Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury

Racial equity in trauma injury: An unresolved enigma

BACKGROUND

Racial disparities in healthcare have been attributed to socioeconomic inequalities while the relative risk (RR) of traumatic injury in people of color has yet to be described.

METHODS

Demographics of our patient population were compared to the population of our service area. The racial and ethnic identities of gunshot wound (GSW) and motor vehicle collision (MVC) patients were used to establish RR of traumatic injury adjusting for socioeconomic status defined by payor mix and geography.

RESULTS

GSW assaults were more common in Blacks (59.1%) while self-inflicted GSWs were more common in Whites (46.2%). RR of having a GSW was 4.65 times greater (95% CI 4.03-5.37; p < 0.01) among Blacks than other populations. MVC patients were 36.8% Black, 26.6% White, and 32.6% Hispanic. Blacks had an increased risk of MVC compared to other races (RR 2.13; 95% CI 1.96-2.32; p < 0.01). The racial and ethnic identity of the patient was not a predictor of GSW or MVC mortality.

CONCLUSIONS

Increased risk of GSW and MVC was not correlated with local population demographics or socioeconomic status.

Disparities in Insurance Status are Associated With Outcomes But Not Timing of Trauma Care

INTRODUCTION

Patient factors influence outcomes after injury. Delays in care have a crucial impact. We investigated the associations between patient characteristics and timing of transfer from the emergency department to definitive care.

METHODS

This was a review of adult trauma patients treated between January 1, 2016, and December 31, 2018. Bivariate analyses were used to build Cox proportional hazards models. We built separate logistic and negative binomial regression models for secondary outcomes using mixed-step selection to minimize the Akaike information criterion c.

RESULTS

A total of 1219 patients were included; 68.5% were male, 56.8% White, 11.2% Black, and 7.8% Asian/Pacific Islander. The average age was 51 ± 21 y. Overall, 13.7% of patients were uninsured. The average length of stay was 5 d and mortality was 5.9%. Shorter transfer time out of the emergency department was associated with higher tier of activation (relative risk [RR] 1.39, 95% confidence interval [CI] 1.09-1.77; P = 0.0074), Injury Severity Score between 16 and 24 points (RR 1.57, 95% CI 1.04-2.32; P = 0.0307) or ≥25 (RR 3.85, 95% CI 2.45-5.94; P = 0.0001), and penetrating injury. Longer time to event was associated with Glasgow coma scale score ≥14 points (RR 0.47, 95% CI 0.27-0.85; P = 0.0141). Uninsured patients were less likely to be admitted (odds ratio 0.29, 95% CI 0.17-0.48; P = 0.0001) and more likely to experience shorter length of stay (incidence rate ratio 0.34, 95% CI 0.24-0.51; P = 0.0001).

CONCLUSIONS

Injury characteristics and insurance status were associated with patient outcomes in this retrospective, single-center study. We found no disparity in timing of intrafacility transfer, perhaps indicating that initial management protocols preserve equity.

Repeal of state laws permitting denial of health claims resulting from alcohol impairment: Impact on treatment utilization

BACKGROUND

Many states in the U.S. still have Alcohol Exclusion Laws (AELs), which allow insurance companies to deny health claims resulting from alcohol impairment. There are concerns that this form of structural stigmatization affects alcohol treatment-seeking behaviors. We examined the effects of AEL repeal on treatment admissions for alcohol use disorder (AUD).

METHODS

Data on alcohol treatment admissions from 1992 to 2017 were obtained from the Treatment Episode Data Set. The state-level aggregate number of treatment admissions was derived, including healthcare professional referrals only, self-referrals only, and both self-referral and healthcare professional referrals. The number of treatment admissions by health insurance status (private, public, and uninsured) was also calculated. The study used a difference-in-differences (DID) quasi-experimental design.

RESULTS

The DID analysis showed that the number of admissions for alcohol treatment from healthcare professional referrals increased 16% in the AEL repeal states compared to states with AELs or that never had AELs (IRR=1.16, 95% CI=1.07, 1.25). These results were consistent for analysis by payment sources. In particular, treatment admissions from healthcare professional referrals for patients covered by private insurance increased about 38% in states with AEL repeal (IRR=1.38, 95% CI=1.17, 1.64) compared to states without AEL repeal. However, the findings were no longer significant when the state-specific time trends were taken into account.

CONCLUSIONS

This study documented that AEL repeal may have had a significant impact on the number of treatment admissions for AUD. These findings suggest that AELs function as a barrier to treatment-seeking behavior.

Iliac ecchymosis, a valuable sign for hollow viscus injuries in blunt pelvic trauma patients

PURPOSE

Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities.

METHODS

We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted.

RESULTS

In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p < 0.001).

CONCLUSION

IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.

Using cable ties to connect thoracostomy tubes to drainage devices decreases frequency of unplanned disconnection

OBJECTIVES

Thoracostomy tube (TT) connection to drainage device (DD) may be unintentionally disconnected, potentiating complications. Tape may strengthen this connection despite minimal data informing optimal practice. Our goal was to analyze the utility of cable ties for TT to DD connection.

METHODS

On April 1, 2015, our trauma center supplanted use of tape or nothing with cable ties for securing TT to DD connection. We abstracted trauma registry patients with TTs placed from March 1, 2014 to May 31, 2016 and dichotomized as prior ("BEFORE") and subsequent ("AFTER") to the cable tie practice pattern change. We analyzed demographics, TT-specific details and outcomes. Primary outcome was TT to DD disconnection. Secondary outcomes included TT dislodgement from the chest, complications, length of stay (LOS), mortality, number of TTs placed and TT days.

RESULTS

121 (83.4% of abstracted) patients were analyzed. Demographics, indications for TT and operative rate were similar for BEFORE and AFTER cohorts. ISS was lower BEFORE (14.12 ± 2.35 vs 18.21 ± 2.71, p = 0.022); however, RTS and AIS for chest were similar (p = 0.155 and 0.409, respectively). TT to DD disconnections per TT days were significantly higher in the BEFORE cohort [6 (2.8%) vs. 1 (0.19%), p = 0.003], and dislodgements were statistically similar [0 vs 3 (0.57%), p = 0.36]. LOS, initial TTs placed and days per TT were similar, and median and mode of days per TT were the same.

CONCLUSIONS

Cable ties secure connections between TT and DDs with higher fidelity compared to tape or nothing but may increase rates of TT dislodgement from the chest.

Penetrating Colon Trauma Outcomes in Black and White Males

INTRODUCTION

Racial disparities have been both published and disputed in trauma patient mortality, outcomes, and rehabilitation. In this study, the objective was to assess racial disparities in patients with penetrating colon trauma.

METHODS

The National Trauma Data Bank was searched for males aged ≥14years from 2010 through 2014 who underwent operative intervention for penetrating colon trauma. The primary outcomes for this study were stoma formation and transfer to rehabilitation; secondary outcomes were postoperative morbidity and mortality. Analyses were performed in 2016-2018.

RESULTS

There were 7,324 patients identified (4,916 black, 2,408 white). Black and white patients underwent fecal diversion with stoma formation at a similar rate (19.6% vs 18.5%, p=0.28). Black patients were more likely than white patients to be uninsured (self-pay; 37.1% vs 29.9%) and more likely to be injured by firearms (88.3% vs 70.2%, p<0.001), but had a lower overall postoperative morbidity rate (52.6% vs 55.3%, p=0.04). The odds of stoma formation (OR=0.92, 95% CI=0.78, 1.09, p=0.35) and the odds of transfer to rehabilitation (OR=1.03, 95% CI=0.82, 1.30, p=0.78) were similar for black versus white patients.

CONCLUSIONS

Black patients experienced similar rates of stoma formation and transfer to rehabilitation as white patients with penetrating colon trauma. Multivariate analysis confirmed expected findings that trauma severity increased the odds of receiving an ostomy and rehabilitation placement. The protocol-based management approach to emergency trauma care potentially decreases the risk for the racial biases that could lead to healthcare disparities.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled African American Men's Health: Research, Practice, and Policy Implications, which is sponsored by the National Institutes of Health.

A Randomized Controlled Trial on Intra-Abdominal Irrigation during Emergency Trauma Laparotomy; Time for Yet Another Paradigm Shift

OBJECTIVE

To determine the optimal volume of abdominal irrigation that will prevent surgical site infections (both deep and superficial), eviscerations and fistula formations; and improve 30-day mortality in trauma patients.

METHODS

We conducted a three-arm parallel clinical superiority randomized controlled trial comparing different volumes of effluent (5, 10 and 20 liters) used in trauma patients (both blunt and penetrating) age 14 and above undergoing an emergency laparotomy between April 2002 and July 2004 in a busy urban Level 1 trauma center.

RESULTS

After randomization, a total of 204 patients were analyzed. All patient groups were comparable with respect to age, gender distribution, admission injury severity score, and mechanism of injury, estimated blood loss and degree of contamination. The mortality rate overall was 1.96% (4/204).No differences were noted with respect to contamination, wound infection, fistula formation, and evisceration. The twenty liter group (Group III) showed a trend toward an increased incidence of deep surgical site infections when compared to the five liter (Group I) (p=0.051) and ten liter (Group II) (p=0.057) groups. This did not however reach statistical significance.

CONCLUSION

The old surgical adage "the solution to pollution is dilution" is not applicable to trauma patients. Our results suggest that using more irrigation, even when large amounts of contamination have occurred, does not reduce post-operative complications or affect mortality; and it may predispose patients to increased incidence of abscess formation. (Trial registration number: ISRCTN66454589).

The Crush Index: Orthopedic Trauma as an Economic Indicator

The purpose of this study was to evaluate the relationship between economic activity and the incidence of high-energy orthopedic trauma. California's Office of Statewide Health Planning and Development patient discharge database was queried to identify monthly orthopedic trauma incidence from 1995 to 2010. Patient inclusion required 1 diagnosis code and 1 associated procedural code for fractures of the femur, tibia, ankle, pelvis, or acetabulum. Data on composite market indices, energy and transportation use, and unemployment were obtained from government sources. Statistical analysis was performed using univariate and multivariate linear regression. The average monthly incidence of orthopedic trauma was 2.92 cases per 100,000 people. Of 15 economic indicators analyzed with univariate regression, 7 variables correlated with trauma incidence to statistical significance. Dow Jones Industrial Average (P=.032), Standard & Poor's 500 (P=.034), vehicle miles driven (P<.001), personal disposable income (P=.033), Coincident Economic Activity Index for California (P=.007), and vehicles purchased (P<.001) were positively correlated with trauma incidence. Unemployment (P<.001) was inversely correlated with trauma incidence. Multivariate regression was used to compute a combination of independent predictors of trauma volume: personal disposable income (P<.001), vehicles purchased (P=.008), and unemployment (P=.005). This combination of variables was used to develop the Crush Index to model the relationship between economic activity and orthopedic trauma volume. The authors show a positive correlation between economic strength and activity and the monthly volume of high-energy orthopedic trauma. The Crush Index serves as a proof of concept that may be useful in guiding preparedness among practitioners and health care system administrators. [Orthopedics. 2017; 40(4):248-255.].

Epidemiology and management of splenic injury: An analysis of a Chinese military registry

In China, there have been few meta-analyses of the epidemiology and management of splenic injury. Due to the success of Chinese military hospitals in the domestic treatment of splenic injury, the present study conducted a systematic review of such cases, identifying a high occurrence rate of splenic trauma, as well as a number of strategies of managing splenic injury in China. Data were collected from sixteen Chinese military hospitals between July 2000 and March 2009, and retrospectively reviewed. It was observed that between July 2000 and March 2009 a total of 7,807 patients (84.32% male and 15.68% female) with splenic injury were admitted to hospital. The mean duration of hospital stay was 17.9±18.6 days and the gender distribution of splenic injury over the successive years did not differ significantly (P>0.05, c=0.034). However, there was a significant difference in the gender distribution of splenic injury patients in different months (P<0.05, c=0.063). In addition, admission numbers for splenic injury were highest in September, October and November. It was also found that splenic injury may occur at all ages, though patients of working age (20-50 years), which comprises 85.59% of patients, the highest proportion of all recorded cases. Associations between mortality rate and each management strategy were as follows: Operative management, 0.11% and non-operative management, 0.15%. Furthermore, multivariate analysis demonstrated that transfusion, New Injury Severity Score and management strategies were all correlated with mortality rate. Thus, despite a lack of data for inpatients from civilian hospitals, the present study has, in part, identified the epidemiology and management strategies of splenic injury in China. These findings may supplement those from previous analyses of splenic injury in other countries and regions.

Discharge disposition as an independent predictor of readmission among patients hospitalised for community-acquired pneumonia

BACKGROUND

Community-acquired pneumonia (CAP) is the most common non-obstetrical reason for hospital admission, the leading infectious cause of death, and a target for public reporting. CAP has thus become a target of quality improvement and pay-for-performance efforts. However, the relationship between discharge disposition and readmission risk has not been investigated.

METHODS

We studied CAP patients admitted to the University of Chicago from 11/2011 to 04/2015. We collected demographic information, comorbidities, laboratory values, vital signs, a modified pneumonia severity index (PSI), length of stay (LOS), clinical instabilities before discharge, discharge disposition and 30-day all-cause readmission. A multivariate logistic regression was performed, specifying readmission as the dependent variable, including as independent variables gender, ethnicity, insurance status, discharge disposition, PSI tertile, the number of clinical instabilities, LOS and comorbidities.

RESULTS

Of the 2892 CAP patients identified, 14.9% were readmitted. The distribution of discharge disposition was: 43.0% home without services, 26.1% home with home health care (HHC), 16.2% to a skilled nursing or subacute rehabilitation facility and 14.8% to an acute rehabilitation or long-term acute care facility. Of patients discharged home with HHC, 20.1% were readmitted, compared to 11.5% discharged home without services. In the multivariate regression model, being discharged home with HHC was associated with a markedly greater risk of readmission (Odds ratio 1.58 [95% confidence interval 1.21-2.07]).

CONCLUSIONS

Discharge home with HHC is an independent predictor of readmission risk among hospitalised CAP patients. Discharging providers should carefully consider follow-up care and social factors that may impact the risk of readmission among such patients.

National estimates of predictors of outcomes for emergency general surgery

BACKGROUND

Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the predictors of in-hospital complications and mortality among EGS patients.

METHODS

The Nationwide Inpatient Sample (2003-2011) was queried for patients with conditions encompassing EGS as determined by the American Association for Surgery of Trauma, categorizing them into predefined EGS groups using DRG International Classification of Diseases-9th Rev.-Clinical Modification codes. Primary outcomes considered included incidence of a major complication (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital mortality. Separate multivariate logistic regression analyses for complications and mortality were performed to identify risk factors of either outcome from the following domains: patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics (location, teaching status, and bed size).

RESULTS

This study included 6,712,151 discharge records, weighted to represent 32,910,446 visits for EGS conditions. Mean age was 58.50 (19.74) years; slightly more than half (54.66%) were female. Uninsured patients were more likely to die (odds ratio,1.25; 95% confidence interval, 1.20-1.30), whereas patients in the highest income quartile had the least likelihood of mortality (odds ratio, 0.86; 95% confidence interval, 0.84-0.87). Old age was an independent predictor of mortality for all EGS subdiagnoses. The overall mortality rate was 1.76%; the overall complication rate was 10.03%. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease.

CONCLUSION

Death patterns of EGS patients were discerned using an administrative data set. Understanding patterns of mortality and complications derived from studies such as this could improve hospital benchmarking for EGS, akin to trauma surgery's previous success.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.