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Exploratory laparotomy remains the mainstay of treatment following blunt abdominal trauma. However, the decision to operate can be difficult in hemodynamically stable patients with unreliable physical exams or equivocal imaging findings. The risk of a negative laparotomy and the subsequent complications must be weighed against the potential morbidity and mortality of a missed abdominal injury. Our study aims to evaluate trends and the effect of negative laparotomies on morbidity and mortality in adults with blunt traumatic injuries in the United States. METHODS We reviewed the National Trauma Data Bank (2007-2019) for adults with blunt traumatic injuries who underwent an exploratory laparotomy. Positive or negative laparotomy of abdominal injury was compared. We performed bivariate analysis and a modified Poisson regression to estimate the effect of negative laparotomy on mortality. A sub-analysis of patients who underwent computed tomography (CT) of the abdomen and pelvis was performed. RESULTS 92,800 patients met the inclusion criteria of the primary analysis. Negative laparotomy rates were 12.0% in this population, down-trending throughout the study. Negative laparotomy patients had a significantly higher crude mortality (31.1% vs. 20.5%, p < 0.001), despite lower injury severity scores (20 (10-29) vs. 25 (16-35), p < 0.001) than positive laparotomy patients. Patients that underwent negative laparotomy had a 33% higher risk for mortality (RR1.33, 95% CI 1.28-1.37, P < 0.001) than positive laparotomy patients after adjusting for pertinent covariates. Patients that underwent CT abdomen/pelvis imaging (n = 45,654) had a lower rate of negative laparotomy (11.1%) and decreased difference in crude mortality (22.6% vs. 14.1%, p < 0.001) compared to positive laparotomy patients. However, the relative risk for mortality remained high at 37% (RR 1.37, 95% CI 1.29 - 1.46, p < 0.001) for this sub-cohort. CONCLUSION Negative laparotomy rates in adults with blunt traumatic injuries are trending down in the United States but remains substantial and may show improvement with increased use of diagnostic imaging. Negative laparotomy has a relative risk for mortality of 33% despite lower injury severity. Thus, surgical exploration in this population should be thoughtfully undertaken with appropriate evaluation via physical exam and diagnostic imaging to prevent unnecessary morbidity and mortality.
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Affiliation(s)
- Kathryn Atkins
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Andrew Schneider
- Department of Surgery, University of North Carolina at Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, USA.
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Ibitoye SE, Braude P, Carter B, Rickard F, Deakin H, Martin R, Thompson J, Walton B, Shipway D. Geriatric Assessment Is Associated With Reduced Mortality at 1 Year for Older Adults Admitted to a Major Trauma Center: A Prospective Observational Study. Ann Surg 2023; 277:343-349. [PMID: 36745762 DOI: 10.1097/sla.0000000000005092] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the effect of geriatrician review on 1-year mortality in older adults admitted with trauma. BACKGROUND Comprehensive geriatric assessment (CGA) has been associated with improved outcomes in older adults with hip fracture, but has not been evaluated in a broader trauma population. METHODS Trauma patients aged ≥ 65years admitted to an English Major Trauma Centre between November 2018 and September 2019 were included. Patients were divided into 3 cohorts: no geriatric assessment, reactive geriatric assessment, and proactive CGA. The primary outcome was time to mortality, secondary outcomes were time to discharge and frequency of complications. Analyses were adjusted for factors known to be associated with outcomes including age, frailty, injury severity, and complications. RESULTS Five hundred eighty-five patients were included (no geriatric assessment = 125; reactive geriatric assessment = 134; proactive CGA = 326): median age was 81 years (IQR 74-88); 326 (55.7%) were women; 297 (50.8%) were living with frailty (Clinical Frailty Scale ≥5). Median Injury Severity Score was 13 (IQR9-25). At 1-year follow-up, 147 (25.1%) patients had died. In multivariate analysis, both types of geriatric assessment were associated with reduced mortality [reactive aHR = 0.31, 95% CI 0.18-0.53; proactive adjusted hazard ratio (aHR) = 0.41, 95% CI 0.26-0.64]. There was no association between either type of geriatric assessment and length of stay (reactive aHR = 0.84, 95% CI 0.62-1.15; proactive aHR = 0.80, 95% CI 0.63-1.02). CONCLUSIONS Geriatrician assessment is associated with reduced mortality in older adults admitted following trauma. Further research should focus on defining optimal models of geriatrician intervention.
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Affiliation(s)
- Sarah E Ibitoye
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Philip Braude
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Frances Rickard
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Helen Deakin
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Rebecca Martin
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Julian Thompson
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - Benjamin Walton
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK
| | - David Shipway
- North Bristol NHS Trust and CLARITY (Collaborative Ageing Research) group, Bristol, UK.,University of Bristol, Bristol, UK
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Mortality from fall: A descriptive analysis of a multicenter Indian trauma registry. Injury 2022; 53:3956-3961. [PMID: 36244832 DOI: 10.1016/j.injury.2022.09.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Fall is the second most common mechanism of trauma worldwide after road traffic injuries. Data on fall predominantly comes from the high-income countries (HICs) and mostly includes injuries in children and elderly. There are very few studies from low- and middle-income countries(LMICs) that describe fall related injuries other than fragility fractures in elderly. This study describes the profile of poly-trauma patients admitted with a history of 'fall' and assesses the variables associated with mortality. METHOD We analyzed data from the 'Towards Improved Trauma Care Outcome' (TITCO) database which prospectively collected data of poly-trauma patients admitted to four major tertiary care hospitals of India between 2013 to 2015. Patients across all age groups admitted to hospital with the history of 'fall'; were included in our study. Single bone fractures were excluded. The Kaplan Meier survival analysis was used to estimate the survival probability in different age groups. RESULTS A total of 3686 patients were included in our study. The median age of the patients was 28 years (IQR: 9, 47) with the majority being males (73.6%). Almost one-third of the patients were within the age group of 0-14 (30.4%). Most of the patients (79.9%) had a diagnosis of traumatic brain injury (TBI). The overall in-hospital mortality was 18% (664), but higher at 39.0% among patients over 65 years of age. Probability of survival decreased with increase of age. CONCLUSION Falling from height is a common injury mechanism in India, occurring more in young males and usually associated with TBI. Isolated TBI and TBI associated with other injuries are the main contributors of mortality in fall injuries. Mortality from these injuries increased with age and ISS.
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Blair KJ, Dissak-Delon FN, Oke R, Carvalho M, Hubbard A, Mbianyor M, Etoundi-Mballa GA, Kinge T, Njock LR, Nkusu DN, Tsiagadigui JG, Dicker RA, Chichom-Mefire A, Juillard C, Christie SA. Chronic Disease Comorbidities Among Injured Patients in Cameroon: A Retrospective Cohort Study. J Surg Res 2022; 280:74-84. [PMID: 35964485 DOI: 10.1016/j.jss.2022.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/20/2022] [Accepted: 06/16/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Chronic diseases are increasing but underdiagnosed in low-income and middle-income countries (LMICs), where injury mortality is already disproportionately high. We estimated prevalence of known chronic disease comorbidities and their association with outcomes among injured patients in Cameroon. MATERIALS AND METHODS Injured patients aged ≥15 y presenting to four Cameroonian hospitals between October 2017 and January 2020 were included. Our explanatory variable was known chronic disease; prevalence was age-standardized. Outcomes were overall in-hospital mortality and admission or transfer from the emergency department (ED). Associations between known chronic disease and outcomes were evaluated using logistic regression adjusted for age, gender, estimated injury severity score (eISS), hospital, and household socioeconomic status. Unadjusted eISS-stratified and age-stratified outcomes were also compared via chi-squared tests. RESULTS Of 7509 injured patients, 370 (4.9%) reported at least one known chronic disease; age-standardized prevalence was 8.4% (95% confidence interval [CI] 7.5%-9.2%). Patients with known chronic disease had higher mortality (4.6% versus 1.5%, adjusted odds ratio [aOR]: 2.61 [95% CI: 1.25-5.47], P = 0.011) and were more likely to be admitted or transferred from the ED (38.7% versus 19.8%, aOR: 1.40 [95% CI: 1.02-1.92], P = 0.038) compared to those without known comorbidities. Crude differences in mortality (11.3% versus 3.3%, P = 0.002) and hospital admission or transfer (63.8% versus 46.6%, P = 0.011) were most notable for patients with eISS 16-24. CONCLUSIONS Despite underdiagnosis among Cameroonians, we demonstrated worse injury outcomes among those with known chronic diseases. Integrating chronic disease screening with injury care may help address underdiagnosis in Cameroon. Future work should assess whether chronic disease prevention in LMICs could improve injury outcomes.
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Affiliation(s)
- Kevin J Blair
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California.
| | - Fanny N Dissak-Delon
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California; Littoral Regional Delegation, Ministry of Public Health, Douala, Cameroon
| | - Rasheedat Oke
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Melissa Carvalho
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Alan Hubbard
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California
| | - Mbiarikai Mbianyor
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | | | - Thompson Kinge
- Hospital Administration, The Limbe Regional Hospital, Limbe, Cameroon
| | - Louis Richard Njock
- Hospital Administration, The Laquintinie Hospital of Douala, Douala, Cameroon
| | - Daniel N Nkusu
- Hospital Administration, The Catholic Hospital of Pouma, Pouma, Cameroon
| | | | - Rochelle A Dicker
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - Alain Chichom-Mefire
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California; Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Catherine Juillard
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California
| | - S Ariane Christie
- Program for the Advancement of Surgical Equity, Department of Surgery, University of California Los Angeles, Los Angeles, California; Division of General and Trauma Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburg, Pennsylvania
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Ahmed N, Kuo YH. Prediction of Trauma Mortality Incorporating Pre-injury Comorbidities into Existing Mortality Scoring Indices. Am Surg 2022; 88:2289-2301. [PMID: 35652909 DOI: 10.1177/00031348221078980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The purpose of the study is to develop a comprehensive risk score of mortality in trauma victims that can predict the in-hospital mortality better than trauma injury severity score (TRISS) and A Severity Characterization of Trauma (ASCOT) score. METHODS All hospitalized trauma patients, between the ages of 16 and 89 years old were included in the study. The National Trauma Quality Improvement Program (TQIP) database of the calendar year 2011-2016 was accessed for the development of a traum mortality scoring system (TMS). The prediction of mortality was tested by creating a receiver operating characteristics (ROC) curve and an area under the curve (AUC). ROCs and AUCs of TMS were compared with TRISS and ASCOT score. RESULTS The AUC of TMS (0.892, 95% CI: 0.888-0.896) was better than TRISS (0.864, 95% CI: 0.859-0.869, P <0.0001) and ASCOT (0.841, 95% CI: 0.835-0.846, P <0.0001), respectively, in blunt injury. Similarly, TMS prediction (AUC: 0.949, 95% CI: 0.940-0.958) was better in penetrating injury when compared with TRISS (0.942, 95% CI: 0.934-0.951, P = 0.030) and ASCOT (0.924, 95% CI: 0.912-0.936, P <0.0001), respectively. CONCLUSION TMS can predict the in-hospital mortality better than TRISS and ASCOT.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma and Surgical Critical Care, 23498Jersey Shore University Medical Center, Neptune, NJ, USA.,Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Yen-Hong Kuo
- Hackensack Meridian School of Medicine, Nutley, NJ, USA.,Office of Research Administration, 23498Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ, USA
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Banerjee N, Sharma N, Soni KD, Bansal V, Mahajan A, Khajanchi M, Gerdin Wärnberg M, Roy N. Are home environment injuries more fatal in children and the elderly? Injury 2022; 53:1987-1993. [PMID: 35367079 DOI: 10.1016/j.injury.2022.03.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/13/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION 'In-home injuries' are those that occur within the house or its immediate surroundings. The literature on the prevalence and magnitude of home injuries is sparse. This study was designed to characterize the mechanisms of 'in-home' injuries and compare their outcomes with 'outside home injuries'. MATERIALS AND METHODS The Australia-India Trauma Systems Collaboration (AITSC) Project created a multicentric registry consisting of trauma patients admitted at four urban tertiary care hospitals in India from April 2016 to March 2018. This registry data was analysed for this study. All admitted patients except for dead on arrival were included. Patients were categorised into 'in-home' and 'outside home' cohorts based on the place where the trauma occurred. The outcome measures were 30 day in-hospital mortality and the length of hospital stay. Two subgroup analyses were performed, the first comprised pediatric patients (<15 years) and the second elderly patients >64 years). RESULTS Among 9354 patients in the AITSC data registry, 8398 patients were included in the study. Out of these, 29 percent were in-home injuries, whereas the rest occurred outside home. The 30 day in-hospital mortality was 10.6 percent in the 'in-home' cohort, as compared to 13.7 percent in the 'outside home' cohort. This difference although significant on univariable analysis (p <0.01), there was no significant difference on multivariable regression analysis, after adjusting for age and injury severity score (OR = 0.88, 95% CI = 0.73-1.04; p = 0.15). The length of hospital stay was shorter in the home injuries group (median = 5 days; IQR = 3-12 days) compared to the outside-home group (median = 7 days; IQR = 4-14 days) (p < 0.01). In the pediatric and the elderly, on multivariable regression analysis, in-home injuries were associated with higher mortality than outside home injuries. CONCLUSION There was no significant difference in the 30 day in-hospital mortality amongst admitted trauma patients sustaining injuries at home or outside the home. However, in pediatric and elderly patients the chances of mortality was significantly higher when injured at home.
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Affiliation(s)
- Niladri Banerjee
- Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Naveen Sharma
- Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Kapil Dev Soni
- Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Varun Bansal
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | | | - Monty Khajanchi
- Department of Surgery, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Nobhojit Roy
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Surgical Unit, WHO Collaborating Centre for Research on Surgical Care Delivery in LMICs, BARC Hospital (Government of India), Mumbai, India.
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Charlson ME, Carrozzino D, Guidi J, Patierno C. Charlson Comorbidity Index: A Critical Review of Clinimetric Properties. PSYCHOTHERAPY AND PSYCHOSOMATICS 2022; 91:8-35. [PMID: 34991091 DOI: 10.1159/000521288] [Citation(s) in RCA: 406] [Impact Index Per Article: 203.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/19/2022]
Abstract
The present critical review was conducted to evaluate the clinimetric properties of the Charlson Comorbidity Index (CCI), an assessment tool designed specifically to predict long-term mortality, with regard to its reliability, concurrent validity, sensitivity, incremental and predictive validity. The original version of the CCI has been adapted for use with different sources of data, ICD-9 and ICD-10 codes. The inter-rater reliability of the CCI was found to be excellent, with extremely high agreement between self-report and medical charts. The CCI has also been shown either to have concurrent validity with a number of other prognostic scales or to result in concordant predictions. Importantly, the clinimetric sensitivity of the CCI has been demonstrated in a variety of medical conditions, with stepwise increases in the CCI associated with stepwise increases in mortality. The CCI is also characterized by the clinimetric property of incremental validity, whereby adding the CCI to other measures increases the overall predictive accuracy. It has been shown to predict long-term mortality in different clinical populations, including medical, surgical, intensive care unit (ICU), trauma, and cancer patients. It may also predict in-hospital mortality, although in some instances, such as ICU or trauma patients, the CCI did not perform as well as other instruments designed specifically for that purpose. The CCI thus appears to be clinically useful not only to provide a valid assessment of the patient's unique clinical situation, but also to demarcate major diagnostic and prognostic differences among subgroups of patients sharing the same medical diagnosis.
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Affiliation(s)
- Mary E Charlson
- Division of Clinical Epidemiology and Evaluative Sciences Research, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Danilo Carrozzino
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
| | - Jenny Guidi
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
| | - Chiara Patierno
- Department of Psychology "Renzo Canestrari," University of Bologna, Bologna, Italy
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Pattern of trauma in elderly patients seen at the trauma centre of national hospital Abuja, Nigeria. Afr J Emerg Med 2021; 11:347-351. [PMID: 34367894 PMCID: PMC8327492 DOI: 10.1016/j.afjem.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/30/2021] [Accepted: 06/04/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction The global population is aging, creating challenges for health systems. The mean age of patients with major trauma has increased over time, posing some challenges for trauma system designs. Elderly trauma patients are said to have higher mortality rates and longer hospital and intensive care unit stays. This study is aimed at assessing the pattern of injuries in elderly population in a dedicated trauma centre of a developing economy. Methods This is a retrospective study of all patients aged 60 years and above seen in the trauma centre of a West African tertiary hospital over a three year period from January 2017 to December 2019. Relevant parameters including Sociodemographic data, injury pattern and injury scores were derived from the trauma registry. Data analysis was done using statistical package for social sciences (SPSS) version 24. Results were presented using tables and a figure. Results A total of 183 patients aged 60 years and above were enrolled out of 4549 general trauma patients, representing 4% of the trauma patient population seen. Male to female ratio was 2.3 with the mean age of 65 ± 6.3. The most frequent mechanisms of injury were motor vehicular crash (MVC) (48.4%), followed by falls (16.5%). More proportion of females (21.8%) were significantly found to suffer falls compared to their males (14.2%) counterparts (p < 0.05). Traumatic brain injury was the commonest diagnosis accounting for 24.3% of cases. The predominant revised trauma scores (RTS) and injury severity scores (ISS) were 12 and 1–15 respectively, with overall mortality of 6.1%. Conclusion The proportion of elderly trauma patients studied in this centre is low. MVC is still the leading mechanism of injury in our elderly trauma population. The mortality rate is however low in this study, in line with the low trauma and severity scores. Preventive measures for MVC should be strongly encouraged to reduce the incidence of elderly trauma patients in this part of the world.
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11
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Haines L, Wang W, Harhay M, Martin N, Halpern S, Courtright K. Opportunities to Improve Palliative Care Delivery in Trauma Critical Illness. Am J Hosp Palliat Care 2021; 39:633-640. [PMID: 34467775 DOI: 10.1177/10499091211042303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite recommendations to integrate palliative care (PC) into care for critically ill trauma patients, little is known about current PC practices in trauma care to inform opportunities for improvement. OBJECTIVE Describe patterns of PC delivery among a large, critically ill trauma cohort. SETTING/SUBJECTS Retrospective cohort study of adult (≥18 years) trauma patients admitted to an intensive care unit (ICU) at an urban, level one trauma center in the United States from March 1, 2017 to March 1, 2019. METHODS We linked the electronic medical record with the institutional trauma registry. PC process measures included a PC consult order, advance care planning (ACP) note, and hospice use. Unadjusted results are reported for the total population, decedents, and subgroups at risk for poor outcomes (age ≥55 years, Black race ≥1 pre-existing comorbidity, and severe injury) after trauma. RESULTS Among 1309 eligible admissions, 902 (68.9%) were male, 640 (48.9%) were Black, and 654 (50.0%) were ≥55 years old. Eighty-one (6.2%) patients received a PC consult order, 66 (5.0%) had an ACP note, and 13 (1.1%) were discharged to hospice. Among decedents (N = 91; 7%), 28 (30.8%) received a PC consult order and 36 (39.6%) had an ACP note. For high-risk subgroups, PC consult orders and ACP note rates ranged from 4.5-12.8% and 4.5-11.8%, respectively. CONCLUSION PC delivery was rare among this cohort, including those at high risk for poor outcomes. Urgent efforts are needed to identify barriers to and develop targeted interventions for high quality PC delivery in trauma ICU care.
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Affiliation(s)
- Lindsay Haines
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Michael Harhay
- Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Niels Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott Halpern
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
| | - Katherine Courtright
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, PA, USA.,Palliative and Advanced Illness Research Center, Perelman School of Medicine at the University of Pennsylvania, PA, USA
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12
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Whiteneck GG, Ketchum JM, Almeida EJ, Goldstein R, Brown AW, Corrigan JD, Hammond FM, Weintraub AH, Tefertiller C. Developing an Index of Medical Conditions Associated with Outcomes after Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma 2021; 38:593-603. [PMID: 33256501 DOI: 10.1089/neu.2020.7366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Medical conditions co-occurring with traumatic brain injury (TBI) are associated with outcomes, and comorbidity indices such as Charlson and Elixhauser are used in TBI research, but they are not TBI specific. The purpose of this research was to develop an index or indices of medical conditions, identified in acute care after moderate to severe TBI, that are associated with outcomes at rehabilitation discharge. Using the TBI Model Systems National Database, the International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes of 8988 participants were converted to Healthcare Cost and Utilization Project (HCUP) diagnostic categories. Poisson regression models were built predicting Disability Rating Scale and Functional Independence Measure Cognitive and Motor subscale scores from HCUP categories after controlling for demographic and injury characteristics. Unweighted, weighted, and anchored indices based on the outcome models predicted 7.5-14.3% of the variance in the observed outcomes. When the indices were applied to a new validation sample of 1613 cases, however, only 2.6-6.6% of the observed outcomes were predicted. Therefore, no models or indices were recommended for future use, but several study findings are highlighted suggesting the importance and the potential for future research in this area.
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Affiliation(s)
| | | | - Emily J Almeida
- Research Department, Craig Hospital, Englewood, Colorado, USA
| | | | - Allen W Brown
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, Ohio State University, Columbus, Ohio, USA
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana School of Medicine, Indianapolis, Indiana, USA.,Rehabilitation Hospital of Indiana, Indianapolis, Indiana, USA
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Kim J, Engelberg RA, Downey L, Lee RY, Powelson E, Sibley J, Lober WB, Curtis JR, Khandelwal N. Predictors of Advance Care Planning Documentation in Patients With Underlying Chronic Illness Who Died of Traumatic Injury. J Pain Symptom Manage 2019; 58:857-863.e1. [PMID: 31349036 PMCID: PMC6823122 DOI: 10.1016/j.jpainsymman.2019.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/12/2019] [Accepted: 07/14/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Advance care planning (ACP) is difficult in the setting of a life-threatening trauma but may be equally important in this context, especially with increasing numbers of trauma victims being elderly or having multimorbidity. OBJECTIVES Identify predictors of absent ACP documentation in the electronic health records of patients with underlying chronic illness who died of traumatic injury. METHODS We used death records and electronic health records to identify decedents with chronic life-limiting illness who died of traumatic injury between 2010 and 2015 and to evaluate factors associated with documentation of living wills, durable powers of attorney, or physician orders for life-sustaining treatment. RESULTS Only 22% of decedents had ACP documentation at time of injury. Among those without preinjury ACP documentation, 4% completed ACP documentation after injury. In multipredictor analyses, patients were less likely to have ACP documentation at the time of injury if they were younger (P < 0.001), had fewer chronic illnesses (P = 0.002), and had fewer nonsurgical hospitalizations (P = 0.042) in the year before injury. Among patients without ACP documentation before injury, those with fewer postinjury nonsurgical hospitalizations were less likely to complete ACP documentation after injury (P = 0.019). CONCLUSIONS Our findings suggest that patient characteristics play an important role in the completion of ACP among patients with chronic life-limiting illness and who died from sudden severe injury. Interventions to improve ACP completion by patients with serious chronic conditions have the potential for increasing goal-concordant care in the event of traumatic injury.
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Affiliation(s)
- Justin Kim
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, New York, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Elisabeth Powelson
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - William B Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
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Gioffrè-Florio M, Murabito LM, Visalli C, Pergolizzi FP, Famà F. Trauma in elderly patients: a study of prevalence, comorbidities and gender differences. G Chir 2019; 39:35-40. [PMID: 29549679 DOI: 10.11138/gchir/2018.39.1.035] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Trauma, in geriatric patients, increases with age, and is a leading cause of disability and institutionalization, resulting in morbidity and mortality. The aim of our study was to analyse the prevalence of trauma, the related risk factors, mortality and sex differences in the prevalence in a geriatric population. PATIENTS AND METHOD We observed 4,554 patients (≥65 years) with home injuries or car accidents. Patients were evaluated with ISS (Injury Severity Score) and major trauma with ATLS (Advanced Trauma Life Support). The instrumental investigation was in the first instance, targeted X-Ray or whole-body CT. RESULTS In over four years of study we treated 4,554 geriatric: 2,809 females and 1,745 Males. When the type of trauma was analysed the most common was head injury, followed by fractures of lower and upper limbs. In our experience hospitalization mainly involved patients over 80. In all patients mortality during assessment was 0.06%. DISCUSSION The geriatric patient is often defined as a "frail elderly", for the presence of a greater "injury sensitivity". This is due to the simultaneous presence of comorbidity, progressive loss of full autonomy and exposure to a high risk of traumatic events. Optimal management of the trauma patient can considerable reduce mortality and morbidity. CONCLUSIONS Falls and injuries in geriatric age are more frequent in women than in men. Among typical elder comorbidities, osteoporosis certainly causes a female preponderance in the prevalence of fractures. Our discharge data demonstrate that disability, which requires transfer to health care institutions, has a greater effect on women than men.
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Dunn H, Quinn L, Corbridge S, Kapella M, Eldeirawi K, Steffen A, Collins E. A latent class analysis of prolonged mechanical ventilation patients at a long-term acute care hospital: Subtype differences in clinical outcomes. Heart Lung 2019; 48:215-221. [PMID: 30655004 PMCID: PMC6874913 DOI: 10.1016/j.hrtlng.2019.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 12/29/2018] [Accepted: 01/02/2019] [Indexed: 01/15/2023]
Abstract
RATIONALE Patients on prolonged mechanical ventilation (PMV) at Long-Term Acute Care Hospital's (LTACHs) are clinically heterogeneous making it difficult to manage care and predict clinical outcomes. OBJECTIVES Identify and describe subgroups of patients on PMV at LTACHs and examine for group differences. METHODS Latent class analysis was completed on data obtained during medical record review at Midwestern LTACH. MAIN RESULTS A three-class solution was identified. Class 1 contained young, obese patients with low clinical and co-morbid burden; Class 2 contained the oldest patients with low clinical burden but multiple co-morbid conditions; Class 3 contained patients with multiple clinical and co-morbid burdens. There were no differences in LTACH length of stay [F(2,246) = 2.243, p = 0.108] or number of ventilator days [F(2,246) = 0.641, p = 0.528]. Class 3 patients were less likely to wean from mechanical ventilation [χ2(2, N = 249) = 25.48, p < 0.001] and more likely to die [χ2(2, N = 249) = 23.68, p < 0.001]. CONCLUSION Patient subgroups can be described that predict clinical outcomes. Class 3 patients are at higher risk for poor clinical outcomes when compared to patients in Class 1 or Class 2.
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Affiliation(s)
- Heather Dunn
- The University of Iowa College of Nursing, United States.
| | - Laurie Quinn
- University of Illinois at Chicago College of Nursing, United States
| | - Susan Corbridge
- University of Illinois at Chicago College of Nursing, United States
| | - Mary Kapella
- University of Illinois at Chicago College of Nursing, United States
| | - Kamal Eldeirawi
- University of Illinois at Chicago College of Nursing, United States
| | - Alana Steffen
- University of Illinois at Chicago College of Nursing, United States
| | - Eileen Collins
- University of Illinois at Chicago College of Nursing, United States
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Calvo RY, Sise CB, Sise MJ, Bansal V. Quantifying the burden of pre-existing conditions in older trauma patients: A novel metric based on mortality risk. Am J Emerg Med 2019; 37:1836-1845. [PMID: 30638628 DOI: 10.1016/j.ajem.2018.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 12/21/2018] [Accepted: 12/22/2018] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Pre-existing medical conditions (PEC) represent a unique domain of risk among older trauma patients. The study objective was to develop a metric to quantify PEC burden for trauma patients. METHODS A cohort of 4526 non-severe blunt-injured trauma patients aged 55 years and older admitted to a Level I trauma center between January 2006 and December 2012 were divided into development (80%) and test (20%) sets. Cox regression was used to develop the model based on in-hospital and 90-day mortality. Regression coefficients were converted into a point-based PEC Risk Score. Performance of the PEC Risk Score was compared in the test set with two other PEC-based metrics and three injury-based metrics. An external cohort of 2284 trauma patients admitted in 2013 was used to evaluate combined metric performance. RESULTS Total mortality was 9.4% and 9.1% in the development and test set, respectively. The final model included 12 PEC. In the test set, the PEC Risk Score (c-statistic: 79.7) was superior for predicting in-hospital and 90-day mortality compared with all other metrics. For in-hospital mortality alone, the PEC Risk Score similarly outperformed all other metrics. Combination of the PEC Risk Score and any injury-based metric significantly improved prediction compared with any injury-based metric alone. CONCLUSION Our 12-item PEC Risk Score performed well compared with other metrics, suggesting that the classification of trauma-related mortality risk may be improved through its use. Among non-severely injured older trauma patients, the utility of prognostic metrics may be enhanced through the incorporation of comorbidities.
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Affiliation(s)
- Richard Y Calvo
- Scripps Mercy Hospital, Trauma Services, 4077 Fifth Avenue, San Diego, CA 92103, USA; SDSU/UCSD Joint Doctoral Program in Public Health (Epidemiology), 5500 Campanile Drive, San Diego, CA, 92182, USA.
| | - C Beth Sise
- Scripps Mercy Hospital, Trauma Services, 4077 Fifth Avenue, San Diego, CA 92103, USA.
| | - Michael J Sise
- Scripps Mercy Hospital, Trauma Services, 4077 Fifth Avenue, San Diego, CA 92103, USA.
| | - Vishal Bansal
- Scripps Mercy Hospital, Trauma Services, 4077 Fifth Avenue, San Diego, CA 92103, USA.
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Elkbuli A, Yaras R, Elghoroury A, Boneva D, Hai S, McKenney M. Comorbidities in Trauma Injury Severity Scoring System: Refining Current Trauma Scoring System. Am Surg 2019. [DOI: 10.1177/000313481908500130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The revised trauma score combined with the Injury Severity Score (ISS) remains the mostly commonly used system for predicting trauma mortality, but these scoring systems do not account for the patient's comorbidities. This study aims to evaluate the effect of comorbidities on ISS-related mortality and length of stay. A review of our trauma center's data registry from 2014 to 2016 was carried out. Patients were divided according to ISS into two groups: ISS ≤ 15 and ISS > 15. Each ISS group was then subdivided by number of comorbidities into two groups: 1 to 2 or ≥3 comorbidities. Demographic characteristics and outcome measures were compared. ANOVA, chi-squared, and t tests were used with significance defined as P < 0.05. A total 9845 adult trauma patients were admitted to our trauma center during the three-year study period. In the ISS ≤ 15 group, patients with <3 comorbidities had significantly higher mortality rate compared with patients with 1 to 2 comorbidities (1.50% vs 0.12%, P << 0.000007). Comparing the ISS ≤ 15 group with ≥3 comorbidities with the ISS > 15 group with 1 to 2 comorbidities, the mortality rate was significantly higher (23.40% vs 4.50%, P << 0.000002). The ICU length of stay was significantly higher in the ISS ≤ 15 groups (17 vs 10 days, P < 0.05) but similar in the ISS > 15 groups (31 vs 29 days) (P > 0.05). It was concluded that when controlling for injury severity, increased comorbidities are associated with a significantly higher mortality, indicating that they may serve as a marker of lower physiologic reserve and be an independent variable. Adding comorbidity parameters to the current trauma scoring systems can assist in predicting more accurate/reliable outcomes.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Reed Yaras
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Ahmad Elghoroury
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Dessy Boneva
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Shaikh Hai
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
| | - Mark McKenney
- Department of Surgery, Kendall Regional Medical Center, Miami, Florida and
- Department of Surgery, University of Florida, Gainesville, Florida
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Barry RG, Wolbert TT, Mozaffari FB, Ray PD, Thompson EC, Gress TW, Denning DA. Comparison of Geriatric Trauma Outcomes When Admitted to a Medical or Surgical Service After a Fall. J Surg Res 2018; 233:391-396. [PMID: 30502275 DOI: 10.1016/j.jss.2018.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/24/2018] [Accepted: 08/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Blunt trauma in the geriatric population is fraught with poor outcomes, with injury severity and comorbidities impacting morbidity and mortality. METHODS We retrospectively reviewed 2172 patients aged ≥65 y who fell, requiring hospital admission between January 2012 and December 2016. There were 403 patients in the surgical arm (SA) and 1769 patients in the medical arm (MA). Ground-level falls were the only mechanism of injury included. We excluded all ICU admissions and deaths within 24 h. RESULTS There were 5 deaths (1.24%) in the SA and 16 deaths (0.90%) in the MA (P = 0.57). The mean trauma injury severity score survival probability prediction in the SA was 96.9% versus 97.1% in the MA. MA patients had more comorbidities overall than SA patients. There was no difference in mortality between the SA and MA groups in multiple logistic regression models that accounted for trauma injury severity scores (TRISS) and comorbidities. Unadjusted hospital length of stay was 1 d shorter (median; 95% CI -1.4 to -0.6) in the SA and 0.5 d shorter (median; 95% CI -0.8 to -0.1) when adjusted for TRISS and comorbidities using multiple quantile regression. Finally, patients in the SA were 2.1 (95% CI 1.7 to 2.6) times more likely to be discharged home compared with patients in the MA, and this remained significant (OR 1.9; 95% CI 1.5 to 2.5) with simultaneous adjustment for TRISS and comorbidities using multiple logistic regression. CONCLUSIONS Geriatric blunt trauma patients admitted to surgical services after mechanical falls have no difference in survival, a shorter median length of stay, and increased likelihood of being discharged home compared with patients admitted to medical services.
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Affiliation(s)
- Rahman G Barry
- Department of Surgery, Marshall University, Huntington, West Virginia.
| | - Thao T Wolbert
- Department of Surgery, Marshall University, Huntington, West Virginia
| | - Farid B Mozaffari
- Department of Surgery, Marshall University, Huntington, West Virginia
| | - Peter D Ray
- Department of Surgery, Marshall University, Huntington, West Virginia
| | | | - Todd W Gress
- Department of Surgery, Marshall University, Huntington, West Virginia
| | - David A Denning
- Department of Surgery, Marshall University, Huntington, West Virginia
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Patterns of health care use of injured adults: A population-based matched cohort study. Injury 2017; 48:1393-1399. [PMID: 28442203 DOI: 10.1016/j.injury.2017.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 04/03/2017] [Accepted: 04/12/2017] [Indexed: 02/02/2023]
Abstract
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.
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Mitchell RJ, Cameron CM, McClure R. Higher mortality risk among injured individuals in a population-based matched cohort study. BMC Public Health 2017; 17:150. [PMID: 28148259 PMCID: PMC5288995 DOI: 10.1186/s12889-017-4087-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/30/2017] [Indexed: 05/01/2023] Open
Abstract
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.
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Affiliation(s)
- Rebecca J. Mitchell
- Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, North Ryde, NSW 2109 Australia
| | - Cate M. Cameron
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Rod McClure
- Harvard Injury Control Research Center, Harvard School of Public Health, Harvard University, Boston, USA
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Kirshenbom D, Ben-Zaken Z, Albilya N, Niyibizi E, Bala M. Older Age, Comorbid Illnesses, and Injury Severity Affect Immediate Outcome in Elderly Trauma Patients. J Emerg Trauma Shock 2017; 10:146-150. [PMID: 28855778 PMCID: PMC5566026 DOI: 10.4103/jets.jets_62_16] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Trauma in elderly population is frequent and is associated with significant mortality, not only due to age but also due to complicated factors such as the severity of injury, preexisting comorbidity, and incomplete general assessment. Our primary aim was to determine whether age, Injury Severity Score (ISS), and preexisting comorbidities had an adverse effect on the outcome in patients aged 65 years and above following blunt trauma. Methods: We included 1027 patients aged ≥65 years who were admitted to our Level I Trauma Center following blunt trauma. Patients’ charts were reviewed for demographics, ISS, mechanism of injury, preexisting comorbidities, Intensive Care Unit and hospital length of stay, complications, and in-hospital mortality. Results: The mean age of injured patients was 78.8 ± 8.3 years (range 65–109). The majority of patients had mild injury severity (ISS 9–14, 66.8%). Multiple comorbidities (≥3) were found in 233 patients (22.7%). Mortality during the hospitalization stay (n = 35, 3.4%) was associated with coronary artery disease, renal failure, dementia, and warfarin use (P < 0.05). Chronic anticoagulation treatment was recorded in 13% of patients. The addition of a single comorbidity increased the odds of wound infection to 1.29 and sepsis to 1.25. Both age and ISS increased the odds of death as −1.08 and −2.47, respectively. Conclusions: Our analysis shows that age alone in elderly trauma population is not a robust measure of outcome, and more valuable predictors such as injury severity, preexisting comorbidities, and medications are accounted for adverse outcome. Trauma care in this population with special considerations should be tailored to meet their specific needs.
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Affiliation(s)
| | - Zila Ben-Zaken
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Nehama Albilya
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Eva Niyibizi
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Miklosh Bala
- Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Mitchell RJ, Cameron CM, McClure R. Quantifying the hospitalised morbidity and mortality attributable to traumatic injury using a population-based matched cohort in Australia. BMJ Open 2016; 6:e013266. [PMID: 27927664 PMCID: PMC5168691 DOI: 10.1136/bmjopen-2016-013266] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/06/2016] [Accepted: 11/08/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To quantify the 12-month hospitalised morbidity and mortality attributable to traumatic injury using a population-based matched cohort in Australia. SETTING New South Wales, Queensland and South Australia, Australia. PARTICIPANTS Individuals ≥18 years who had an injury-related hospital admission in 2009 formed the injured cohort. The non-injured comparison cohort was randomly selected from the electoral roll and was matched 1:1 on age, gender and postcode of residence at the date of the index injury admission of their matched counterpart. PRIMARY OUTCOME MEASURES Using linked emergency department presentation, hospital admission and mortality records from 1 January 2008 to 31 December 2010 for both the injured and non-injured cohorts, 12-month mortality and pre-index and post-index injury hospital service use was examined. Adjusted rate ratios and attributable risk were calculated. RESULTS There were 167 600 individuals injured in 2009 and admitted to hospital in New South Wales, South Australia or Queensland with a matched comparison. The injured cohort had 3 times higher proportion of having ≥1 comorbidity preinjury, higher preinjury hospital service use, and a higher 12-month mortality compared with a non-injured comparison group. The injured cohort had 2.20 (95% CI 2.12 to 2.28) times higher rate of hospital admissions in the 12 months post the index injury admission compared with the non-injured comparison cohort. Injury was a likely contributory factor in at least 55% of hospitalisations within 12 months of the index injury hospitalisation. CONCLUSIONS Individuals who had an injury-related hospitalisation had higher mortality and are hospitalised at increased rates for many months postinjury. While comorbid conditions are significant, they do not account for the differences in outcomes. This study contributes to informing research efforts on better quantifying the attributable burden of hospitalised injury-related disability and mortality in Australia.
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Affiliation(s)
- Rebecca J Mitchell
- Australian Institute of Health Innovation, Macquarie University, Australia
| | - Cate M Cameron
- Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia
| | - Rod McClure
- Harvard Injury Control Research Center, Harvard School of Public Health, Harvard University, Cambridge, Massachusetts, USA
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Hicks CW, Canner JK, Zarkowsky DS, Arhuidese I, Obeid T, Malas MB. Racial disparities after vascular trauma are age-dependent. J Vasc Surg 2016; 64:418-424. [DOI: 10.1016/j.jvs.2016.01.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 01/28/2016] [Indexed: 10/22/2022]
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Sammy I, Lecky F, Sutton A, Leaviss J, O'Cathain A. Factors affecting mortality in older trauma patients-A systematic review and meta-analysis. Injury 2016; 47:1170-83. [PMID: 27015751 DOI: 10.1016/j.injury.2016.02.027] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 02/29/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Major trauma in older people is a significant health burden in the developed world. The aging of the population has resulted in larger numbers of older patients suffering serious injury. Older trauma patients are at greater risk of death from major trauma, but the reasons for this are less well understood. The aim of this review was to identify the factors affecting mortality in older patients suffering major injury. MATERIALS AND METHODS A systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with meta-analysis. Multi-centre cohort studies of existing trauma registries that reported risk-adjusted mortality (adjusted odds ratios, AOR) in their outcomes and which analysed patients aged 65 and older as a separate cohort were included in the review. RESULTS 3609 papers were identified from the electronic databases, and 28 from manual searches. Of these, 15 papers fulfilled the inclusion criteria. Demographic variables (age and gender), pre-existing conditions (comorbidities and medication), and injury-related factors (injury severity, pattern and mechanism) were found to affect mortality. The 'oldest old', aged 75 and older, had higher mortality rates than younger patients, aged 65-74 years. Older men had a significantly higher mortality rate than women (cumulative odds ratio 1.51, 95% CI 1.37-1.66). Three papers reported a higher risk of death in patients with pre-existing conditions. Two studies reported increased mortality in patients on warfarin (cumulative odds ratio 1.32, 95% CI 1.05-1.66). Higher mortality was seen in patients with lower Glasgow coma scores and systolic blood pressures. Mortality increased with increased injury severity and number of injuries sustained. Low level falls were associated with higher mortality than motor vehicle collisions (cumulative odds ratio 2.88, 95% CI 1.26-6.60). CONCLUSIONS Multiple factors contribute to mortality risk in older trauma patients. The relation between these factors and mortality is complex, and a fuller understanding of the contribution of each factor is needed to develop a better predictive model for trauma outcomes in older people. More research is required to identify patient and process factors affecting mortality in older patients.
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Affiliation(s)
- Ian Sammy
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
| | - Fiona Lecky
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | - Anthea Sutton
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | - Joanna Leaviss
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
| | - Alicia O'Cathain
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
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The differential associations of preexisting conditions with trauma-related outcomes in the presence of competing risks. Injury 2016; 47:677-84. [PMID: 26684173 DOI: 10.1016/j.injury.2015.10.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 10/15/2015] [Accepted: 10/21/2015] [Indexed: 02/02/2023]
Abstract
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.
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Hildebrand F, Pape HC, Horst K, Andruszkow H, Kobbe P, Simon TP, Marx G, Schürholz T. Impact of age on the clinical outcomes of major trauma. Eur J Trauma Emerg Surg 2015; 42:317-32. [PMID: 26253883 DOI: 10.1007/s00068-015-0557-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/31/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients. METHODS Review of the literature. RESULTS Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality. CONCLUSION The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.
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Affiliation(s)
- F Hildebrand
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany. .,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany.
| | - H-C Pape
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - K Horst
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - H Andruszkow
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.,Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University, Aachen, Germany
| | - P Kobbe
- Department of Orthopaedic Trauma, Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - T-P Simon
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - G Marx
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
| | - T Schürholz
- Department of Intensive Care Medicine, Aachen University, Aachen, Germany
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Ball CG, Das D, Roberts DJ, Vis C, Kirkpatrick AW, Kortbeek JB. The evolution of trauma surgery at a high-volume Canadian centre: implications for public health, prevention, clinical care, education and recruitment. Can J Surg 2015; 58:19-23. [PMID: 25427332 DOI: 10.1503/cjs.001314] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Trauma centres continue to evolve with respect to clinical care and their impact on public health. Despite improvements in patient outcomes, operative volumes, and therefore maintenance of surgical skills, has become a challenging issue. We sought to determine whether injury demographics and treatments at a high-volume centre changed over time. METHODS We used the Alberta Trauma Registry to analyze all severely injured (injury severity score [ISS] ≥ 12) patient admissions over a 16-year period (1995-2011). RESULTS Of the 12,879 severely injured patients requiring admission, there was a 1.5- fold increase in the annual admission rate despite population normalization (p = 0.001). Over the 16-year interval, patients were older with a subsequent lower mortality (p = 0.001) and length of hospital stay (p = 0.007). In patients with the most severe ISS (≥ 48), there was no change in mortality (27%, p = 0.26). In 2011, falls were the most common mechanism compared with motor vehicle crashes (41% v. 23%; p < 0.001); this was a complete reversal compared with 1995 (25% v. 41%). Motorized recreational vehicle and motorcycle injuries also increased (p < 0.001). The mean number of operations performed by trauma surgeons decreased (laparotomies: 67 [17%] in 1995 v. 47 [5%] in 2011, p < 0.001). Thoracotomies and tracheostomies remained unchanged (p = 0.19). CONCLUSION Clinical care has improved despite an increasing overall volume of severely injured patient admissions. The number of operative interventions performed by trauma surgeons continues to decrease concurrent to a change in injury mechanisms. Despite these improvements, maintenance of technical skills among trauma surgeons has become an important issue.
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Affiliation(s)
- Chad G Ball
- The Departments of Surgery and the Regional Trauma Services, University of Calgary and the Foothills Medical Centre, Calgary, Alta
| | - Debanjana Das
- The Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta
| | - Derek J Roberts
- The Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alta
| | - Christine Vis
- The Department of Regional Trauma Services, University of Calgary and the Foothills Medical Centre, Calgary, Alta
| | - Andrew W Kirkpatrick
- The Departments of Surgery and the Regional Trauma Services, University of Calgary and the Foothills Medical Centre, Calgary, Alta
| | - John B Kortbeek
- The Departments of Surgery, Regional Trauma Services, and Critical Care Medicine, University of Calgary and the Foothills Medical Centre, Calgary, Alta
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Hicks CW, Hashmi ZG, Velopulos C, Efron DT, Schneider EB, Haut ER, Cornwell EE, Haider AH. Association between race and age in survival after trauma. JAMA Surg 2014; 149:642-7. [PMID: 24871941 DOI: 10.1001/jamasurg.2014.166] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
IMPORTANCE Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information. OBJECTIVE To determine whether racial disparities in trauma survival persist in patients 65 years or older. DESIGN, SETTING, AND PARTICIPANTS Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index. MAIN OUTCOMES AND MEASURES In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index. RESULTS A total of 1,073,195 patients were included (502,167 patients 16-64 years of age and 571,028 patients ≥65 years of age). Most older patients were white (547,325 [95.8%]), female (406 158 [71.1%]), and insured (567,361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323,741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods. CONCLUSIONS AND RELEVANCE Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes.
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Affiliation(s)
- Caitlin W Hicks
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Zain G Hashmi
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Catherine Velopulos
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David T Efron
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Eric B Schneider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elliott R Haut
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Edward E Cornwell
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Adil H Haider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Bala M, Willner D, Klauzni D, Bdolah-Abram T, Rivkind AI, Gazala MA, Elazary R, Almogy G. Pre-hospital and admission parameters predict in-hospital mortality among patients 60 years and older following severe trauma. Scand J Trauma Resusc Emerg Med 2013; 21:91. [PMID: 24360246 PMCID: PMC3878042 DOI: 10.1186/1757-7241-21-91] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 12/03/2013] [Indexed: 11/10/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Gidon Almogy
- Department of Surgery and Trauma Unit, Hadassah University Hospital, Ein Kerem, pob 12000, Jerusalem, 91120, Israel.
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Hicks CW, Wick EC. Standardized quality performance metrics: beware of the pitfalls. J Surg Res 2013; 185:524-5. [PMID: 24216385 DOI: 10.1016/j.jss.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 12/29/2012] [Accepted: 01/03/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Caitlin W Hicks
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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Neuhaus V, King J, Hageman MG, Ring DC. Charlson comorbidity indices and in-hospital deaths in patients with hip fractures. Clin Orthop Relat Res 2013; 471. [PMID: 23179125 PMCID: PMC3613553 DOI: 10.1007/s11999-012-2705-9] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Charlson Comorbidity Index (CCI) and its modifications are comorbidity-based measures that predict mortality. It was developed for patients without trauma and inconsistently predicted mortality and adverse events in several previous studies of patients with trauma. PURPOSE We therefore (1) determined whether the three different CCIs were predictors for in-hospital deaths in patients with hip fractures, (2) verified if the CCI mortality prediction had changed with time, (3) evaluated other predictors of in-hospital death in patients with hip fractures, and (4) determined if the CCI has predicted in-hospital adverse events. METHODS We retrospectively reviewed a nationwide probability sample survey, the National Hospital Discharge Survey. More than 6 million adult patients with hip fractures and their associated comorbidities were scored by the original 1987 CCI, the 1994 age-adjusted CCI, and the 2011 updated, reweighted CCI. The three mortality indices' predictive values and predictors of in-hospital adverse events were compared. RESULTS For patients with hip fractures, all three CCI variations predicted in-hospital mortality. The receiver operating curves (ROC) of the models were less than 0.68, but they improved when we used statistical models that included age, sex, concomitant injuries, and other comorbidities not contained in the CCI models (ROC > 0.74). The age-adjusted CCI accuracy was slightly better than the other two CCIs. Adverse events during hospital stays were associated with a higher CCI, pertrochanteric fracture (versus transcervical), abdominal, chest, or head trauma, atrial fibrillation, multiple fractures, female sex, and longer hospital stays; however, the accuracy of this model was poor (ROC = 0.65). CONCLUSIONS While all three CCI variations predicted in-hospital mortality in patients with hip fractures, other factors may be of value in patients with trauma.
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Affiliation(s)
- Valentin Neuhaus
- Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - John King
- Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - Michiel G. Hageman
- Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
| | - David C. Ring
- Orthopaedic Hand and Upper Extremity Service, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, MA 02114 USA
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