Local access to care programs increase trauma patient follow-up compliance

Risk Factors for Missed Follow-up Appointments among Facial Trauma Patients

A retrospective case-control study was performed to characterize the rate of missed follow-up appointments after facial trauma and identify associated risk factors.Follow-up appointments for facial trauma over a 3-month period at a single, safety net hospital were analyzed. Appointment-specific, sociodemographic, trauma, and management data were compared between cases (missed appointments) and controls (attended appointments). Univariate testing and multivariable logistic regression were employed.A total of 116 cases and 259 controls were identified, yielding a missed appointment rate of 30.9% (116/375). Missed appointments were significantly associated with initial clinic appointments compared to return visits (odds ratio [OR] 2.21 [1.38-3.54]), afternoon visits compared to morning (OR 3.14 [1.94-5.07]), lack of private health insurance (OR 2.91 [1.68-5.18]), and presence of midface fractures (OR 2.04 [1.28-3.27]). Missed appointments were negatively associated with mandible fractures (OR 0.56 [0.35-0.89]), surgical management (OR 0.48 [0.30-0.77]), and the presence of nonremovable hardware (OR 0.39 [0.23-0.64]). Upon multivariable logistic regression, missed appointments remained independently associated with afternoon visits (adjusted OR [aOR] 1.95 [1.12-3.4]), lack of private health insurance (aOR 2.73 [1.55-4.8]), and midface fractures (aOR 2.09 [1.21-3.59]).Nearly one-third of facial trauma patients missed follow-up appointments, with the greatest risk among those with afternoon appointments, lacking private health insurance, and with midface fractures.

Risk factors for loss to follow-up after traumatic injury: An updated view of a chronic problem

BACKGROUND

Loss to follow-up after traumatic injury occurs at rates of up to 47%. However, the most recent data are over a decade old, and recent changes in traumatic injury patterns necessitate an updated assessment of risk factors for loss to follow-up after trauma.

METHODS

We conducted a retrospective chart review of trauma admissions from January 1, 2018 to December 31, 2021. Categorical variables were compared using χ2 analyses, and continuous variables were analyzed using Mann-Whitney Wilcoxon tests. Multivariable logistic regression was used to adjust for relevant factors identified on unadjusted analysis.

RESULTS

Among 3,034 patients, overall loss to follow-up was 36.9%. Non-White patients, patients who underwent operations or non-surgical procedures, and patients discharged to rehabilitation facilities were more likely to have follow-up appointments within 30 days. Patients with substance use disorder and, among White patients, those with public insurance had higher loss to follow-up rates. Having a follow-up appointment scheduled with a primary care provider was the single most significant factor associated with attending a follow-up appointment.

CONCLUSION

Social determinants of health, such as insurance status and substance use disorder, are associated with loss of follow-up after trauma. Primary care appointments are associated with the highest attendance rates, supporting that all patients should be offered primary care appointments after traumatic injury.

Transitional care programs for trauma patients: A scoping review

BACKGROUND

Transitional care programs establish comprehensive outpatient care after hospitalization. This scoping review aimed to define participant characteristics and structure of transitional care programs for injured adults as well as associated readmission rates, cost of care, and follow-up adherence.

METHODS

We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard. Information sources searched were Medline, the Cochrane Library, CINAHL, and Scopus Plus with Full Text. Eligibility criteria were systematic reviews, clinical trials, and observational studies of transitional care programs for injured adults in the United States, published in English since 2000. Two independent reviewers screened all full texts. A data charting process extracted patient characteristics, program structure, readmission rates, cost of care, and follow-up adherence for each study.

RESULTS

A total of 10 studies described 9 transitional care programs. Most programs (60%) were nurse/social-worker-led post-discharge phone call programs that provided follow-up reminders and inquired regarding patient concerns. The remaining 40% of programs were comprehensive interdisciplinary case-coordination transitional care programs. Readmissions were reduced by 5% and emergency department visits by 13% among participants of both types of programs compared to historic data. Both programs improved follow-up adherence by 75% compared to historic data.

CONCLUSION

Transitional care programs targeted at injured patients vary in structure and may reduce overall health care use.

Orthopaedic trauma patient non-adherence to follow-up visits at a level 1 trauma center serving an urban and rural population

OBJECTIVE

To assess key demographic and psychosocial variables that may be associated with non-adherence to clinic visits following orthopaedic trauma injuries to patients in an urban and rural population.

METHODS

This retrospective review included all operative and non-operative patients presenting to a Level I academic trauma center serving an urban and rural population in the Midwest following an orthopaedic injury. The study tracked patient attendance to scheduled orthopaedic trauma follow-up clinic visits after a scheduled visit in the clinic following a trauma-related injury.

RESULTS

Data were obtained for 5816 unique orthopaedic trauma patients who had 21,066 post-treatment follow-up visits scheduled. 1627 "no-show" appointments were recorded. Factors associated with no-shows included male sex, age between 26 and 35 years, self-reported race other than white, employment listed as disabled, household income below $25,000, education less than a high school level, uninsured, Medicaid insured, and relationship status reported as single.

CONCLUSIONS

In the present study, key demographic and psychosocial factors were significantly associated with patient adherence to scheduled follow-up appointments after treatment for orthopaedic trauma. Identifying patients at higher risk for nonadherence will allow healthcare teams to educate patients, providers, and staff, link patients to resources to enhance adherence, and work with their institutions to develop and implement protocols for improving adherence to follow-up appointments.

Hospital readmission after blunt traumatic rib fractures

BACKGROUND

Hospital readmissions are resource intensive, associated with increased morbidity, and often used as hospital-level quality indicators. The factors that determine hospital readmission after blunt thoracic trauma have not been sufficiently defined. We sought to identify predictors of hospital readmission in patients with traumatic rib fractures.

METHODS

We performed an 8-year (2011-2019) retrospective chart review of patients with traumatic rib fractures who required unplanned readmission within 30 days of discharge at a Level 1 trauma center. Patient characteristics, injury severity, and hospital complications were examined using quantitative analysis to identify readmission risk factors.

RESULTS

There were 13,046 trauma admissions during the study period. The traumatic rib fracture cohort consisted of 3,720 patients. The cohort included 206 patients who were readmitted within 30 days of discharge. The mean age of the traumatic rib fracture cohort was 57 years, with a 6-day median length of stay. The 30-day mortality rate was 5%. Use of anticoagulation (11.0 vs. 5.4; p = 0.029), diagnosis of a psychiatric disorder (10.2 vs. 5.3; p = 0.01), active smoking (7.3 vs. 5.0; p = 0.008), associated hemothorax (8.3 vs. 5.2; p = 0.010), higher abdominal Abbreviated Injury Scale (33.3 vs. 8.4 vs. 6.5; p = 0.002), rapid response activation (8.9 vs. 5.2; p = 0.005), admission to intensive care unit (7.7 vs. 4.5; p = 0.001), and diagnosis of in-hospital pneumonia (10.1 vs. 5.4; p = 0.022) were predictors of hospital readmission. On multivariate analysis, prescribed anticoagulation (odds ratio [OR], 2.22; p = 0.033), active smoking (OR, 1.58; p = 0.004), higher abdominal Abbreviated Injury Scale (OR, 1.50; p = 0.054), and diagnosis of a psychiatric disorder (OR, 2.00; p = 0.016) predicted hospital readmission.

CONCLUSION

In patients with traumatic rib fractures, those with anticoagulant use, those who actively smoke, those with a psychiatric diagnosis, or those with associated abdominal injuries are at the highest risk of rehospitalization following discharge. Quality improvement should focus on strategies and protocols directed toward these groups to reduce nonelective readmissions.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

CENTER FOR TRAUMA SURVIVORSHIP IMPROVES POST-DISCHARGE FOLLOW-UP AND RETENTION

BACKGROUND

Although the need for high-level care persists post-discharge, severely injured trauma survivors have historically poor adherence to follow-up. We hypothesized that a dedicated Center for Trauma Survivorship (CTS) improves follow-up and facilitates post-discharge specialty care.

METHODS

Retrospective study of "CTS eligible" trauma patients before (Jan - Dec 2017) and after (Jan - Dec 2019) creation of the CTS. Patients with an ICU stay ≥2 days or a New Injury Severity Score ≥ 16 are CTS eligible. The before (PRE) cohort was followed through Dec 2018 and the after (CTS) cohort through Dec 2020. Primary outcome was follow-up within the hospital system exclusive of mental health and rehabilitative therapy appointments. Secondary outcomes include post-discharge surgical procedures and specialty-specific follow-up.

RESULTS

There were no significant differences in demographics or hospital duration in the PRE (n = 177) and CTS (n = 119) cohorts. Of the CTS group, 91% presented for outpatient follow-up within the hospital system, compared to 73% in the Pre group (p < 0.001). In the PRE cohort, only 39% were seen by the trauma service compared to 62% in the CTS cohort (p < 0.001). CTS patients also had increased follow-up with other providers (80% vs 65%; p = 0.006). Notably, 33% of CTS patients had additional surgery compared to only 20% in the PRE group (p = 0.011). CTS patients had over 20% more outpatient visits (1,280 vs 1,006 visits).

CONCLUSION

Despite the follow-up period for the CTS cohort occurring during the peak of the COVID-19 pandemic, limiting availability of outpatient services, our CTS significantly improved follow-up with trauma providers, as well as with other specialties. The CTS patients also underwent significantly more secondary operations. These data demonstrate that creation of a CTS can improve the post-discharge care of severely injured trauma survivors, allowing for care coordination within the healthcare system, retaining patients, generating revenue and providing needed follow-up care.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Predictors of appointment adherence following operative treatment of pediatric supracondylar humerus fractures: which patients are not following up?

This study aims to identify characteristics associated with poor appointment adherence after surgical stabilization of supracondylar humerus fractures (SCHFX) in children. A retrospective review of 560 consecutive, surgically managed patients with SCHFX from 2010 to 2015 was performed. One missed follow-up appointment was classified as 'low adherence', whereas missing two or more appointments was classified as 'very low adherence'. Demographics, insurance status, estimated family income and distance from clinic were analyzed to identify differences in variables between adherent and low-adherent groups. Of 560, 121 (21.8%) missed one follow-up visit and 39/560 (7.1%) missed more than two visits. Age, gender, distance traveled, insurance status and primary language were nonpredictive. Estimated income <$50 000 was associated with a >200% increase in low adherence vs patients with estimated income >$50 000 (9.3 vs 3.8%; P = 0.012). African American patients had significantly lower adherence vs patients of other races (47.5 vs 19.6%; P < 0.0001). Ethnicity remained the only significant factor correlated to adherence after multivariate analysis. African Americans were three times more likely demonstrate low adherence (P = 0.0014). Ethnicity and estimated income <$50 000 were predictors of missing two or more visits. African American patients were four times more likely to miss two or more visits [odds ratio (OR), 4.17; P = 0.0026] than others; estimated income <$50 000 was associated with a two-fold increase in missing two or more visits (OR, 2.33; P = 0.035). By identifying at-risk patient populations, healthcare systems can adopt strategies to remove barriers of accessing follow-up care.

The Center for Trauma Survivorship: Addressing the great unmet need for posttrauma center care

BACKGROUND

Returning patients to preinjury status is the goal of a trauma system. Trauma centers (TCs) provide inpatient care, but postdischarge treatment is fragmented with clinic follow-up rates of <30%. Posttraumatic stress disorder (PTSD) and depression are common, but few patients ever obtain necessary behavioral health services. We postulated that a multidisciplinary Center for Trauma Survivorship (CTS) providing comprehensive care would meet patient's needs, improve postdischarge compliance, deliver behavioral health, and decrease unplanned emergency department (ED) visits and readmissions.

METHODS

Focus groups of trauma survivors were conducted to identify issues following TC discharge. Center for Trauma Survivorship eligible patients are aged 18 to 80 years and have intensive care unit stay of >2 days or have a New Injury Severity Score of ≥16. Center for Trauma Survivorship visits were scheduled by a dedicated navigator and included physical and behavioral health care. Patients were screened for PTSD and depression. Patients screening positive were referred for behavioral health services. Patients were provided 24/7 access to the CTS team. Outcomes include compliance with appointments, mental health visits, unplanned ED visits, and readmissions in the year following discharge from the TC.

RESULTS

Patients universally felt abandoned by the TC after discharge. Over 1 year, 107 patients had 386 CTS visits. Average time for each appointment was >1 hour. Center for Trauma Survivorship "no show" rate was 17%. Eighty-six percent screening positive for PTSD/depression successfully received behavioral health services. Postdischarge ED and hospital admissions were most often for infections or unrelated conditions. Emergency department utilization was significantly lower than a similarly injured group of patients 1 year before the inception of the CTS.

CONCLUSION

A CTS fills the vast gaps in care following TC discharge leading to improved compliance with appointments and delivery of physical and behavioral health services. Center for Trauma Survivorship also appears to decrease ED visits in the year following discharge. To achieve optimal long-term recovery from injury, trauma care must continue long after patients leave the TC.

LEVEL OF EVIDENCE

Therapeutic, Level III.

[Analysis of causes and factors associated with hospital readmission in mild and moderate polythraumatism: An observational study]

BACKGROUND

Early readmissions (ER) occur during the 30 days after discharge, ER are common and expensive, associated with a decrease in the quality of care. The rate of ER in polytraumatic patients (PTP) is estimated between 4.3-15%. Our objective was to identify those factors associated with ER and its characteristics after suffering mild-moderate trauma in our area.

MATERIAL AND METHOD

This is a retrospective observational study, including data of patients with (PTP) mild or moderate admitted between July 2012 and June 2017 in our institution and their ER in public hospitals and/or outpatient centers. Demographic variables, diagnoses, procedures and characteristics of readmissions were collected. After a bivariant analysis was done, a Logistic regression had benn performed to determine risk factors for ER.

RESULTS

1013 patients were included, with median age of 38 years, ISS of 3 points and initial hospital stay of 1 day. 185 patients were readmitted (18.3%). Independent factors associated with ER were: injury mechanism, especially bicycle accident (OR 2.26), comorbidities highlighting HBP (OR 1.83) and COPD (OR 1.98), fracture immobilization (OR 1.99) and hospital admission in the initial care (OR 0.56). The causes of ER were: pain 61.6%, wound infection 15.1%, scheduled cures and deferred interventions 12.97%, medical 6.4% and psychiatric decompensation. 2.7% CONCLUSION: The ERs in mild-moderate PTP are multifactorial, our results show an association between factors such as injury mechanism, the presence of comorbidities and the procedures performed in the sentinel episode and the rate of ER. The implementation of simple interventions at discharge could reduce its incidence clearly.

Using clinical analysis to classify 30-day trauma readmissions

BACKGROUND

Unplanned hospital readmissions are common across specialties. Descriptive readmission studies commonly query large administrative databases, which some speculate lack clinical granularity. This article provides the framework for a process improvement initiative aimed at identifying clinically meaningful reasons for trauma readmission. Our study hypothesizes an expected difference between the clinically abstracted reasons for readmission and those documented by the data processing staff in the trauma registry and that those differences will be the starting point to target performance improvement.

METHODS

This is a retrospective, cohort study from 2014 to 2016 involving 18,998 trauma evaluations at a Level I trauma center. The systematic categorization of trauma readmissions was completed via clinical chart review. Readmissions were categorized following an organizational flowchart. The chart reviews ultimately resulted in two readmission categories: primary and secondary reasons for 30-day trauma readmission.

RESULTS

There were 413 readmissions, an overall readmission rate of 2.7%. The highest rate of readmission, by mechanism of injury, was gunshot wounds (11%). Secondary reasons for readmission predominated (76.1%). Complications led (41%), followed by observation (8.8%) and pain (8.6%). Following readmission chart review and categorization, the trauma registry data were queried and categorized via the same method. When the two methods of data collection were compared, there was a significant difference (p < 0.0001).

CONCLUSIONS

The granular dissection of readmission charts proved to assist in isolating clinically significant readmission variables, providing clarity into the reasons behind trauma readmission. If determined solely by the trauma registry data, our performance and quality improvement initiatives would be misguided. We recommend clinical oversight of databases, with clinical review of key areas in order to guide performance improvement.

Improving Surveillance of Traumatic Thoracic Aortic Injuries Repaired with Thoracic Endovascular Graft Placement

The optimal follow-up protocol for patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic thoracic aortic injury remains unclear. The objective of this study was to assess follow-up patterns in such patients and present an approach to improve long-term follow-up in this cohort. The University of Louisville Trauma Registry was queried for patients who underwent TEVAR for traumatic thoracic aortic injuries between 2006 and 2016. Demographic, injury-specific, perioperative, and outcome measures were recorded for each patient. Follow-up evaluation and duration of follow-up were captured. Follow-up imaging was reviewed for any evidence of vascular complications. A total of 56 patients underwent TEVAR for traumatic thoracic aortic injury. Median age was 48 (range 18–86). Injury mechanism was largely blunt trauma (55 (98%)). Median injury severity score was 34 (range 17–43). Median length of stay was 12.5 days (range 1–40 days), and 51 patients (91%) survived to discharge. Of these, 30 (54%) made at least one follow-up appointment, and 21 of those 30 (70%) received a follow-up CT scan. Median time to last follow-up was one month (range 0–48 months), with 12 patients (21%) having follow-up beyond two months. No patients demonstrated any evidence of vascular complications on imaging at last follow-up. Despite the increased use of TEVAR to treat traumatic aortic injuries, limited follow-up data exist to predict the long-term outcomes of such interventions. Development of statewide or regional databases may help better track outcomes and identify late complications.

Evaluation of Orthopedic Trauma Surgery Follow-up and Impact of a Routine Callback Program

A high rate of patients lost to follow-up is a common problem in orthopedic trauma surgery. This adversely affects the ability to produce accurate clinical outcomes research. The purpose of this project was to (1) evaluate the rate of loss to follow-up at an academic level I trauma center; (2) identify the patient-reported reasons for loss to follow-up; and (3) evaluate the efficacy of a routine patient callback program. All patients who underwent surgery in the orthopedic trauma division of the University of Virginia Medical Center from April 1, 2014, to September 30, 2014, and did not complete their postoperative clinic follow-up were analyzed. The characteristics of these patients were evaluated, and the primary reason for not completing the recommended follow-up was identified. All patients were then offered additional orthopedic follow-up at the time of contact. Of the 480 patients who met the inclusion criteria, 41 (8.5%) failed to complete the recommended postoperative follow-up course. The most common reason for being lost to follow-up was feeling well and not having the need to be seen (46.3%). Only 6 (14.6%) of the 41 patients requested follow-up care at the time of contact. The lost to follow-up rate in this study, 8.5%, was considerably lower than that previously reported, but patient characteristics were consistent with those of prior studies on this subject. The low lost to follow-up rate may reflect a difference in geographic location or patient population. The patient callback program had a low yield of patients requesting additional follow-up after being contacted. [Orthopedics. 2017; 40(2):e312-e316.].

Adjacent Segment Pathology: Progressive Disease Course or a Product of Iatrogenic Fusion?

Objective: Cervical spine clinical adjacent segment pathology (CASP) has a reported 3% annual incidence and 26% ten-year prevalence. Its pathophysiology remains controversial, whether due to mechanical stress of a fusion segment on adjacent levels or due to patient propensity to develop progressive degenerative change. We investigate this relationship by comparing prevalence of CASP in traumatic and spondylotic patient cohorts. Method: A retrospective review of traumatic cervical spine fusion cases performed by the local group of neurosurgeons from 2004-2008 was completed. Surgery for CASP and presence of radiological adjacent segment pathology (RASP) were identified by telephone and electronic medical record (EMR) review, and compared to those in patients having elective cervical fusion for degenerative disease. Results: There was a higher proportion of males (50/100 vs. 37/46, p<0.001) in the traumatic group. Median age between groups was not significantly different (47 years in the trauma cohort, 50 years in the degenerative cohort; p>0.05). Mean follow-up times were different (6.4 years in the trauma group, 7.1 years in the degenerative group; p<0.01), although this was not thought to be clinically significant. The degenerative group was found to have a significantly higher reoperation rate for CASP (10/100 vs. 0/46, p=0.031, Fisher’s Exact Test), and rate of RASP (20/100 vs. 1/32, p=0.025) Conclusion: This is the only cohort study to our knowledge comparing surgery for CASP in trauma patients to those with degenerative disease. A higher rate of repeat surgery in degenerative disease patients was found. This suggests that CASP is more related to patient factors predisposing to progressive degenerative disease and not increased mechanical stress.

Postdischarge complications following nonoperative management of blunt splenic injury

BACKGROUND

Nonoperative management (NOM) is the standard of care in majority of blunt splenic injuries. However, little is known about the postdischarge complications.

METHODS

Patients admitted for blunt splenic injury were identified in the California State Inpatient Database (2007 to 2011). We examined patterns and risk factors for postdischarge complications among these patients.

RESULTS

In total, 2,704 (61.45%) patients had NOM without splenic artery embolization (SAE) and 257 (5.84%) had NOM with adjunct SAE. Thirty-day readmission rate was higher in those who had adjunct SAE (12.84% vs 7.36%, P = .002). Subsequent operations during readmission were seen in 18.10% of readmitted patients and 38.10% of all patients were readmitted at nonindex hospitals. Major diagnoses on readmission were spleen injury (36.2%) and respiratory complications (9.05%). Adjunct SAE was an independent risk factor for readmission (adjusted odds ratio 1.82, 95% confidence interval 1.19 to 2.78).

CONCLUSIONS

Nearly one fifth of readmitted patients initially managed nonoperatively required an operative intervention. Improving predischarge assessments and postdischarge follow-up may reduce readmissions among these patients.

Uninsured status may be more predictive of outcomes among the severely injured than minority race

AIM

Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.

METHODS

We performed a retrospective analysis of the 2010-2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18-64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.

RESULTS

There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29-1.98, p<0.001) and black race (OR 1.24, 1.04-1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36-0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29-2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32-0.63, p<0.001).

CONCLUSION

Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.