The trauma registry compared to All Patient Refined Diagnosis Groups (APR-DRG)

GIFTS: Geriatric Intensive Functional Therapy Sessions-for the older trauma patient

BACKGROUND

Considering resources for comprehensive geriatric care, it would be beneficial for geriatric trauma patients (GTPs) and medical patients to be comanaged in one program focusing on ancillary therapeutics (AT): physical therapy, occupational therapy, speech language pathology, respiratory therapy, and sleep wake hygiene. This pilot study describes outcomes of GTPs in a hospital-wide program focused on geriatric-specific AT.

METHODS

Geriatric trauma patients and geriatric patients were screened by program coordinator for enrollment at one Level II trauma center from August 2021 to December 2022. Enrolled patients (EPs) were admitted to trauma or medicine floors and received repetitive AT with attention to sleep wake hygiene throughout hospitalization and compared with similar nonenrolled patients (NEPs). Excluded patients had any of the following: indication of geriatric syndrome with a fatigue, resistance, ambulation, illness, and loss of weight (FRAIL) score of 5, no frailty with a FRAIL score of 0, comfort focused plans, or arrived from skilled care. Retrospective chart review of demographics and outcomes was completed for both EPs and NEPs.

RESULTS

A total of 224 EPs (28 trauma [TR]) were compared with 574 NEPs (148 TR). Enrolled patients showed shorter length of stay (mean, 3.8 vs. 6.1; p = 0.0001), less delirium (3.1% vs. 9.6%, p = 0.00222), less time to ambulation (13 hours vs. 39 hours, p = 0.0005), and higher likelihood to discharge home (56% vs. 27%, p < 0.0001) as compared with NEPs. The median FRAIL score was 3 for both groups. Enrolled medical patients ambulated the soonest at 11 average hours, compared with 23 hours for enrolled trauma patients and 39 hours for NEPs. There were zero delirium events among enrolled trauma patients; 25% was found among nonenrolled trauma patients ( p = 0.00288).

CONCLUSION

Despite a small trauma cohort, results support feasibility to include GTPs in hospital-wide programs with geriatric-specific AT. Mobility and cognitive strategies may improve opportunities to avoid delirium, decrease length of stay, and influence more frequent disposition to home.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Impact of Medicaid Expansion on Trauma Patients at Extreme Risk of Mortality: A Time-Series Analysis

BACKGROUND

The 2014 expansion of Medicaid under the Affordable Care Act (ACA) reshaped healthcare delivery in the United States. This study assessed how Medicaid expansion affected in-hospital mortality in patients with extreme risk of mortality (EROM) from traumatic injuries.

METHODS

Data from inpatients aged 18-64 years, registered in the National Inpatient Sample between 2007 and 2020, and identified with trauma-related All-Patient Refined Diagnosis Related Groups (APRDRG) codes, were analyzed. Within this group, a subset of patients was selected based on the APRDRG classification identifying them as at EROM for the principal unit of analysis. The cohort was divided into high-implementation (HIR) and low-implementation (LIR) regions based on Medicaid expansion coverage. In-hospital mortality was assessed using interrupted time-series analysis. Sensitivity analyses considered seasonality, autocorrelation, and exogenous events.

RESULTS

Analysis encompassed 70 381 trauma inpatient stays, corresponding to 346 659 patients based on National Inpatient Sample weighting. There was a consistent monthly decline in in-hospital mortality of .08% (95% CI: -.103 to -.048; P < .001) prior to Medicaid expansion, a trend unaffected by expansion. This pattern persisted across both LIR and HIR Medicaid implementation regions. Although Medicaid enrollment increased in HIR, that in LIR remained unchanged.

DISCUSSION

Over the study period, the in-hospital mortality among severely injured patients consistently decreased, and this trend was not influenced by Medicaid expansion. The statistical models and results from this study can offer valuable guidance to policymakers and healthcare leaders as they formulate more efficient and effective policies.

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

BACKGROUND

Persistent disparities in trauma in-hospital mortality owing to insurance status and race remain a prominent issue within healthcare. This study explores the relationships among insurance status, race, length of stay (LOS) in-hospital mortality outcomes in trauma patients at extreme risk of mortality (EROM) trauma patients.

METHODS

Data was retrieved from the National Inpatient Sample, focusing on high-acuity trauma patients from 2007 to 2020, aged 18-64 years. Patients were identified using specific All Patient Refined Diagnosis Related Groups codes. Emphasis was placed on those with EROM owing to their resource-intensive nature and the potential influence of insurance on outcomes. Patients aged 65 years or older were excluded owing to distinct trauma patterns, as were those diagnosed with burns or non-trauma conditions.

RESULTS

The study encompassed 70,381 trauma inpatients with EROM, representing a national estimate of 346,659. Being insured was associated with a 34% decrease in the odds of in-hospital mortality compared to being uninsured. The in-hospital mortality risk associated with insurance status varied over time, with insurance having no impact on in-hospital mortality during hospitalizations of less than 2 days (short LOS). In the overall group, Black patients showed an 8% lower risk of in-hospital mortality compared to White patients, while they experienced a 33% higher risk of in-hospital mortality during short LOS.

CONCLUSION

Insured trauma inpatients demonstrated a significant reduction in the odds of in-hospital mortality compared to their uninsured counterparts, although this advantage was not present in the short LOS group. Black patients experienced lower in-hospital mortality rates compared to White patients, but this trend reversed in the short LOS group. These findings underscore the intricate relationships between insurance status, race, and duration of hospitalization, highlighting the need for interventions to improve patient outcomes.

Understanding the contribution of general medical services to acute inpatient care in Victorian public hospitals

BACKGROUND

General medicine is an integral part of health services, yet there is little data highlighting their contribution to acute hospital care in Australia.

AIMS

To utilise the Victorian Department of Health's administrative dataset for hospital admissions to evaluate the relative contribution and trends over time of general medical services to acute multiday inpatient hospital separations in the Victorian public healthcare system.

METHODS

A retrospective time-series study of general medical activity compared to other major specialties using hospital-level data provided by the Department of Health: (i) extrapolation from diagnosis-related group (DRG) activity data (2011-2021) and, (ii) directly reported discharge unit-based activity (available from 2018). Acute multiday separations of all patients aged ≥18 years from all metropolitan and rural Victorian public hospitals were included.

RESULTS

Using the DRG-based data, general medicine ranked as the largest care provider of all specialties studied, accounting for 12.1% of separations. Despite the largest increase at a rate of 2831 separations/year (0.336%/year of total, P < 0.001) compared to others, mean length of stay declined by 0.08 days/year (P < 0.001). These findings were significant for metropolitan and rural hospitals. The use of directly reported discharge unit-based data also ranked general medicine as the largest care provider accounting for 32.9% of total separations, with rural hospital general medical services contributing nearly 50% of all multiday separations.

CONCLUSIONS

Both DRG-based data and discharge unit-based data indicate that general medicine is the largest provider of acute multiday inpatient care in Victorian hospitals. The estimate of contribution of general medicine differed between the two datasets as DRG data likely over-represents the role of other specialties possibly due to assumptions regarding specialty management of varying groups of diagnoses.

Effects of an electronic health record-based mobility assessment and automated referral for inpatient physical therapy on patient outcomes: A quasi-experimental study

OBJECTIVE

To assess the effectiveness of a hospital physical therapy (PT) referral triggered by scores on a mobility assessment embedded in the electronic health record (EHR) and completed by nursing staff on hospital admission.

DATA SOURCES

EHR and billing data from 12 acute care hospitals in a western Pennsylvania health system (January 2017-February 2018) and 11 acute care hospitals in a northeastern Ohio health system (August 2019-July 2021).

STUDY DESIGN

We utilized a regression discontinuity design to compare patients admitted to PA hospitals with stroke who reached the mobility score threshold for an EHR-PT referral (treatment) to those who did not (control). Outcomes were hospital length of stay (LOS) and 30-day readmission or mortality. Control variables included demographics, insurance, income, and comorbidities. Hospital systems with EHR-PT referrals were also compared to those without (OH hospitals as alternative control). Subgroup analyses based on age were also conducted.

DATA EXTRACTION

We identified adult patients with a primary or secondary diagnosis of stroke and mobility assessments completed by nursing (n = 4859 in PA hospitals, n = 1749 in OH hospitals) who completed their inpatient stay.

PRINCIPAL FINDINGS

In the PA hospitals, patients with EHR-PT referrals had an 11.4 percentage-point decrease in their 30-day readmission or mortality rates (95% CI -0.57, -0.01) relative to the control. This effect was not observed in the OH hospitals for 30-day readmission (β = 0.01; 95% CI -0.25, 0.26). Adults over 60 years old with EHR-PT referrals in PA had a 26.2 percentage-point (95% CI -0.88, -0.19) decreased risk of readmission or mortality compared to those without. Unclear relationships exist between EHR-PT referrals and hospital LOS in PA.

CONCLUSIONS

Health systems should consider methodologies to facilitate early acute care hospital PT referrals informed by mobility assessments.

Child Opportunity Index and Hospital Utilization in Children With Traumatic Brain Injury Admitted to the PICU

The need to understand how Community-based disparities impact morbidity and mortality in pediatric critical illness, such as traumatic brain injury. Test the hypothesis that ZIP code-based disparities in hospital utilization, including length of stay (LOS) and hospital costs, exist in a cohort of children with traumatic brain injury (TBI) admitted to a PICU using the Child Opportunity Index (COI).

DESIGN

Multicenter retrospective cohort study.

SETTING

Pediatric Health Information System (PHIS) database.

PATIENTS

Children 0-18 years old admitted to a PHIS hospital with a diagnosis of TBI from January 2016 to December 2020 requiring PICU care. To identify the most severely injured children, a study-specific definition of "Complicated TBI" was created based on radiology, pharmacy, and procedure codes.

INTERVENTIONS

None.

Main Outcomes and Measures

Using nationally normed ZIP code-level COI data, patients were categorized into COI quintiles. A low COI ZIP code has low childhood opportunity based on weighted indicators within educational, health and environmental, and social and economic domains. Population-averaged generalized estimating equation (GEE) models, adjusted for patient and clinical characteristics examined the association between COI and study outcomes, including hospital LOS and accrued hospital costs. The median age of this cohort of 8,055 children was 58 months (interquartile range [IQR], 8-145 mo). There were differences in patient demographics and rates of Complicated TBI between COI levels. The median hospital LOS was 3.0 days (IQR, 2.0-6.0 d) and in population-averaged GEE models, children living in very low COI ZIP codes were expected to have a hospital LOS 10.2% (95% CI, 4.1-16.8%; p = 0.0142) longer than children living in very high COI ZIP codes. For the 11% of children with a Complicated TBI, the relationship between COI and LOS was lost in multivariable models. COI level was not predictive of accrued hospital costs in this study.

CONCLUSIONS

Children with TBI requiring PICU care living in low-opportunity ZIP codes have higher injury severity and longer hospital LOS compared with children living in higher-opportunity ZIP codes. Additional studies are needed to understand why these differences exist.

Association of the All-Patient Refined Diagnosis-Related Groups Severity of Illness and Risk of Mortality Classification with Outcomes

OBJECTIVES

Diagnosis-related groups (DRGs) is a patient classification system used to characterize the types of patients that the hospital manages and to compare the resources needed during hospitalization. The DRG classification is based on International Classification of Diseases diagnoses, procedures, demographics, discharge status, and complications or comorbidities and compares hospital resources and outcomes used to determine how much Medicare pays the hospital for each "product/medical condition." The All-Patient Refined DRG (APR-DRG) incorporated severity of illness (SOI) and risk of mortality (ROM) into the DRG system to adjust for patient complexity to compare resource utilization, complication rates, and lengths of stay.

METHODS

This study included 18,478 adult patients admitted to a tertiary care center in Lubbock, Texas during a 1-year period. We recorded the APR-DRG SOI and ROM and some clinical information on these patients, including age, sex, admission shock index, admission glucose and lactate levels, diagnoses based on International Classification of Diseases, Tenth Revision discharge coding, length of stay, and mortality. We compared the levels of SOI and ROM across this clinical information.

RESULTS

As the levels of SOI and ROM increase (which indicates increased disease severity and risk of mortality), age, glucose levels, lactate levels, shock index, length of stay, and mortality increased significantly (P < 0.001). Multiple logistic regression analysis demonstrated that each unit increase in ROM and SOI level was significantly associated with an 11.45 and a 10.37 times increase in the odds of in-hospital mortality, respectively. The C-statistics for the corresponding models are 0.947 and 0.929, respectively. When both ROM and SOI were included in the model, the magnitudes of increase in odds of in-hospital mortality were 5.61 and 1.17 times for ROM and SOI, respectively. The C-statistic is 0.949.

CONCLUSIONS

This study indicates that the APR-DRG SOI and ROM scores provide a classification system that is associated with mortality and correlates with other clinical variables, such as the shock index and lactate levels, which are available on admission.

Is Discordance Between Recommended and Actual Postacute Discharge Setting a Risk Factor for Readmission in Patients With Congestive Heart Failure?

Background

Readmissions in patients with congestive heart failure are common and often preventable. Limited data suggest that patients discharged to a less intensive postacute care setting than recommended are likely to readmit. We examined whether postacute setting discordance (discharge to a less intensive postacute setting than recommended by a physical and occupational therapist) was associated with hospital readmission in patients with congestive heart failure. We also assessed sociodemographic and clinical predictors of setting discordance.

Methods and Results

Retrospective analysis of administrative claims and electronic health record data was conducted on 25 500 adults with a discharge diagnosis of congestive heart failure from 12 acute care hospitals in Western Pennsylvania. Generalized linear mixed models were estimated to examine the association between postacute setting discordance and 30‐day hospital readmission and to identify predictors of setting discordance. The 30‐day readmission and postacute setting discordance rates were high (23.7%, 20.6%). While controlling for demographic and clinical covariates, patients in discordant postacute settings were more likely to be readmitted within 30 days (adjusted odds ratio [OR], 1.12; 95% CI, 1.04–1.20). The effect was also seen in the subgroup of patients with low mobility scores (adjusted OR, 1.20; 95% CI, 1.08–1.33). Factors associated with setting discordance were lower‐income, higher comorbidity burden, therapist recommendation disagreement, and midrange mobility limitations.

Conclusions

Postacute setting discordance was associated with an increased readmission risk in patients hospitalized with congestive heart failure. Maximizing concordance between therapist recommended and actual postacute discharge setting may decrease readmissions. Understanding factors associated with post‐acute setting discordance can inform strategies to improve the quality of the discharge process.

Variation in Acute Care Rehabilitation and 30-Day Hospital Readmission or Mortality in Adult Patients With Pneumonia

IMPORTANCE

Pneumonia often leads to functional decline during and after hospitalization and is a leading cause of hospital readmissions. Physical and occupational therapists help improve functional mobility and may be of help in this population.

OBJECTIVE

To evaluate whether use of physical and occupational therapy in the acute care hospital is associated with 30-day hospital readmission risk or death.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included the electronic health records and administrative claims data of 30 746 adults discharged alive with a primary or secondary diagnosis of pneumonia or influenza-related conditions from January 1, 2016, to March 30, 2018. Patients were treated at 12 acute care hospitals in a large health care system in western Pennsylvania. Data for this study were analyzed from September 2019 through March 2020.

EXPOSURES

Number of physical and occupational therapy visits during the acute care stay categorized as none, low (1-3), medium (4-6), or high (>6).

MAIN OUTCOMES AND MEASURES

Outcomes were 30-day hospital readmission or death. Generalized linear mixed models were estimated to examine the association of therapy use and outcomes, controlling for patient demographic and clinical characteristics. Subgroup analyses were conducted for patients older than 65 years, for patients with low functional mobility scores, for patients discharged to the community, and for patients discharged to a post-acute care facility (ie, skilled nursing or inpatient rehabilitation facility).

RESULTS

Of 30 746 patients, 15 507 (50.4%) were men, 26 198 (85.2%) were White individuals, and the mean (SD) age was 67.1 (17.4) years. The 30-day readmission rate was 18.4% (5645 patients), the 30-day death rate was 3.7% (1146 patients), and the rate of either outcome was 19.7% (6066 patients). Relative to no therapy visits, the risk of 30-day readmission or death decreased as therapy visits increased (1-3 visits: odds ratio, 0.98; 95% CI, 0.89-1.08; 4-6 visits: odds ratio, 0.89; 95% CI, 0.79-1.01; >6 visits: odds ratio, 0.86; 95% CI, 0.75-0.98). The association was stronger in the subgroup with low functional mobility and in individuals discharged to a community setting.

CONCLUSIONS AND RELEVANCE

In this study, the number of therapy visits received was inversely associated with the risk of readmission or death. The association was stronger in the subgroups of patients with greater mobility limitations and those discharged to the community.

Pediatric firearm injuries: Racial disparities and predictors of healthcare outcomes

BACKGROUND/PURPOSE

The U.S. has an alarming rate of firearm injuries. Racial disparities among victims and predictors of outcomes are not well established. Our objective was to assess costs, length of stay (LOS), and inpatient mortality among nonfatal and fatal pediatric firearm injuries that required hospitalization.

METHODS

Pediatric (≤18 years of age) hospitalizations with a firearm injury discharge diagnosis were identified from the national Kids' Inpatient Databases (KID) for 2006 through 2012. Firearm injury intent, weapon type, and hospitalization rates by racial groups were examined. Inpatient mortality, costs, and length of stay were examined using regression models.

RESULTS

Of 15,211 hospitalizations, the majority of injuries were due to assault (60%) and the intentions of firearm injury differed by race (p < 0.001). The median cost per hospitalization was $10,159 (interquartile range: $5071 to $20,565), totaling more than a quarter of a billion dollars. On regression analysis, Black (OR: 0.41; CI: 0.30-0.55) and Hispanic (OR: 0.47; CI: 0.34-0.66) patients were less likely to die than White patients.

CONCLUSION

Pediatric firearm injury circumstances and survival vary by race with Whites being more likely to experience unintentional injury and suicide, while Blacks and Hispanics are more likely to experience inflicted injury.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Clinical Research Study.

Comparison of registry and government evaluation data to ascertain severe trauma cases in Japan

Aims

Accurate evaluation of health care quality requires high-quality data, and case ascertainment (confirming eligible cases and deaths) is a foundation for accurate data collection. This study examined the accuracy of case ascertainment from two Japanese data sources.

Methods

Using hospital-level data, we investigated the concordance in ascertaining trauma cases between a nationwide trauma registry (the Japan Trauma Data Bank) and annual government evaluations of tertiary hospitals between April 2012 and March 2013. We compared the median values for trauma case volumes, numbers of deaths, and case fatality rates from both data sources, and also evaluated the variability in discrepancies for the intrahospital differences of these outcomes.

Results

The analyses included 136 hospitals. In the registry and annual evaluation data, the median case volumes were 120.5 cases and 180.5 cases, respectively; the median numbers of deaths were 11 and 12, respectively; and the median case fatality rates were 8.1% and 6.4%, respectively. There was broad variability in the intrahospital differences in these outcomes.

Conclusions

The observed discordance between the two data sources implies that these data sources may have inaccuracies in case ascertainment. Measures are needed to evaluate and improve the accuracy of data from these sources.