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Surviving Burn Injury: Drivers of Length of Hospital Stay. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020761. [PMID: 33477442 PMCID: PMC7829802 DOI: 10.3390/ijerph18020761] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 11/17/2022]
Abstract
With a reduction in the mortality rate of burn patients, length of stay (LOS) has been increasingly adopted as an outcome measure. Some studies have attempted to identify factors that explain a burn patient’s LOS. However, few have investigated the association between LOS and a patient’s mental and socioeconomic status. There is anecdotal evidence for links between these factors; uncovering these will aid in better addressing the specific physical and emotional needs of burn patients and facilitate the planning of scarce hospital resources. Here, we employ machine learning (clustering) and statistical models (regression) to investigate whether segmentation by socioeconomic/mental status can improve the performance and interpretability of an upstream predictive model, relative to a unitary model. Although we found no significant difference in the unitary model’s performance and the segment-specific models, the interpretation of the segment-specific models reveals a reduced impact of burn severity in LOS prediction with increasing adverse socioeconomic and mental status. Furthermore, the socioeconomic segments’ models highlight an increased influence of living circumstances and source of injury on LOS. These findings suggest that in addition to ensuring that patients’ physical needs are met, management of their mental status is crucial for delivering an effective care plan.
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Piatt J. Mediators of racial disparities in mortality rates after traumatic brain injury in childhood: data from the Trauma Quality Improvement Program. J Neurosurg Pediatr 2020; 26:476-482. [PMID: 32736354 DOI: 10.3171/2020.5.peds20336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Social disparities in healthcare outcomes are almost ubiquitous, and trauma care is no exception. Because social factors cannot cause a trauma outcome directly, there must exist mediating causal factors related to the nature and severity of the injury, the robustness of the victim, access to care, or processes of care. Identification of these causal factors is the first step in the movement toward health equity. METHODS A noninferiority analysis was undertaken to compare mortality rates between Black children and White children after traumatic brain injury (TBI). Data were derived from the Trauma Quality Improvement Program (TQIP) registries for the years 2014 through 2017. Inclusion criteria were age younger than 19 years and head Abbreviated Injury Scale scores of 4, 5, or 6. A noninferiority margin of 10% was preselected. A logistic regression propensity score model was developed to distinguish Black and White children based on all available covariates associated with race at p < 0.10. Stabilized inverse probability weighting and a one-tailed 95% CI were used to test the noninferiority hypothesis. RESULTS There were 7273 observations of White children and 2320 observations of Black children. The raw mortality rates were 15.6% and 22.8% for White and Black children, respectively. The final propensity score model included 31 covariates. It had good fit (Hosmer-Lemeshow χ2 = 7.1604, df = 8; p = 0.5194) and good discrimination (c-statistic = 0.752). The adjusted mortality rates were 17.82% and 17.79% for White and Black children, respectively. The relative risk was 0.9986, with a confidence interval upper limit of 1.0865. The relative risk corresponding to the noninferiority margin was 1.1. The hypothesis of noninferiority was supported. CONCLUSIONS Data captured in the TQIP registries are sufficient to explain the observed racial disparities in mortality after TBI in childhood. Speculations about genetic or epigenetic factors are not supported by this analysis. Discriminatory care may still be a factor in TBI mortality disparities, but it is not occult. If it exists, evidence for it can be sought among the data included in the TQIP registries.
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de Jongh MAC, Kruithof N, Gosens T, van de Ree CLP, de Munter L, Brouwers L, Polinder S, Lansink KWW. Prevalence, recovery patterns and predictors of quality of life and costs after non-fatal injury: the Brabant Injury Outcome Surveillance (BIOS) study. Inj Prev 2016; 23:59. [PMID: 27154507 DOI: 10.1136/injuryprev-2016-042032] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 03/15/2016] [Accepted: 04/02/2016] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Trauma is a major public health problem worldwide that leads to high medical and societal costs. Overall, improved understanding of the full spectrum of the societal impact and burden of injury is needed. The main purpose of the Brabant Injury Outcome Surveillance (BIOS) study is to provide insight into prevalence, predictors and recovery patterns of short-term and long-term health-related quality of life (HRQoL) and costs after injury. MATERIALS AND METHODS This is a prospective, observational, follow-up cohort study in which HRQoL, psychological, social and functional outcome, and costs after trauma will be assessed during 24 months follow-up within injured patients admitted in 1 of 10 hospitals in the county Noord-Brabant, the Netherlands. Data will be collected by self-reported questionnaires at 1 week (including preinjury assessment), and 1, 3, 6, 12 and 24 months after injury. If patients are not capable of filling out the questionnaires, proxies will be asked to participate. Also, information about mechanism and severity of injury, comorbidity and indirect and direct costs will be collected. Mixed models will be used to examine the course of HRQoL, functional and psychological outcome, costs over time and between different groups, and to identify predictors for poor or good outcome. RELEVANCE This study should make a substantial contribution to the international collaborative effort to assess the societal impact and burden of injuries more accurately. The BIOS results will also be used to develop an outcome prediction model for outcome evaluation including, besides the classic fatal, non-fatal outcome. TRIAL REGISTRATION NUMBER NCT02508675.
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Affiliation(s)
- M A C de Jongh
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Network Emergency Care Brabant, Brabant Trauma Registry, The Netherlands
| | - N Kruithof
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - T Gosens
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Department of Orthopaedics, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - C L P van de Ree
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - L de Munter
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - L Brouwers
- Network Emergency Care Brabant, Brabant Trauma Registry, The Netherlands
| | - S Polinder
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - K W W Lansink
- Department Trauma TopCare, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands.,Network Emergency Care Brabant, Brabant Trauma Registry, The Netherlands.,Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Cisse B, Moore L, Kuimi BLB, Porgo TV, Boutin A, Lavoie A, Bourgeois G. Impact of socio-economic status on unplanned readmission following injury: A multicenter cohort study. Injury 2016; 47:1083-90. [PMID: 26746984 DOI: 10.1016/j.injury.2015.11.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 11/11/2015] [Accepted: 11/21/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Unplanned readmissions cost the US economy approximately $17 billion in 2009 with a 30-day incidence of 19.6%. Despite the recognised impact of socio-economic status (SES) on readmission in diagnostic populations such as cardiovascular patients, its impact in trauma patients is unclear. We examined the effect of SES on unplanned readmission following injury in a setting with universal health insurance. We also evaluated whether additional adjustment for SES influenced risk-adjusted readmission rates, used as a quality indicator (QI). STUDY DESIGN We conducted a multicenter cohort study in an integrated Canadian trauma system involving 56 adult trauma centres using trauma registry and hospital discharge data collected between 2005 and 2010. The main outcome was unplanned 30-day readmission; all cause, due to complications of injury and due to subsequent injury. SES was determined using ecological indices of material and social deprivation. Odds ratios of readmission and 95% confidence intervals adjusted for covariates were generated using multivariable logistic regression with a correction for hospital clusters. We then compared a readmission QI validated previously (original QI) to a QI with additional adjustment for SES (SES-adjusted QI) using the mean absolute difference. RESULTS The cohort consisted of 52,122 trauma admissions of which 6.5% were rehospitalised within 30 days of discharge. Compared to patients in the lowest quintile of social deprivation, those in the highest quintile had a 20% increase in the odds of all-cause unplanned readmission (95% CI=1.06-1.36) and a 27% increase in the odds of readmission due to complications of injury (95% CI=1.04-1.54). No association was observed for material deprivation or for readmissions due to subsequent injuries. We observed a strong agreement between the original and SES-adjusted readmission (mean absolute difference= 0.04%). CONCLUSIONS Patients admitted for traumatic injury who suffer from social deprivation have an increased risk of unplanned rehospitalisation due to complications of injury in the 30 days following discharge. Better discharge planning or follow up for such patients may improve patient outcome and resource use for trauma admissions. Despite observed associations, results suggest that the trauma QI based on unplanned readmission does not require additional adjustment for SES.
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Affiliation(s)
- Brahim Cisse
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada.
| | - Lynne Moore
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Brice Lionel Batomen Kuimi
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Teegwendé Valérie Porgo
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- Department of social and preventive medicine, Université Laval, Québec, QC, Canada; Axe Santé des Populations - Pratiques Optimales en Santé (Population Health - Practice - Changing Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Université Laval, Québec, QC, Canada
| | - André Lavoie
- Institut National d'Excellence en Santé et en Services Sociaux, Montréal, QC, Canada
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Montréal, QC, Canada
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Moore L, Cisse B, Batomen Kuimi BL, Stelfox HT, Turgeon AF, Lauzier F, Clément J, Bourgeois G. Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study. BMC Health Serv Res 2015; 15:285. [PMID: 26204932 PMCID: PMC4513757 DOI: 10.1186/s12913-015-0949-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 07/14/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007-2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression. RESULTS Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles. CONCLUSIONS Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.
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Affiliation(s)
- Lynne Moore
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
| | - Brahim Cisse
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
| | - Brice Lionel Batomen Kuimi
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
| | - Henry T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Alexis F Turgeon
- Department of social and preventive medicine, Laval University, Quebec, QC, Canada.
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Laval University, Québec, QC, Canada.
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec - Hôpital de l'Enfant-Jésus), Laval University, Québec, QC, Canada.
- Department of Medicine, Laval University, Québec, QC, Canada.
| | - Julien Clément
- Department of Surgery, Laval University, Québec, QC, Canada.
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Montréal, Qc, Canada.
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Bhayana R, Vermeulen MJ, Li Q, Hellings CR, Berdahl C, Schull MJ. Socioeconomic status and the use of computed tomography in the emergency department. CAN J EMERG MED 2015; 16:288-95. [PMID: 25060082 DOI: 10.2310/8000.2013.131102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACT
Background:
Low socioeconomic status (SES) is associated with adverse health outcomes. Possible explanations include differences in health status, access to health care, and care provided by clinicians. We sought to determine whether SES is associated with computed tomography (CT) use in the emergency department (ED).
Methods:
A retrospective cohort study of all Ontario ED patients (April 1, 2009, to March 31, 2010) using administrative databases was conducted, and patients were stratified into SES quintiles based on median neighbourhood income. Using multivariate logistical regression, CT scan use within SES quintiles was compared for all patients and subgroups based on chief complaints: headache, abdominal pain, and complex abdominal pain (age ≥ 65 years, high acuity, and admittance to hospital).
Results:
We analyzed 4,551,101 patient visits, of which 52% were female. Overall, 8.2% underwent CT scanning. In adjusted analyses, the lowest SES patients were less likely to undergo CT scanning overall and in all clinical subgroups, except for complex abdominal pain. Compared to the lowest SES quintile, the adjusted odds ratios of CT scanning in the highest SES quintile were 1.08 (95% CI 1.07–1.09), 1.28 (95%CI 1.22–1.34), and 1.24 (95% CI 1.21–1.27) for all patients, headache pain patients, and abdominal pain patients, respectively. For patients presenting with complex abdominal pain, no significant difference in CT use was observed.
Conclusion:
Lowest SES ED patients were less likely to receive CT scans overall and in headache and abdominal pain subgroups. No difference was seen among complex abdominal pain patients, suggesting that as clinical indications for the test become more clearcut, use across SES quintiles differs less.
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Szynkaruk M, Stephens D, Borschel GH, Wright JG. Socioeconomic status and wait times for pediatric surgery in Canada. Pediatrics 2014; 134:e504-11. [PMID: 25002658 DOI: 10.1542/peds.2013-3518] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Even in a publicly funded health care system, access to care may be related to socioeconomic status (SES). For children, delays in surgical procedures can have profound functional, social, and psychological effects with lifelong impact. The purpose of this study was to determine whether SES was related to meeting surgical wait time access targets for children. We also assessed the effects of gender, age, and distance to hospital on meeting access targets. METHODS Patient addresses, referral wait times, and surgical wait times were obtained for 39,287 surgical procedures between 2005 and 2011 at the Hospital for Sick Children. Using census data, we derived household income quintile, distance to hospital, and indices of social and material deprivation. These indices were correlated with the percentage of children meeting clinic referral wait time targets and receiving surgery within the Pediatric Canadian Access Targets for Surgery. RESULTS Across all SES quintiles, 33% of children exceeded their referral wait time targets, and 28% of children exceeded their surgical wait time targets. Indices of material or social deprivation and age did not correlate with the time from referral to clinic consultation (P = .54, .40, and .58, respectively). Gender was statistically significant (P < .001), but the difference was small (odds ratio = 0.87 for girls). Distance was also statistically significant (P = .005), and these differences translate into clinically meaningful differences in meeting wait time targets. Regarding completion of surgical procedures, material deprivation, distance, and gender did not correlate with longer wait times for surgery (P = .44, .09, .59, respectively). Social deprivation was statistically significant (P = .02) but not clinically significant. Increasing patient age was significantly associated with increased proportion of out-of-window wait times (P < .001). SES did not affect the timeliness of completion of surgery even when the urgency of the surgery (priority level based on diagnosis) was considered. CONCLUSIONS SES does not predict the timeliness of delivery for pediatric surgical services.
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Affiliation(s)
- Mark Szynkaruk
- Division of Plastic and Reconstructive Surgery, Department of Surgery, and
| | | | - Gregory H Borschel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, andInstitute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada; andProgram in Neuroscience, and
| | - James G Wright
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, CanadaDivision of Orthopaedic Surgery, The Hospital for Sick Children and University of Toronto, Toronto, Canada
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Abstract
BACKGROUND The delivery of equitable trauma care in Canada is not without challenges within our universal health care system. Notably, the tyranny of geography is intermittently at odds with adequate access for our rural, indigenous, and impoverished populations. Other differences exist when compared with neighbouring trauma systems, for example in the United States. METHODS As a critical review, we chose to compare and critique the overall system of trauma organization and perceived societal expectations of a high-income, North American country (Canada) to assist with discussions on trauma systems for the future. RESULTS Tele-technology is providing some early solutions. Trauma systems and delivery of care in Canada differ from the United States due to our single-payer system, regionalization and universal provision. Care for injured Canadians has a long history of being multidisciplinary, with collaborative research programs. Canada also has a history of global surgical endeavours, beginning with Dr. Norman Bethune and his recognition of the political causes of trauma and continuing as a global public health concern for all. CONCLUSIONS While challenges continue to exist for the provision of equitable trauma care in Canada, unique multidisciplinary, collaborative and technology-based solutions continue to be developed, both locally and globally, to address this critical public health issue.
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Affiliation(s)
- Tanya Zakrison
- DeWitt Daughtry Department of Surgery, Miller School of Medicine, University of Miami, 1800 NW 10th Avenue, T247, Miami, FL 33136, USA.
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