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Knowlton LM, Scott JW, Dowzicky P, Murphy P, Davis KA, Staudenmayer K, Martin RS. Financial toxicity part II: A practical guide to measuring and tracking long-term financial outcomes among acute care surgery patients. J Trauma Acute Care Surg 2024; 96:986-991. [PMID: 38439149 DOI: 10.1097/ta.0000000000004310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
ABSTRACT Acute care surgery (ACS) patients are frequently faced with significant long-term recovery and financial implications that extend far beyond their hospitalization. While major injury and emergency general surgery (EGS) emergencies are often viewed solely as acute moments of crisis, the impact on patients can be lifelong. Financial outcomes after major injury or emergency surgery have only begun to be understood. The Healthcare Economics Committee from the American Association for the Surgery of Trauma previously published a conceptual overview of financial toxicity in ACS, highlighting the association between financial outcomes and long-term physical recovery. The aims of second-phase financial toxicity review by the Healthcare Economics Committee of the American Association for the Surgery of Trauma are to (1) understand the unique impact of financial toxicity on ACS patients; (2) delineate the current limitations surrounding measurement domains of financial toxicity in ACS; (3) explore the "when, what and how" of optimally capturing financial outcomes in ACS; and (4) delineate next steps for integration of these financial metrics in our long-term patient outcomes. As acute care surgeons, our patients' recovery is often contingent on equal parts physical, emotional, and financial recovery. The ACS community has an opportunity to impact long-term patient outcomes and well-being far beyond clinical recovery.
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Affiliation(s)
- Lisa Marie Knowlton
- From the Section of Trauma, Surgical Critical Care and Acute Care Surgery, Department of Surgery (L.M.K., K.S.), Stanford University School of Medicine, Stanford, California; Department of Surgery (J.W.S.), Division of Trauma, Burn, and Critical Care Surgery, University of Washington, Seattle, Washington; Department of Surgery (P.D.), Division of Trauma and Acute Care Surgery, University of Chicago, Chicago, Illinois; Department of Surgery (P.M.), Division of Trauma/Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Section of Acute Care Surgery, Department of Surgery (K.A.D.), Division of General Surgery, Yale University, New Haven, Connecticut; and Department of Surgery (R.S.M.), Wake Forest School of Medicine, Winston-Salem, North Carolina
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Romijn ASC, Proaño-Zamudio JA, Rastogi V, Yadavalli SD, Lagazzi E, Giannakopoulos GF, Schermerhorn ML, Saillant NN. Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury. Eur J Trauma Emerg Surg 2024; 50:551-559. [PMID: 38224357 DOI: 10.1007/s00068-023-02432-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/28/2023] [Indexed: 01/16/2024]
Abstract
PURPOSE Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI. METHODS Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD). RESULTS We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29-58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p < .001). CONCLUSION We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.
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Affiliation(s)
- Anne-Sophie C Romijn
- Division of Trauma & Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., White Building, Suite 506, Boston, MA, 02114, USA.
- Division of Trauma & Emergency Surgery, Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Jefferson A Proaño-Zamudio
- Division of Trauma & Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., White Building, Suite 506, Boston, MA, 02114, USA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Vascular Surgery, Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Emanuele Lagazzi
- Division of Trauma & Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., White Building, Suite 506, Boston, MA, 02114, USA
| | - Georgios F Giannakopoulos
- Division of Trauma & Emergency Surgery, Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Acute Care and Trauma Surgery, Department of Surgery, Boston Medical Center, Boston, MA, USA
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Shilati FM, Silver CM, Baskaran A, Jang A, Wafford QE, Slocum J, Schilling C, Schaeffer C, Shapiro MB, Stey AM. Transitional care programs for trauma patients: A scoping review. Surgery 2023; 174:1001-1007. [PMID: 37550166 PMCID: PMC10527729 DOI: 10.1016/j.surg.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 08/09/2023]
Abstract
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.
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Affiliation(s)
| | - Casey M Silver
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Archit Baskaran
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Angie Jang
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Q Eileen Wafford
- Galter Health Sciences Library and Learning Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - John Slocum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christine Schilling
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christine Schaeffer
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago IL
| | - Michael B Shapiro
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anne M Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL. https://twitter.com/AnneMStey
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Castillo-Angeles M, Zogg CK, Jarman MP, Nitzschke SL, Askari R, Cooper Z, Salim A, Havens JM. Predictors of care discontinuity in geriatric trauma patients. J Trauma Acute Care Surg 2023; 94:765-770. [PMID: 36941228 PMCID: PMC10205689 DOI: 10.1097/ta.0000000000003961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Readmission to a non-index hospital, or care discontinuity, has been shown to have worse outcomes among surgical patients. Little is known about its effect on geriatric trauma patients. Our goal was to determine predictors of care discontinuity and to evaluate its effect on mortality in this geriatric population. METHODS This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients. Care discontinuity was defined as readmission within 30 days to a non-index hospital. Demographic and clinical characteristics (including readmission diagnosis category) were collected. Multivariate logistic regression analysis was performed to identify predictors of care discontinuity and to assess its association with mortality. RESULTS We included 754,313 geriatric trauma patients. Mean age was 82.13 years (SD, 0.50 years), 68% were male and 91% were White. There were 21,615 (2.87%) readmitted within 30 days of discharge. Of these, 34% were readmitted to a non-index hospital. Overall 30-day mortality after readmission was 25%. In unadjusted analysis, readmission to index hospitals was more likely to be due to surgical infection, GI complaints, or cardiac/vascular complaints. After adjusted analysis, predictors of care discontinuity included readmission diagnoses, patient- and hospital-level factors. Care discontinuity was not associated with mortality (OR, 0.93; 95% confidence interval, 0.86-1.01). CONCLUSION More than a third of geriatric trauma patients are readmitted to a non-index hospital, which is driven by readmission diagnosis, travel time and hospital characteristics. However, unlike other surgical settings, this care discontinuity is not associated with increased mortality. Further work is needed to understand the reasons for this and to determine which standardized processes of care can benefit this population. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Manuel Castillo-Angeles
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Cheryl K. Zogg
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
- Yale School of Medicine, New Haven, CT
| | - Molly P. Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Stephanie L. Nitzschke
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Reza Askari
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Zara Cooper
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Ali Salim
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Joaquim M. Havens
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School and Harvard T. H. Chan School of Public Health, Boston, MA
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Quintana M, Bornstein S, Zwemer C, Zebley JA, Amdur R, Trankiem CT, Burd RS, McKenna E, Williams M, Sarani B. A multicenter, citywide report on recurrent violent injury. Injury 2023:S0020-1383(23)00245-0. [PMID: 36925376 DOI: 10.1016/j.injury.2023.03.005] [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: 11/15/2022] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION The incidence of and risk factors for recurrent violent trauma are not well known. This information is needed to focus violence prevention efforts on at-risk cohorts. The purpose of this study was to determine the incidence of and risk factors for recurrence following violent injury in a large urban setting. We hypothesize that the overall incidence of recurrent violent injury is low but there are specific at-risk cohorts. METHODS A retrospective, citywide study of patients who sustained blunt assault or penetrating trauma from 2013 to 2019 was performed. Patients were tracked across all trauma centers using their name and date of birth. The primary outcome was incidence of recurrent violent injury, which was calculated by dividing the number of readmitted patients by the number who survived previous admissions due to penetrating trauma or blunt assault. Associations between readmission and injury severity score, abbreviated injury score, age, sex, hospital, mechanism of injury (MOI), and disposition were determined. Kaplan-Meier curves were plotted to determine the incidence of recurrent injury over time. A multivariable Cox proportional hazard model was used to examine the relationships between characteristics at first admission and time-to-readmission. RESULTS The recurrent injury rate was 836 patients (6.33%) out of 13,211 injured patients. Male, age 14-45 years old, discharge to jail or left against medical advice, and moderate/severe head injury were associated with re-injury. There was no association between recurrence and mechanism of injury or overall injury severity. Discharge to home was associated with a lower re-injury rate. CONCLUSION The low recurrent injury rate despite high injury prevalence suggests injury prevention efforts should target this demographic and their non-injured peers.
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Affiliation(s)
- Megan Quintana
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Sydney Bornstein
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Catherine Zwemer
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - James A Zebley
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Richard Amdur
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA
| | - Christine T Trankiem
- Division of Trauma, Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Randall S Burd
- Department of Pediatric Surgery, Children's National Medical Center, Washington, DC, USA
| | - Elise McKenna
- Department of Pediatric Surgery, Children's National Medical Center, Washington, DC, USA
| | - Mallory Williams
- Department of Surgery, Howard University Hospital, Washington, DC, USA
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, 2150 Pennsylvania Ave, NW, Suite 6B, Washington, DC 20037, USA.
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Harcombe H, Barson D, Samaranayaka A, Davie G, Wyeth E, Derrett S, McBride P. Predictors of hospital readmission after trauma: A retrospective cohort study in New Zealand. Injury 2023:S0020-1383(23)00252-8. [PMID: 36931967 DOI: 10.1016/j.injury.2023.03.009] [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: 10/10/2022] [Revised: 02/27/2023] [Accepted: 03/06/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Understanding predictors of hospital readmission following major trauma is important as readmissions are costly and some are potentially avoidable. This study describes the incidence of, and sociodemographic, injury-related and treatment-related factors predictive of, hospital readmission related to: a) all-causes, b) the index trauma injury, and c) subsequent injury events in the 30 days and 12 months following discharge for major trauma patients nationally in New Zealand. METHODS Data from the New Zealand Trauma Registry (NZTR) was linked with Ministry of Health hospital discharge data. Hospital readmissions were examined for all patients entered into the NZTR for an injury event between 1 January and 31 December 2018. Readmissions were examined for the 12-months following the discharge date for participant's index trauma injury. RESULTS Of 1986 people, 42% had ≥1 readmission in the 12 months following discharge; 15% within 30 days. Seven percent had ≥1 readmission related to the index trauma within 30 days of discharge; readmission was 3.43 (95% CI 1.87, 6.29) times as likely if the index trauma was self-inflicted compared to unintentional, and 1.64 (95% CI 1.15, 2.34) times as likely if the index trauma involved intensive care unit admission. Those admitted to hospital for longer for their index trauma were less likely to be readmitted due to their index trauma injury within 30 days compared to those admitted for 0-1 day. Seventeen percent were readmitted for a subsequent injury event within 12 months, with readmission more likely for older people (>65 years), those with comorbidities, Māori compared with non-Māori and those with higher trauma injury severity. CONCLUSION A substantial proportion of people are readmitted after discharge for major trauma. Factors identified in this study will be useful to consider when developing interventions to reduce preventable readmissions including those related to the index trauma injury, readmissions from other causes and subsequent injury-related readmissions. Further research specifically examining planned and unplanned readmissions is warranted.
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Affiliation(s)
- Helen Harcombe
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Dave Barson
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Ari Samaranayaka
- Biostatistics Centre, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Gabrielle Davie
- Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
| | - Emma Wyeth
- Ngāi Tahu Māori Health Research Unit, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Sarah Derrett
- Ngāi Tahu Māori Health Research Unit, Division of Health Sciences, University of Otago, Dunedin, New Zealand.
| | - Paul McBride
- Health Quality & Safety Commission, PO Box 25496, Wellington, 6146, New Zealand.
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Abstract
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.
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Ross MR, Hurst PM, Asti L, Cooper JN. Impact of Medicaid expansion on young adult firearm and motor vehicle crash trauma patients. Surg Open Sci 2022; 8:9-19. [PMID: 35243283 PMCID: PMC8881723 DOI: 10.1016/j.sopen.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/25/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The Affordable Care Act Medicaid expansion has increased insurance coverage and reduced some disparities in care and outcomes among trauma patients, but its impact on subsets of trauma patients with particular mechanisms of injury are unclear. This study evaluated the association of the Affordable Care Act Medicaid expansion with insurance coverage, trauma care, and outcomes among young adults hospitalized for firearm- or motor vehicle crash-related injuries. MATERIALS AND METHODS We used statewide hospital discharge data from 5 Medicaid expansion and 5 nonexpansion states to compare changes in insurance coverage and outcomes among firearm and motor vehicle crash trauma patients aged 19-44 from before (2011-2013) to after (2014-2017) Medicaid expansion. We examined difference in differences overall, by race/ethnicity, and by zip-code-level median income quartile. RESULTS Medicaid expansion was associated with a decrease in the proportion of young adult motor vehicle crash and firearm trauma patients who were uninsured (motor vehicle crash: difference in differences - 12.7 percentage points, P < .001; firearm: difference in differences - 30.7 percentage points, P < .001). Medicaid expansion was also associated with increases in the percentage of patients discharged to any rehabilitation (motor vehicle crash: difference in differences 1.78 percentage points, P = .001; firearm: difference in differences 2.07 percentage points, P = .02) and inpatient rehabilitation (motor vehicle crash: difference in differences 1.21 percentage points, P = .001; firearm: difference in differences 1.58 percentage points, P = .002). Among patients with firearm injuries, Medicaid expansion was associated with a reduction in in-hospital mortality (difference in differences - 1.55 percentage points, P = .002). CONCLUSION In its first 4 years, the Affordable Care Act Medicaid expansion increased insurance coverage and access to rehabilitation among young adults hospitalized for firearm- or motor vehicle crash-related injuries while reducing inpatient mortality among firearm trauma patients.
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Affiliation(s)
- Michael R. Ross
- The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, United States,Medical Student Research Program, The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, United States
| | - Philip M. Hurst
- The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH 43210, United States,Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, United States
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, United States,Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, United States
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, United States,Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205, United States,Department of Pediatrics, College of Medicine, The Ohio State University, 370 W 9th Ave, Columbus, OH 43210, United States,Division of Epidemiology, College of Public Health, The Ohio State University, 1841 Neil Ave Columbus, OH 43210, United States,Corresponding author at: The Ohio State University, 700 Children's Drive Columbus, OH 43205, United States. Tel.: + 1(614)355-4526.
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Metzger GA, Asti L, Quinn JP, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level. J Am Coll Surg 2021; 233:776-793.e16. [PMID: 34656739 PMCID: PMC8627499 DOI: 10.1016/j.jamcollsurg.2021.08.694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/21/2021] [Accepted: 08/25/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income. STUDY DESIGN Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years. RESULTS Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points). CONCLUSIONS The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.
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Affiliation(s)
- Gregory A Metzger
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - John P Quinn
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Medical Student Research Program, College of Medicine, The Ohio State University, Columbus, OH
| | - Deena J Chisolm
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, Columbus, OH
| | - Henry Xiang
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Injury Research and Policy, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH; Department of Surgery, College of Medicine, The Ohio State University, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH; Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH.
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Kay AB, Morris DS, Gardner S, Majercik S, White TW. Readmission for pleural space complications after chest wall injury: Who is at risk? J Trauma Acute Care Surg 2021; 91:981-987. [PMID: 34538827 DOI: 10.1097/ta.0000000000003408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about patient characteristics predicting postdischarge pleural space complications (PDPSCs) after thoracic trauma. We sought to analyze the patient population who required unplanned hospital readmission for PDPSC. METHODS Retrospective review of adult patients admitted to a Level I Trauma Center with a chest Abbreviated Injury Scale (AIS) score of 2 or greater between January 2015 and August 2020. Those readmitted within 30 days of index hospitalization discharge for PDPSC were compared with those not readmitted. Demographics, injury characteristics, surgical procedures, imaging, and readmission data were retrieved. RESULTS Out of 17,192 trauma evaluations, 3,412 (19.8%) suffered a chest AIS score of 2 or greater injury and 155 experienced an unplanned 30-day hospital readmission. Of those, 49 (1.4%) were readmitted for the management of PDPSC (readmit PDPSC) and were compared with patients who were not readmitted (no readmit, n = 3,257). The readmit PDPSC group was significantly older age, heavier, comprised of fewer men, and suffered a higher mean chest AIS score. The readmit PDPSC group had a significantly higher incidence of rib fractures, flail chest, pneumothorax, hemothorax, scapula fractures, and a higher rate of tube thoracostomy placement during index admission. The discharge chest X-ray in the readmit PDPSC group demonstrated a pleural space abnormality in 36 (73%) of patients. Mean time to readmission was 10.2 (7.2) days, and hospital length of stay on readmission was 5.8 (3.7) days. Pleural effusion was the most common readmission diagnosis (44 [90%]), and 42 (86%) required tube thoracostomy. CONCLUSION We describe the subset of chest wall injury patients who require hospital readmission for PDPSC. Characteristics from index hospitalization associated with PDPSC include older age, female sex, heavier weight, presence of rib fractures, pleural space abnormality, scapular fracture, and chest tube placement. Further studies are needed to characterize this at-risk chest wall injury population, and to determine what interventions can facilitate outpatient management of postdischarge pleural space complications and mitigate readmission risk. LEVEL OF EVIDENCE Prognostic and epidemiologic, Level IV; Care management, Level V.
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Affiliation(s)
- Annika B Kay
- From the Division of Trauma Services and Surgical Critical Care, Intermountain Medical Center, Murray, Utah
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11
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Carr MJ, Badiee J, Benham DA, Diaz JA, Calvo RY, Sise CB, Sise MJ, Bansal V, Martin MJ. Fragmentation of care in the blunt abdominal trauma patient: Capturing our true outcomes and impact on care. J Trauma Acute Care Surg 2021; 91:829-833. [PMID: 34695059 DOI: 10.1097/ta.0000000000003217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma care is associated with unplanned readmissions, which may occur at facilities other than the index treatment facility. This "fragmentation of care" may be associated with adverse outcomes. We evaluated a statewide database that includes readmissions to analyze the incidence and impact of FC. METHODS The California Office of Statewide Health Planning and Development patient discharge data set was evaluated for calendar years 2016 to 2018. Patients 15 years or older diagnosed with blunt abdominal solid organ injury during the index admission were identified. Readmissions were evaluated postdischarge at 1, 3, and 6 months. Patients readmitted within 6 months to a facility other than the index admission facility (fragmented care [FC]) were compared with those readmitted to their index admission facility (non-FC). Logistic regression modeling was used to evaluate risk of FC. RESULTS Of the total 1,580 patients, there were 752 FC (47.6%) and 828 (52.4%) non-FC. Readmissions representing FC at months 1, 3, and 6 were 40.3%, 49.3%, and 53.4%, respectively. At index admission, the groups were demographically and clinically similar, with similar rates of abdominal operations and complications. Non-FC patients had a higher rate of abdominal reoperation at readmission (5.8% non-FC vs. 2.9% FC, p = 0.006). In an adjusted model, multiple readmissions (odds ratio [OR] 1.11, p = 0.014), readmission >30 days after index facility discharge (OR, 1.98; p < 0.001), and discharge to a nonmedical facility (OR, 2.46; p < 0.0001) were associated with increased odds of FC. Operative intervention at index admission was associated with lower odds of FC (OR, 0.77; p = 0.039). However, FC was not independently associated with demographic or insurance characteristics. CONCLUSION The rate of FC among patients with blunt abdominal injury is high. The risk of FC is mitigated when patients are managed operatively during the index admission. Trauma systems should implement measures to ensure that these patients are followed postdischarge. LEVEL OF EVIDENCE Prognostic and epidemiological, level III; Care management, level IV.
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Affiliation(s)
- Matthew J Carr
- From the Trauma Service, Scripps Mercy Hospital, San Diego, California
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12
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Hoyos JP, Alaniz L, Llerenas M, Mendoza R, Tay E, Barrios C. Post-Trauma Follow-up Phone Call Shows Lower Readmission Rates for Patients Discharged From Emergency Department Compared to Inpatient Stay. Am Surg 2021; 87:1633-1637. [PMID: 34672823 DOI: 10.1177/00031348211051694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Studies show follow-up phone calls decrease readmission rates (RR) in trauma patients and social vulnerabilities may play a role as well. Minimal literature exists comparing RR of trauma patients who required an inpatient stay to those whose treatment was limited to the Emergency Department (ED), as they are at high risk of recidivism. We hypothesized post-trauma follow-up calls would show higher RR for ED patients than those requiring inpatient stay, as well as potentially differing outcomes for minorities. STUDY DESIGN A retrospective analysis from 2019-2020 of 1328 trauma patients from UCI Medical Center, discharged from inpatient facilities or the ED. A questionnaire script read by a nurse practitioner to patients via phone call following discharge. Data associated with readmission were captured. Multivariable logistic regression analysis was performed, controlling for patient factors including severity of injury. RESULTS Patients discharged from the ED were 47.4% less likely to be readmitted than those who required an inpatient stay (P < .01). However, ED patients were 88.7% less likely to receive a prescription than inpatient stay patients (P < .01). No difference between ED and inpatient discharge contact rates was noted (P < .99). Furthermore, no difference in readmission rates was noted for minorities. CONCLUSION Post-trauma follow-up calls showed lower RR for index ED visit patients than those requiring inpatient stay, contrary to expectations. However, ED visit patients were also less likely to receive/fill prescriptions compared to those requiring inpatient stay. Ongoing analysis is warranted to further validate and improve follow-up call programs to ensure equitable health care.
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Affiliation(s)
- Juan Pablo Hoyos
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 218539University of California Irvine, Irvine, CA, USA
| | - Leonardo Alaniz
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 218539University of California Irvine, Irvine, CA, USA
| | - Miguel Llerenas
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 218539University of California Irvine, Irvine, CA, USA
| | - Rosemarie Mendoza
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 218539University of California Irvine, Irvine, CA, USA
| | - Erika Tay
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 218539University of California Irvine, Irvine, CA, USA
| | - Cristobal Barrios
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 218539University of California Irvine, Irvine, CA, USA
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Nasif A, Masroor S. Readmissions, mortality, and HRRP: The bane of a cardiac surgeon's existence! J Card Surg 2021; 36:3259-3260. [PMID: 34143524 DOI: 10.1111/jocs.15750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Abdullah Nasif
- Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Saqib Masroor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Toledo Medical Center, Toledo, Ohio, USA
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Endorf FW, Nygaard RM. High Cost and Resource Utilization of Frostbite Readmissions in the United States. J Burn Care Res 2021; 42:857-864. [PMID: 33993288 DOI: 10.1093/jbcr/irab076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Frostbite is a high morbidity, high-cost injury that can lead to digit or limb necrosis requiring amputation. Our primary aim is to describe the rate of readmission following frostbite injury. Our secondary aims are to describe the overall burden of care, cost, and characteristics of repeat hospitalizations of frostbite-injured people. METHODS Hospitalizations following frostbite injury (index and readmissions) were identified in the 2016 and 2017 Nationwide Readmission Database. Multivariable logistic regression was clustered by hospital and additionally adjusted for severe frostbite injury, gender, year, payor group, severity, and comorbidity index. Population estimates were calculated and adjusted for by using survey weight, sampling clusters, and stratum. RESULTS In the two-year cohort, 1,065 index hospitalizations resulted in 1,907 total hospitalizations following frostbite injury. Most patients were male (80.3%), lived in metropolitan/urban areas (82.3%), and nearly half were insured with Medicaid (46.4%). Of the 842 readmissions, 53.7% were associated with complications typically associated with frostbite injury. Overall, 29% of frostbite injuries resulted in at least one amputation. The average total cost and total LOS of readmissions was $236,872 and 34.7 days. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge AMA were independent predictors of unplanned readmission. Factors associated with multiple readmissions include discharge AMA and Medicare Insurance, but not drug or alcohol abuse or homelessness. The population-based estimated unplanned readmission rate following frostbite injury was 35.4% (95% CI 32.2 - 38.6%). CONCLUSIONS This is the first study examining readmissions following frostbite injury on a national level. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge AMA were independent predictors of unplanned readmission, while only AMA discharge and Medicare insurance were associated with multiple readmissions. Supportive resources (community and hospital-based) may reduce unplanned readmissions of frostbite injured patients with those additional risk factors.
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Killien EY, Huijsmans RLN, Vavilala MS, Schleyer AM, Robinson EF, Maine RG, Rivara FP. Association of Psychosocial Factors and Hospital Complications with Risk for Readmission After Trauma. J Surg Res 2021; 264:334-345. [PMID: 33848832 DOI: 10.1016/j.jss.2021.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/26/2021] [Accepted: 02/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Unplanned hospital readmissions are associated with morbidity and high cost. Existing literature on readmission after trauma has focused on how injury characteristics are associated with readmission. We aimed to evaluate how psychosocial determinants of health and complications of hospitalization combined with injury characteristics affect risk of readmission after trauma. MATERIALS AND METHODS We conducted a retrospective cohort study of adult trauma admissions from July 2015 to September 2017 to Harborview Medical Center in Seattle, Washington. We assessed patient, injury, and hospitalization characteristics and estimated associations between risk factors and unplanned 30-d readmission using multivariable generalized linear Poisson regression models. RESULTS Of 8916 discharged trauma patients, 330 (3.7%) had an unplanned 30-d readmission. Patients were most commonly readmitted with infection (41.5%). Independent risk factors for readmission among postoperative patients included public insurance (adjusted Relative Risk (aRR) 1.34, 95% CI 1.02-1.76), mental illness (aRR 1.39, 1.04-1.85), and chronic renal failure (aRR 2.17, 1.39-3.39); undergoing abdominal, thoracic, or neurosurgical procedures; experiencing an index hospitalization surgical site infection (aRR 4.74, 3.00-7.50), pulmonary embolism (aRR 3.38, 2.04-5.60), or unplanned ICU readmission (aRR 1.74, 1.16-2.62); shorter hospital stay (aRR 0.98/d, 0.97-0.99), and discharge to jail (aRR 4.68, 2.63-8.35) or a shelter (aRR 4.32, 2.58-7.21). Risk factors varied by reason for readmission. Injury severity, trauma mechanism, and body region were not independently associated with readmission risk. CONCLUSIONS Psychosocial factors and hospital complications were more strongly associated with readmission after trauma than injury characteristics. Improved social support and follow-up after discharge for high-risk patients may facilitate earlier identification of postdischarge complications.
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Affiliation(s)
- Elizabeth Y Killien
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, Washington.
| | - Roel L N Huijsmans
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; University Medical Center Utrecht, Utrecht, Netherlands
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Anneliese M Schleyer
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington; Hospital Quality and Patient Safety, Harborview Medical Center, Seattle, Washington
| | - Ellen F Robinson
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rebecca G Maine
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery, University of Washington, , Washington
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington; Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, Washington
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Moran ME, Hodgson JL, Jensen JF, Wood TL. Musculoskeletal injury survivors' resiliency: A systematic review. Disabil Health J 2020; 14:100987. [PMID: 32888877 DOI: 10.1016/j.dhjo.2020.100987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/29/2020] [Accepted: 08/07/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Musculoskeletal traumas are on the rise in the United States; however, limited studies are available to help trauma providers assess and treat concerns beyond the physical impact. Little is understood about the psychological, social, and spiritual factors that protect patients from adverse effects after a physical trauma or their experiences with each factor afterward. OBJECTIVE This systematic review was conducted to investigate and review advancements in research related to risk and resiliency factors experienced by survivors of traumatic musculoskeletal injuries. The use of biopsychosocial-spiritual (BPS-S) framework and resiliency theory guided the analysis. METHODS Researchers reviewed 1003 articles, but only seven met the search criteria. Due to the complexity and uniqueness of traumatic brain injuries, studies on that target population were excluded. RESULTS Of the seven articles reviewed, three identified psychological protective factors that protect against negative health outcomes; three identified negative psychological, social, or spiritual outcomes; and none investigated social or spiritual health. CONCLUSIONS There are significant gaps in the literature surrounding risk and resiliency factors related to the BPS-S health of musculoskeletal injury survivors.
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Affiliation(s)
- Mary E Moran
- Division of Trauma, Department of Surgery, Summa Health System - Akron Campus, 525 East Market, Akron, OH, 44304, USA.
| | - Jennifer L Hodgson
- Department of Human Development and Family Science, East Carolina University, E. 5th Street, Greenville, NC, 27858, USA
| | - Jakob F Jensen
- Department of Human Development and Family Science, East Carolina University, E. 5th Street, Greenville, NC, 27858, USA
| | - Teresa L Wood
- Nursing Research, OhioHealth Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH, 43214, USA
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17
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Readmission for infection after blunt splenic injury: A national comparison of management techniques. J Trauma Acute Care Surg 2020; 88:390-395. [PMID: 32107354 DOI: 10.1097/ta.0000000000002564] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As nonoperative management (NOM) of blunt splenic injury (BSI) increases, understanding risks, especially infectious complications, becomes more important. There are no national studies on BSI outcomes that track readmissions across hospitals. Prior studies demonstrate that infection is a major cause of readmission after trauma and that a significant proportion is readmitted to different hospitals. The purpose of this study was to compare nationwide outcomes of different treatment modalities for BSI including readmissions to different hospitals. METHODS The Nationwide Readmissions Database for 2010 to 2014 was queried for patients 18 years to 64 years old admitted nonelectively with a primary diagnosis of BSI. Organ space infection; a composite infectious incidence of surgical site infection (SSI), urinary tract infection, and pneumonia; and sepsis were identified in three groups: NOM, splenic artery embolization (SAE), and operative management (OM). Rates of infection were quantified during index admission and 30-day and 1-year readmission. Multivariable logistic regression was performed. Results were weighted for national estimates. RESULTS Of the 37,986 patients admitted for BSI, 54.1% underwent NOM, 12.2% SAE, and 33.7% OM. Compared with OM and NOM, SAE had the highest rates of organ space SSI at 1 year (3.9% vs. 2.2% vs. 1.7%, p < 0.001). Compared with NOM, at 1 year, SAE had higher rates of infection (17.2% vs. 8.1%, p < 0.001) and sepsis (3.2% vs. 1.1%, p < 0.001). Compared with NOM, SAE had an increased risk of infection (odds ratio [OR], 1.24; 95 confidence interval [95% CI], 1.10-1.39; p < 0.001) and sepsis (OR, 1.37; 95% CI, 1.06-1.76; p < 0.001) at 1 year. At 1 year, SAE had increased risk of organ space SSI (OR, 1.99; 1.60-2.47; p < 0.001) but OM did not. CONCLUSION Blunt splenic injury treated with SAE is at increased risk of both immediate and long-term infectious complications. Despite being considered splenic preservation, surgeons should be aware of these risks and incorporate such knowledge into their practice accordingly. LEVEL OF EVIDENCE Epidemiological study, level IV.
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18
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Interhospital variability in time to discharge to rehabilitation among insured trauma patients. J Trauma Acute Care Surg 2020; 86:406-414. [PMID: 30531207 DOI: 10.1097/ta.0000000000002163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospital costs are partly a function of length of stay (LOS), which can be impacted by the local availability of postacute care (PAC) resources (inpatient rehabilitation and skilled nursing facilities), particularly for injured patients. We hypothesized that LOS for trauma patients destined for PAC would be variable based on insurance type and hospitals from which they are discharged. METHODS We used the 2014 to 2015 National Inpatient Sample from the Healthcare Cost and Utilization Project. We included all adult admissions with a primary diagnosis of trauma (International Classification of Diseases, 9th Revision, Clinical Modification codes), who were insured and discharged to PAC. We then ranked hospitals based upon mean LOS and divided them into quartiles to determine differences. The primary outcome was inpatient LOS; secondary outcome was cost. RESULTS There are 958,005 trauma patients that met the inclusion criteria. Mean LOS varied based upon insurance type (Medicaid vs. Private vs. Medicare: 12.7 days vs. 8.8 days and 5.7 days; p < 0.001). Shortest LOS hospitals had a marginal variation in LOS (Medicaid vs. Private vs. Medicare: 5.5 days vs. 4.8 days vs. 4.2 days; p < 0.001). Longest LOS hospitals had mean LOS that varied substantially (16.4 days vs. 11.0 days vs. 6.7 days; p < 0.001). Multivariate regression controlling for patient and hospital characteristics revealed that Medicaid patients spent Medicaid patients spent an additional 0.4 days in shortest LOS hospitals and an additional 2.6 days in longest LOS hospitals (p < 0.001). The average daily cost of inpatient care was US $3,500 (SD, US $132). Even with conservative estimates, Medicaid patients at hospitals without easy access to rehabilitation incur significant additional inpatient costs over $10,000 in some hospitals. CONCLUSION Prolonged LOS is likely a function of access to postacute facilities, which is largely out of the hands of trauma centers. Efficiencies in care are magnified by access to postacute beds, suggesting that increased availability of rehabilitation facilities, particularly for Medicaid patients, might help to reduce LOS. LEVEL OF EVIDENCE Epidemiologic, level III; care management, level IV.
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19
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Passman J, Xiong R, Hatchimonji J, Kaufman E, Sharoky C, Yang W, Smith BP, Holena D. Readmissions After Injury: Is Fragmentation of Care Associated With Mortality? J Surg Res 2020; 250:209-215. [DOI: 10.1016/j.jss.2019.12.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/24/2019] [Accepted: 12/27/2019] [Indexed: 12/11/2022]
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Abstract
BACKGROUND There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury. METHODS A retrospective review was performed based on trauma patients evaluated at an urban Level I trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with more than one rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only one rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p less than 0.05. RESULTS During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. One hundred forty-two (8.3%) patients were reevaluated specifically for chest-related complaints, and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score greater than 15, hospital length of stay longer than 7 days, intensive care unit (ICU) length of stay longer than 3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age of 15 years to 35 years, Risk Assessment Profile score greater than 8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation. CONCLUSION Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission. LEVEL OF EVIDENCE Level IV, Prognostic and Epidemiologic.
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21
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Herrera-Escobar JP, Castillo-Angeles MA, Osman SY, Orlas CP, Janjua MB, Abdullah-Arain M, Reidy E, Jarman MP, Price MA, Bulger EM, Nehra D, Haider AH. Long-term patient-reported outcome measures after injury: National Trauma Research Action Plan (NTRAP) scoping review protocol. Trauma Surg Acute Care Open 2020; 5:e000512. [PMID: 32537519 PMCID: PMC7264830 DOI: 10.1136/tsaco-2020-000512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022] Open
Abstract
Background A significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics. Objectives To describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury. Methods A systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Dissemination This scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals.
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Affiliation(s)
- Juan Pablo Herrera-Escobar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Manuel A Castillo-Angeles
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Samia Y Osman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Claudia P Orlas
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Emma Reidy
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Deepika Nehra
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Aga Khan University Medical College, Karachi, Pakistan
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The economic footprint of acute care surgery in the United States: Implications for systems development. J Trauma Acute Care Surg 2020; 86:609-616. [PMID: 30589750 DOI: 10.1097/ta.0000000000002181] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics. METHODS We queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates. RESULTS Of the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25% of total US inpatient costs (US $341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US $10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients. CONCLUSION Acute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs. LEVEL OF EVIDENCE Epidemiologic, level III.
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Readmissions after nonoperative trauma: Increased mortality and costs with delayed intervention. J Trauma Acute Care Surg 2020; 88:219-229. [PMID: 31804415 DOI: 10.1097/ta.0000000000002560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND We sought to examine patterns of readmission after nonoperative trauma, including rates of delayed operative intervention and mortality. METHODS The Nationwide Readmissions Database (2013-2014) was queried for all adult trauma admissions and 30-day readmissions. Index admissions were classified as operative (OI) or nonoperative (NOI), and readmissions examined for major operative intervention (MOR). Multivariable regression modeling was used to evaluate risk for readmission requiring MOR and in-hospital mortality. RESULTS Of 2,244,570 trauma admissions, there were 59,573 readmissions: 66% after NOI, and 35% after OI. Readmission rate was higher after NOI compared with OI (3.6% vs. 1.7% p < 0.001). Readmitted NOI patients were older, with a higher proportion of Injury Severity Score ≥15 and were readmitted earlier (NOI median 8 days vs. OI 11 days). Thirty-one percent of readmitted NOI patients required MOR and experienced higher overall mortality compared with OI patients with operative readmission (NOI 2.9% vs. OI 2%, p = 0.02). Intracranial hemorrhage was an independent risk factor for NOI readmission requiring MOR in both the overall (hazard ratio, 1.11; 95% confidence interval [CI], 1.01-1.22) and Injury Severity Score of 15 or greater cohorts (hazard ratio, 1.46; 95% CI, 1.24-1.7), with a predominance of nonspine neurosurgical procedures (20.3% and 55.1%, respectively). Operative readmission after NOI cost a median of $17,364 (interquartile range, US $11,481 to US $27,816) and carried a total annual cost of US $147 million (95% CI, US $141 million to $154 million). CONCLUSIONS Nonoperative trauma patients have a higher readmission rate than operative index patients and nearly one third require operative intervention during readmission. Operative readmission carries a higher overall mortality rate in NOI patients and together accounts for nearly US $150 million in annual costs. LEVEL OF EVIDENCE Epidemiological, level III.
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Unplanned readmission after traumatic injury: A long-term nationwide analysis. J Trauma Acute Care Surg 2020; 87:188-194. [PMID: 31045723 DOI: 10.1097/ta.0000000000002339] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term outcomes after trauma admissions remain understudied. We analyzed the characteristics of inpatient readmissions within 6 months of an index hospitalization for traumatic injury. METHODS Using the 2010 to 2015 Nationwide Readmissions Database, which captures data from up to 27 US states, we identified patients at least 15 years old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within 1 month, 3 months, and 6 months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors. RESULTS Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within 1 month, 21.6% within 6 months, and 29.8% within 6 months, with limited variability by year. After adjustment, the following were associated with all-cause 6 months inpatient readmissions: male sex (adjusted odds ratio [aOR], 1.10; 95% confidence interval [95% CI], 1.09-1.10), comorbidities (aOR, 1.21; 95% CI, 1.21-1.22), low-income quartiles (first and second) (aOR, 1.08; 95% CI, 1.07-1.10 and aOR, 1.04; 95% CI, 1.03-1.06, respectively), Medicare (aOR, 1.65; 95% CI, 1.62-1.69), Medicaid (aOR, 1.51; 95% CI, 1.48-1.53), being treated at private, investor-owned hospitals (aOR, 1.15; 95% CI, 1.12-1.18), longer hospital length of stay (aOR, 1.01; 95% CI, 1.01-1.01) and patient disposition to short-term hospital (aOR, 1.55; 95% CI, 1.49-1.62), skilled nursing facility (aOR, 1.43; 95% CI, 1.42-1.45), home health care (aOR, 1.27; 95% CI, 1.25-1.28), or leaving against medical advice (aOR, 1.85; 95% CI, 1.78-1.92). CONCLUSION Unplanned readmission after trauma is high and remains this way 6 months after discharge. Understanding the factors that increase the odds of readmissions within 1 month, 3 months, and 6 months offer a focus for quality improvement and have important implications for hospital benchmarking. LEVEL OF EVIDENCE Epidemiological study, level III.
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Alegret N, Vargas AM, Valle A, Martínez J, Rabaneda E, Oncins X. [Analysis of causes and factors associated with hospital readmission in mild and moderate polythraumatism: An observational study]. J Healthc Qual Res 2020; 35:42-49. [PMID: 31870863 DOI: 10.1016/j.jhqr.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/15/2019] [Accepted: 07/29/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- N Alegret
- Servicio de Anestesiología y Reanimación, Corporación Sanitaria Parc Taulí, Sabadell, Barcelona, España.
| | - A-M Vargas
- Servicio de Anestesiología y Reanimación, Corporación Sanitaria Parc Taulí, Sabadell, Barcelona, España
| | - A Valle
- Servicio de Anestesiología y Reanimación, Corporación Sanitaria Parc Taulí, Sabadell, Barcelona, España
| | - J Martínez
- Servicio de Anestesiología y Reanimación, Corporación Sanitaria Parc Taulí, Sabadell, Barcelona, España
| | - E Rabaneda
- Servicio de Anestesiología y Reanimación, Corporación Sanitaria Parc Taulí, Sabadell, Barcelona, España
| | - X Oncins
- Servicio de Traumatología, Corporación Sanitaria Parc Taulí, Sabadell, Barcelona, España
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Assessment of the "Weekend Effect" in Lower Extremity Vascular Trauma. Ann Vasc Surg 2019; 66:233-241.e4. [PMID: 31863955 DOI: 10.1016/j.avsg.2019.11.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/24/2019] [Accepted: 11/26/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Studies suggest that patients admitted on weekends may have worse outcomes as compared with those admitted on weekdays. Lower extremity vascular trauma (LEVT) often requires emergent surgical intervention and might be particularly sensitive to this "weekend effect." The objective of this study was to determine if a weekend effect exists for LEVT. METHODS The National and Nationwide Inpatient Sample Database (2005-2014) was queried to identify all adult patients who were admitted with an LEVT diagnosis. Patient and hospital characteristics were recorded or calculated and outcomes including in-hospital mortality, amputation, length of stay (LOS), and discharge disposition were assessed. Independent predictors of outcomes were identified using multivariable regression models. RESULTS There were 9,282 patients admitted with LEVT (2,866 weekend admissions vs. 6,416 weekday admissions). Patients admitted on weekends were likely to be younger than 45 years (68% weekend vs. 55% weekday, P < 0.001), male (81% weekend vs. 75% weekday, P < 0.001), and uninsured (22% weekend vs. 17% weekday, P < 0.001) as compared with patients admitted on weekdays. There were no statistically significant differences in mortality (3.8% weekend vs. 3.3% weekday, P = 0.209), amputation (7.2% weekend vs. 6.6% weekday, P = 0.258), or discharge home (57.4% weekend vs. 56.1% weekday, P = 0.271). There was no clinically significant difference in LOS (median 7 days weekend vs. 7 days weekday), P = 0.009. On multivariable regression analyses, there were no statistically significant outcome differences between the groups. CONCLUSIONS This study did not identify a weekend effect in LEVT patients in the United States. This suggests that factors other than the day of admission may be important in influencing outcomes after LEVT.
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Metcalfe D, Zogg CK, Haut ER, Pawlik TM, Haider AH, Perry DC. Data resource profile: State Inpatient Databases. Int J Epidemiol 2019; 48:1742-1742h. [PMID: 31280297 PMCID: PMC6929527 DOI: 10.1093/ije/dyz117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | | | - Elliott R Haut
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Adil H Haider
- Center for Surgery and Public Health, Harvard Medical School, Boston, MA, USA
| | - Daniel C Perry
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Abstract
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.
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Hall EC, Tyrrell RL, Doyle KE, Scalea TM, Stein DM. Trauma transitional care coordination: A mature system at work. J Trauma Acute Care Surg 2019; 84:711-717. [PMID: 29370060 DOI: 10.1097/ta.0000000000001818] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND We have previously demonstrated effectiveness of a Trauma Transitional Care Coordination (TTCC) Program in reducing 30-day readmission rates for trauma patients most at risk. With program maturation, we achieved improved readmission rates for specific patient populations. METHODS TTCC is a nursing driven program that supports patients at high risk for 30-day readmission. The TTCC interventions include calls to patients within 72 hours of discharge, complete medication reconciliation, coordination of medical appointments, and individualized problem solving. Account IDs were used to link TTCC patients with the Health Services Cost Review Commission database to collect data on statewide unplanned 30-day readmissions. RESULTS Four hundred seventy-five patients were enrolled in the TTCC program from January 2014 to September 2016. Only 10.5% (n = 50) of TTCC enrollees were privately insured, 54.5% had Medicaid (n = 259), and 13.5% had Medicare (n = 64). Seventy-three percent had Health Services Cost Review Commission severity of injury ratings of 3 or 4 (maximum severity of injury = 4). The most common All Patient Refined Diagnosis Related Groups for participants were: lower-extremity procedures (n = 67, 14%); extensive abdominal/thoracic procedures (n = 40, 8.4%); musculoskeletal procedures (n = 37, 7.8%); complicated tracheostomy and upper extremity procedures (n = 29 each, 6.1%); infectious disease complications (n = 14, 2.9%); major chest/respiratory trauma, major small and large bowel procedures and vascular procedures (n = 13 each, 2.7%). The TTCC participants with lower-extremity injury, complicated tracheostomy, and bowel procedures had 6-point reduction (10% vs. 16%, p = 0.05), 11-point reduction (13% vs. 24%, p = 0.05), and 16-point reduction (11% vs. 27%, p = 0.05) in 30-day readmission rates, respectively, compared to those without TTCC. CONCLUSION Targeted outpatient support for high-risk patients can decrease 30-day readmission rates. As our TTCC program matured, we reduced 30-day readmission in patients with lower-extremity injury, complicated tracheostomy and bowel procedures. This represents over one million-dollar savings for the hospital per year through quality-based reimbursement. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Erin C Hall
- From the Department of Surgery (E.C.H.), MedStar Washington Hospital Center, Washington, DC; Department of Surgery (E.C.H.), Georgetown University School of Medicine, Washington, DC. R Adams Cowley Shock Trauma Center (R.T., K.D., T.M.S., D.M.S.), University of Maryland School of Medicine, Baltimore, Maryland
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Parreco J, Eidelson SA, Revell S, Zakrison TL, Schulman CI, Rattan R. Nationwide risk factors for hospital readmission for subsequent injury after motor vehicle crashes. TRAFFIC INJURY PREVENTION 2018; 19:S127-S132. [PMID: 30543465 DOI: 10.1080/15389588.2018.1540866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 10/06/2018] [Accepted: 10/22/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Some drivers involved in motor vehicle crashes across the United States may be identified as at risk of subsequent injury by a similar mechanism. The purpose of this study was to perform a national review of the risk factors for hospitalization for a new injury due to a subsequent motor vehicle crash. It was hypothesized that presenting to a different hospital after subsequent injury would result in worse patient outcomes when compared to presentation at the same hospital. METHODS The Nationwide Readmissions Database for 2010-2014 was queried for all inpatient hospitalizations with injury related to motor vehicle traffic. The primary patient outcome of interest was subsequent motor vehicle crash-related injury within 1 year. The secondary patient outcomes were different hospital subsequent injury presentation, higher Injury Severity Score (ISS), longer length of stay (LOS), and in-hospital death after subsequent injury. The analysis of secondary patient outcomes was performed only on patients who were reinjured. Univariable analysis was performed for each outcome using all variables during the index admission. Multivariable logistic regression was performed using all significant (P < .05) variables on univariate analysis. Results were weighted for national estimates. RESULTS During the study period, 1,008,991 patients were admitted for motor vehicle-related injury; 12,474 patients (1.2%) suffered a subsequent injury within 1 year. From the reinjured patients, 32.9% presented to a different hospital, 48.9% had a higher ISS, and 22.1% had a longer LOS. The in-hospital mortality rate after subsequent injury was 1.1%. Presentation to a different hospital for subsequent injury was associated with a longer LOS (odds ratio [OR] = 1.32; 95% confidence interval [CI], 1.20-1.45; P < .01) and a higher ISS (OR = 1.38; 95% CI, 1.27-1.49; P < .01). Motorcyclists were more likely to suffer subsequent injury (OR = 1.39; 95% CI, 1.32-1.46; P < .01) and motorcycle passengers were more likely to present to a different hospital with a subsequent injury (OR = 2.49; 95% CI, 1.73-3.59; P < .01). Alcohol abuse was associated with subsequent injury (OR = 1.12; 95% CI, 1.07-1.18; P < .01). CONCLUSIONS Nearly a third of patients suffering subsequent motor vehicle crash-related injury after an initial motor vehicle crash in the United States present to a different hospital. These patients are more likely to suffer more severe injuries and longer hospitalizations due to their subsequent injury. Future efforts to prevent these injuries must consider the impact of this fragmentation of care and the implications for quality and cost improvements.
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Affiliation(s)
- Joshua Parreco
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Sarah A Eidelson
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Scott Revell
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Tanya L Zakrison
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Carl I Schulman
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
| | - Rishi Rattan
- a Department of Surgery , University of Miami Leonard M. Miller School of Medicine , Miami , Florida
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Siracuse JJ, Farber A, James T, Cheng TW, Zuo Y, Kalish JA, Jones DW, Kalesan B. Readmissions after Firearm Injury Requiring Vascular Repair. Ann Vasc Surg 2018; 56:36-45. [PMID: 30500659 DOI: 10.1016/j.avsg.2018.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Firearm injuries can be morbid and potentially have high resource utilization. Historically, trauma and vascular surgery patients are at higher risk for readmissions. Our goal was to assess the risk for readmission among patients undergoing vascular repair after a firearm injury. METHODS The National Readmission Database was queried from 2011 to 2014. All firearm injuries with or without vascular repair were analyzed. Multivariable analysis was conducted to assess the effect of concurrent vascular repair on readmissions at 30, 90, and 180 days. RESULTS There were 42,184 firearm injury admissions identified, where 93.3% did not undergo vascular repair and 6.7% required vascular repair. The overall in-hospital death rate was 8.2%. Average age was 29.9 ± 0.2 years, and 89.2% were male. Intent was most frequently assault (61.2%) followed by unintentional injury (26.5%), suicide (5.2%), and legal intervention (3.1%). Patients with vascular repair compared to those without vascular repair were more frequently admitted at teaching hospitals (85.2% vs. 81.8%, P = 0.042), had higher Agency for Healthcare Research and Quality (AHRQ) extreme severity of illness, AHRQ risk of mortality, New Injury Severity Score (NISS), and had more diagnoses and procedures (P < 0.0001). Patients with vascular repair compared to those without vascular repair also more frequently sustained abdominal/pelvis injury (40.4% vs. 23.4%, P < 0.0001) and were more likely to have anemia (5.9% vs. 3.6%, P = 0.009). Patients undergoing vascular repair had a higher rate for 30-day (8.9% vs. 5.5%, P = 0.0001), 90-day (18.1% vs 9.5%, P < 0.0001), and 180-day (22.3% vs. 13%, P < 0.0001) readmission. Kaplan-Meier analysis of unadjusted data showed a higher readmission rate over time with vascular repair. Multivariable analysis demonstrated that vascular repair was not associated with higher 30-day readmission (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.92-1.72, P = 0.14) but was for 90-day (OR 1.38, 95% CI 1.14-1.68, P = 0.001) and 180-day readmission (OR 1.24, 95% CI 1.06-1.45, P = 0.009). Additional factors associated with 30-day readmission were higher NISS, discharge to a care facility, and Elixhauser score. Other factors associated with 90-day readmission were unintentional intent of injury, NISS, discharge to a care facility, and Elixhauser score. Factors also associated with 180-day readmission were insurance type, unintentional intent of injury, NISS, care facility discharge, and Elixhauser score. CONCLUSIONS Firearm injury resulting in vascular injury was associated with increased readmissions at 90 and 180 days. This study establishes baseline rates for readmission after vascular repair for firearm traumas and allows opportunity for improvement through targeted interventions for these patients. Vascular surgeons can have a more active role in managing this high-profile public health issue.
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Affiliation(s)
- Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thea James
- Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Yi Zuo
- Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Preventative Medicine & Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Bindu Kalesan
- Center for Clinical Translational Epidemiology and Comparative Effectiveness Research, Preventative Medicine & Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA.
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Parreco J, Alawa N, Rattan R, Tashiro J, Sola JE. Teenage Trauma Patients Are at Increased Risk for Readmission for Mental Diseases and Disorders. J Surg Res 2018; 232:415-421. [PMID: 30463750 DOI: 10.1016/j.jss.2018.06.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 05/28/2018] [Accepted: 06/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Most studies of readmission after trauma are limited to single institutions or single states. The purpose of this study was to determine the risk factors for readmission after trauma for mental illness including readmissions to different hospitals across the United States. MATERIALS AND METHODS The Nationwide Readmission Database for 2013 and 2014 was queried for all patients aged 13 to 64 y with a nonelective admission for trauma and a nonelective readmission within 30 d. Multivariable logistic regression was performed for readmission for mental diseases and disorders. RESULTS During the study period, 53,402 patients were readmitted within 30 d after trauma. The most common major diagnostic category on readmission was mental diseases and disorders (12.1%). The age group with the highest percentage of readmissions for mental diseases and disorders was 13 to 17 y (38%). On multivariable regression, the teenage group was also the most likely to be readmitted for mental diseases and disorders compared to 18-44 y (odds ratio [OR] 0.45, P < 0.01) and 45-64 y (OR 0.24, P < 0.01). Other high-risk comorbidities included HIV infection (OR 2.4, P < 0.01), psychosis (OR 2.2, P < 0.01), drug (OR 2.0, P < 0.01), and alcohol (OR 1.4, P < 0.01) abuse. CONCLUSIONS Teenage trauma patients are at increased risk for hospital readmission for mental illness. Efforts to reduce these admissions should be targeted toward individuals with high-risk comorbidities such as HIV infection, psychosis, and substance abuse.
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Affiliation(s)
- Joshua Parreco
- Department of Surgery, DeWitt-Daughtry Family, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Nawara Alawa
- Department of Surgery, DeWitt-Daughtry Family, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Rishi Rattan
- Department of Surgery, DeWitt-Daughtry Family, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Jun Tashiro
- Department of Surgery, DeWitt-Daughtry Family, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Juan E Sola
- Department of Surgery, DeWitt-Daughtry Family, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
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Wheeler KK, Shi J, Xiang H, Thakkar RK, Groner JI. US pediatric trauma patient unplanned 30-day readmissions. J Pediatr Surg 2018; 53:765-770. [PMID: 28844536 PMCID: PMC5803463 DOI: 10.1016/j.jpedsurg.2017.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/22/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE We sought to determine readmission rates and risk factors for acutely injured pediatric trauma patients. METHODS We produced 30-day unplanned readmission rates for pediatric trauma patients using the 2013 National Readmission Database (NRD). RESULTS In US pediatric trauma patients, 1.7% had unplanned readmissions within 30days. The readmission rate for patients with index operating room procedures was no higher at 1.8%. Higher readmission rates were seen in patients with injury severity scores (ISS)=16-24 (3.4%) and ISS ≥25 (4.9%). Higher rates were also seen in patients with LOS beyond a week, severe abdominal and pelvic region injuries (3.0%), crushing (2.8%) and firearm injuries (4.5%), and in patients with fluid and electrolyte disorders (3.9%). The most common readmission principal diagnoses were injury, musculoskeletal/integumentary diagnoses and infection. Nearly 39% of readmitted patients required readmission operative procedures. Most common were operations on the musculoskeletal system (23.9% of all readmitted patients), the integumentary system (8.6%), the nervous system (6.6%), and digestive system (2.5%). CONCLUSIONS Overall, the readmission rate for pediatric trauma patients was low. Measures of injury severity, specifically length of stay, were most useful in identifying those who would benefit from targeted care coordination resources. LEVEL OF EVIDENCE This is a Level III retrospective comparative study.
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Affiliation(s)
- Krista K. Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210
| | - Rajan K. Thakkar
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210,Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205,The Ohio State University College of Medicine, 370 W 9th Ave, Columbus, OH, 43210,Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205
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Effects of Medicaid expansion on disparities in trauma care and outcomes in young adults. J Surg Res 2018; 228:42-53. [PMID: 29907229 DOI: 10.1016/j.jss.2018.02.058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/08/2018] [Accepted: 02/27/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Racial/ethnic and socioeconomic disparities in trauma care and outcomes among young adults are well documented. As the Patient Protection and Affordable Care Act Medicaid expansion has increased insurance coverage among young adults, we aimed to investigate its impact on disparities in insurance coverage and outcomes among hospitalized young adult trauma patients. MATERIALS AND METHODS We used the healthcare cost and utilization project state inpatient databases to examine changes in insurance coverage and risk-adjusted outcomes from before (2012-2013) to after (2014) Medicaid expansion among young adults (age 19-44) hospitalized for injury across 11 Medicaid expansion states. Changes were compared across racial/ethnic and community-level income groups. We also compared changes in disparities between three expansion and three nonexpansion states in the US south. RESULTS In the first year of Medicaid expansion, non-Hispanic black trauma patients experienced a large decrease in uninsurance (34.3%-14.2%, P < 0.01), reducing the disparity in uninsurance between non-Hispanic black and non-Hispanic white patients (P < 0.05). There were no differences across racial/ethnic groups in changes in in-hospital mortality, failure to rescue, discharge to rehabilitation, or 30-d unplanned readmissions. Socioeconomic disparities in discharge to rehabilitation decreased (1.63% versus 0.06% increase among patients from the lowest and highest income communities, P < 0.05). In contrast, in the selected southern states, Medicaid expansion was associated with the introduction of a disparity in discharge to inpatient rehabilitation between Hispanics and non-Hispanic whites. CONCLUSIONS Medicaid expansion, in its first year, decreased racial and socioeconomic disparities in uninsurance and socioeconomic disparities in access to rehabilitation.
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Continuing Trauma Care After Discharge, the Experience of Outpatient Trauma Clinics in British Columbia. J Trauma Nurs 2018. [PMID: 29521780 DOI: 10.1097/jtn.0000000000000355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The recovery process from traumatic injuries, and the potential for complications, extends beyond the time of hospital discharge. In 2014, the Fraser Health Trauma Network established outpatient clinics to provide follow-up care for trauma patients after discharge from hospital. The following research questions were asked: Which services were commonly performed by our trauma clinics and how satisfied were patients with the care they received at our clinics? A survey was distributed to patients after their clinic visit to assess overall satisfaction and areas for improvement. A retrospective medical record review was performed to illustrate and quantify the interventions provided during clinic visits. During the first 22 months of clinic operation, a total of 412 appointments were scheduled and the attendance rate was 88%. The provided services included obtaining additional imaging (41% of visits), providing wound and brace care (16%), and initiating referrals to specialists (12%). Seventy-seven patient satisfaction surveys were returned during the study period, 34 in 2014 and 43 in 2015. Seventy-four percent of respondents strongly agreed, and 21% agreed that they were satisfied with the care they received in the clinic. Ninety percent found their visit helpful, and only 10% reported having additional medical issues that were not addressed during the appointment. At trauma clinic follow-up, discharged patients have ongoing care requirements, including a need for further investigation, specialist referral, and wound or brace issues that are likely to benefit from specialist trauma care. Patients were satisfied with the care provided by a postdischarge trauma clinic.
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Unplanned readmission after hospital discharge in burn patients in Iran. Eur J Trauma Emerg Surg 2018; 45:365-371. [PMID: 29468270 DOI: 10.1007/s00068-018-0919-6] [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: 10/04/2017] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Burns are considered as one of the most serious health problems throughout the world. They may lead to adverse consequences and outcomes. One of these outcomes is unplanned readmission. Unplanned readmission has been commonly used as a quality indicator by hospitals and governments. This study aimed to determine the predictors of unplanned readmission in patients with burns hospitalized in a burn center in the North of Iran (Guilan province, Rasht). METHODS This retrospective analytic study has been done on the medical records of hospitalized patients with burns in Velayat Sub-Specialty Burn and Plastic Surgery Center, Rasht, Iran during 2008-2013. In general, 703 medical records have been reviewed but statistical analysis was performed on 626 medical records. All data were entered in SPSS (version 16) and analyzed by descriptive and inferential statistics. RESULTS Among 626 patients with burns, the overall readmission rate was 5.1%. Predictors of readmission included total body surface area (OR 1.030, CI 1.011-1.049), hypertension (OR 2.923, CI 1.089-7.845) and skin graft (OR 7.045, CI 2.718-18.258). CONCLUSION Considering the outcome, predictors following burn have a crucial role in the allocation of treatment cost for patients with burns and they can be used as one of the quality indicators for health care providers and governments.
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Hall EC, Tyrrell R, Scalea TM, Stein DM. Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission. Trauma Surg Acute Care Open 2018; 3:e000149. [PMID: 29766133 PMCID: PMC5887824 DOI: 10.1136/tsaco-2017-000149] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/12/2018] [Accepted: 01/16/2018] [Indexed: 12/17/2022] Open
Abstract
Background Unplanned hospital readmissions increase healthcare costs and patient morbidity. We hypothesized that a program designed to reduce trauma readmissions would be effective. Methods A Trauma Transitional Care Coordination (TTCC) program was created to support patients at high risk for readmission. TTCC interventions included call to patient (or caregiver) within 72 hours of discharge to identify barriers to care, complete medication reconciliation, coordination of appointments, and individualized problem solving. Information on all 30-day readmissions was collected. 30-day readmission rates were compared with center-specific readmission rates and population-based, risk-adjusted rates of readmission using published benchmarks. Results 260 patients were enrolled in the TTCC program from January 2014 to September 2015. 30.8% (n=80) of enrollees were uninsured, 41.9% (n=109) reported current substance abuse, and 26.9% (n=70) had a current psychiatric diagnosis. 74.2% (n=193) attended outpatient trauma appointments within 14 days of discharge. 96.3% were successfully followed. Only 6.6% (n=16) of patients were readmitted in the first 30 days after discharge. This was significantly lower than both center-specific readmission rates before start of the program (6.6% vs. 11.3%, P=0.02) and recently published population-based trauma readmission rates (6.6% vs. 27%, P<0.001). Discussion A nursing-led TTCC program successfully followed patients and was associated with a significant decrease in 30-day readmission rates for patients with high-risk trauma. Targeted outpatient support for these most vulnerable patients can lead to better utilization of outpatient resources, increased patient satisfaction, and more consistent attainment of preinjury level of functioning or better. Level of evidence Level IV.
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Affiliation(s)
- Erin C Hall
- Department of Surgery, Division of Trauma, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Rebecca Tyrrell
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Abstract
OBJECTIVES To determine the rate, etiology, and timing of unplanned and planned hospital readmissions and to identify risk factors for unplanned readmission in children who survive a hospitalization for trauma. DESIGN Multicenter retrospective cohort study of a probabilistically linked dataset from the National Trauma Data Bank and the Pediatric Health Information System database, 2007-2012. SETTING Twenty-nine U.S. children's hospitals. PATIENTS 51,591 children (< 18 yr at admission) who survived more than or equal to a 2-day hospitalization for trauma. MEASUREMENTS AND MAIN RESULTS The primary outcome was unplanned readmission within 1 year of discharge from the injury hospitalization. Secondary outcomes included any readmission, reason for readmission, time to readmission, and number of readmissions within 1 year of discharge. The primary exposure groups were isolated traumatic brain injury, both traumatic brain injury and other injury, or nontraumatic brain injury only. We hypothesized a priori that any traumatic brain injury would be associated with both planned and unplanned hospital readmission. We used All Patient Refined Diagnosis Related Groups codes to categorize readmissions by etiology and planned or unplanned. Overall, 4,301/49,982 of the patients (8.6%) with more than or equal to 1 year of observation time were readmitted to the same hospital within 1 year. Many readmissions were unplanned: 2,704/49,982 (5.4%) experienced an unplanned readmission in the first year. The most common reason for unplanned readmission was infection (22%), primarily postoperative or posttraumatic infection (38% of readmissions for infection). Traumatic brain injury was associated with lower odds of unplanned readmission in multivariable analyses. Seizure or RBC transfusion during the index hospitalization were the strongest predictors of unplanned, earlier, and multiple readmissions. CONCLUSIONS Many survivors of pediatric trauma experience unplanned, and potentially preventable, hospital readmissions in the year after discharge. Identification of those at highest risk of readmission can guide targeted in-hospital or postdischarge interventions.
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Affiliation(s)
- Aline B. Maddux
- Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
| | - Peter E. DeWitt
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Peter M. Mourani
- Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
| | - Tellen D. Bennett
- Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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Tran A, Mai T, El-Haddad J, Lampron J, Yelle JD, Pagliarello G, Matar M. Preinjury ASA score as an independent predictor of readmission after major traumatic injury. Trauma Surg Acute Care Open 2017; 2:e000128. [PMID: 29766118 PMCID: PMC5887763 DOI: 10.1136/tsaco-2017-000128] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 09/23/2017] [Accepted: 10/08/2017] [Indexed: 01/17/2023] Open
Abstract
Background Patients with trauma have a high predisposition for readmission after discharge. Unplanned solicitation of medical services is a validated quality of care indicator and is associated with considerable economic costs. While the existing literature emphasizes the severity of the injury, there is heterogeneity in defining preinjury health status. We evaluate the validity of the American Society of Anesthesiologists (ASA) Physical Status score as an independent predictor of readmission and compare it to the Charlson Comorbidity Index (CCI). Methods This is a single center, retrospective cohort study based on adult patients (>18 years of age) with trauma admitted to the Ottawa Hospital from January 1, 2004 to November 1, 2014. A multivariate logistic regression model is used to control for confounding and assess individual predictors. Outcome is readmission to hospital within 30 days, 3 months and 6 months. Results A total of 4732 adult patients were included in this analysis. Readmission rates were 6.5%, 9.6% and 11.8% for 30 days, 3 months and 6 months, respectively. Higher preinjury ASA scores demonstrated significantly increased risk of readmission across all levels in a dose-dependent manner for all time frames. The effect of preinjury ASA scores on readmission is most striking at 30 days, with patients demonstrating a 2.81 (1.88–4.22, P<0.0001), 3.59 (2.43–5.32, P<0.0001) and 7.52 (4.72–11.99, P<0.0001) fold odds of readmission for ASA class 2, 3 and 4, respectively, as compared with healthy ASA class 1 patients. The ASA scores outperformed the CCI at 30 days and 3 months. Conclusions The preinjury ASA score is a strong independent predictor of readmission after traumatic injury. In comparison to the CCI, the preinjury ASA score was a better predictor of readmission at 3 and 6 months after a major traumatic injury. Level of Evidence Prognostic and Epidemiological Study, Level III.
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Affiliation(s)
- Alexandre Tran
- Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada.,Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Trinh Mai
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie El-Haddad
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacinthe Lampron
- Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jean-Denis Yelle
- Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Maher Matar
- Division of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Risk factors and costs associated with nationwide nonelective readmission after trauma. J Trauma Acute Care Surg 2017; 83:126-134. [PMID: 28422906 DOI: 10.1097/ta.0000000000001505] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Most prior studies of readmission after trauma have been limited to single institutions, whereas multi-institutional studies have been limited to single states and an inability to distinguish between elective and nonelective readmissions. The purpose of this study was to identify the risk factors and costs associated with nonelective readmission after trauma across the United States. METHODS The Nationwide Readmission Database was queried for all patients with nonelective admissions in 2013 and 2014 with a primary diagnosis of trauma. Univariate and multivariate logistic regression identified risk factors for 30-day nonelective same- and different-hospital readmission. The diagnosis groups on readmission were evaluated, and the total cost of readmissions was calculated. RESULTS There were 1,180,144 patients admitted for trauma, the 30-day readmission rate was 9.4%, and 26.4% of readmissions occurred at a different hospital. The median readmission cost for patients readmitted to the same hospital was $8,298 (interquartile range, $4,899-$14,911), whereas the median readmission cost for patients readmitted to a different hospital was $8,568 (interquartile range, $4,935-$16,078; p < 0.01). Multivariate regression revealed that patients discharged against medical advice were at increased risk of readmission (odds ratio, 2.79; p < 0.01) and readmission to a different facility (odds ratio, 1.58; p < 0.01). Home health care was associated with a decreased risk of readmission to a different hospital (odds ratio, 0.74; p < 0.01). Septicemia and disseminated infections were the most common diagnoses on readmission (8.4%) and readmission to a different hospital (8.6%). CONCLUSIONS A significant portion of US readmissions occur at different hospitals with implications for continuity of care, quality metrics, cost, and resource allocation. Home health care reduces the likelihood of nonelective readmission to a different hospital. Infection was the most common reason for readmission, with ramifications for outcomes research and quality improvement. LEVEL OF EVIDENCE Care management/epidimeological, level IV.
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Early unplanned trauma readmissions in a safety net hospital are resource intensive but not due to resource limitations. J Trauma Acute Care Surg 2017; 83:135-138. [PMID: 28452893 DOI: 10.1097/ta.0000000000001540] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In an era of decreasing reimbursements, the incentive to decrease readmissions has never been greater. It has been suggested that trauma readmission is an indicator of poor hospital care or fragmented discharge. Even though trauma readmissions are relatively low, readmissions add significant cost, tie up already limited resources and lead to worse outcomes, including mortality. The literature on trauma readmissions is sparse, and the reasons and risk factors for readmission are inconsistent across studies. If readmissions are to serve as useful indicators of quality of care, we must elucidate factors that may predict readmissions. METHODS We performed a retrospective review of all admissions to our urban Level I trauma center from July 1, 2012, to June 30, 2015. All patients aged 16 years or older who were discharged alive were included. We identified all unplanned readmissions that occurred within 30 days of discharge and performed an extensive chart review to determine the reasons for readmission. We performed univariate and multivariable analyses. RESULTS We identified 6,026 index trauma admissions, with 158 (2.6%) unplanned readmissions within 30 days of discharge. The most common reasons for readmission were disease/symptom progression (30.2%), wound complications (28.9%), and pain control (11.8%). On multivariate analysis, only Injury Severity Score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.05; p=0.016), penetrating injuries (OR, 1.9; 95% CI, 1.12-3.24; p=0.018), and smoking (OR, 1.73; 95% CI, 1.05-2.86; p=0.031) were found to be significant. Hospital length of stay, insurance status, and race were not significant. CONCLUSION In a resource-limited environment, we expected a lack of access to care would lead to increased trauma readmissions; however, we were still able to achieve similar readmission rates, irrespective of insurance status and race. Our trauma readmission rate is low and consistent with previously published studies. Our results at our Level I trauma center support previously published studies that found Injury Severity Score and penetrating injury to be risk factors for readmission; however, more ubiquitous risk factors, such as hospital length of stay and discharge destination, were not significant. With no consensus on the risk factors for unplanned early trauma readmission, individual trauma centers should evaluate their specific risk factors for readmission to improve patient outcomes and decrease hospital costs. LEVEL OF EVIDENCE Care management, level IV; Epidemiologic, level IV.
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How long should we fear? Long-term risk of venous thromboembolism in patients with traumatic brain injury. J Trauma Acute Care Surg 2017; 81:71-8. [PMID: 27015575 DOI: 10.1097/ta.0000000000001046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although patients with traumatic brain injury (TBI) are known to be at high risk for venous thromboembolism (VTE), it is not clear how long this risk persists after injury. We aimed to determine the risk of VTE in patients with TBI during one year after injury and to identify associated factors. METHODS Patients 18 years and older with International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses of isolated TBI (head Abbreviated Injury Scale [AIS] ≥3 and AIS <3 for all other body regions) were identified in the California State Inpatient Database (2007-2011). Patient and admission (injury severity score, length of stay, and discharge disposition) characteristics were assessed. Hospital factors (teaching status, trauma center verification, and bed size) were extracted from the American Hospital Association database. Patients who developed VTE during the index admission and at different time points after discharge were determined. Multivariate logistic regression models were used to assess the associated risk factors for VTE after discharge. RESULTS There were 38,984 patients with isolated TBI identified. The incidence of VTE was 1.31% during the index admission and the cumulative incidence of VTE involving hospitalization within one year of injury was 2.83%. The major risk factors for VTE one year after injury (not including the index admission) were discharge to extended care facilities versus home [adjusted odds ratio, 2.69 (95% confidence interval, 2.14-3.37)], age older than 64 years versus 18 to 44 years [2.62 (1.80-3.81)], having an operation during the index admission [1.65 (1.36-2.01)], and hospital length of stay of more than 7 days versus 3 days or less [1.64 (1.27-2.11)]. CONCLUSION The risk of VTE persists long after discharge in a significant proportion of patients with TBI. Demographic and admission characteristics of patients play significant roles in the risk of VTE after discharge. These results highlight the need for sustained surveillance and preventive measures among patients with TBI at increased risk for long-term VTE. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Woodfall MC, Browder TD, Alfaro JM, Claudius MA, Chan GK, Robinson DG, Spain DA. Trauma advanced practice provider programme development in an academic setting to optimize care coordination. Trauma Surg Acute Care Open 2017; 2:e000068. [PMID: 29766082 PMCID: PMC5877895 DOI: 10.1136/tsaco-2016-000068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 12/26/2016] [Accepted: 01/02/2017] [Indexed: 11/23/2022] Open
Abstract
Background Benchmark data from the Trauma Quality Improvement Program (TQIP) identified an opportunity for improvement in our trauma programme. Our unexpected return to the intensive care unit (ICU) was found to be higher than the national averages and we also noticed that our readmission rate had increased. We chose to address these complications as continuous quality improvement projects. It was hypothesized that restructuring the workflow of the trauma advanced practice providers (APPs) to focus on the delivery of comprehensive clinical care would decrease return to ICU and readmission rates of trauma patients. Methods The development of the APP programme occurred from 2012 to 2014. First, APP daily shifts were extended to mirror the resident physicians’ coverage. Second, the APPs’ original job description was expanded from ‘task-oriented’ workflow to providing comprehensive clinical care. Third, the APPs were involved in the evaluation and decision-making process for transferring trauma patients from the ICU. Finally, the APPs implemented a new discharge process that included all information in a standardized format and a follow-up phone call 24–48 hours after discharge. The trauma registry at our verified, academic level I trauma center was use to assess our ICU and hospital readmission rates during the time we instituted the new APP workflow programme. Results In 2012, our ICU readmission rate was 5.7% (TQIP=1.9%) but then decreased to 4.4% in 2013 (TQIP=2.5%) and 2.1% in 2014 (TQIP=2.8%). Our hospital readmission rate was 2.0% in 2012 but then decreased to 1.38% and 0.96% over the next 2 years. Conclusions After extending the APP service coverage, implementing a comprehensive clinical care model and standardizing the discharge process, our unplanned return to ICU rates have decreased to below the TQIP national average and hospital readmission rates have also decreased by half. Level of evidence III.
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Affiliation(s)
| | - Timothy D Browder
- Department of Surgery, Stanford University, Stanford, California, USA
| | | | | | | | | | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
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