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Imbroane MR, Badrinathan A, Friedl SL, Mo A, Tran A, Carrane H, Tseng ES, Ho VP. A critical view: Examining disparities regarding timely cholecystectomy. Surgery 2024:S0039-6060(24)00540-3. [PMID: 39218740 DOI: 10.1016/j.surg.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 06/14/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Implicit bias may prevent patients with abdominal pain from receiving optimal workup and treatment. We hypothesized that patients from socially disadvantaged backgrounds would be more likely to experience delays in receiving operative treatment for cholecystitis. To study this question, we examined factors related to having a prior emergency department presentation for abdominal pain (prior emergency department visit) within 3 months of urgent cholecystectomy. METHODS We performed a retrospective analysis of consecutive patients who received an urgent cholecystectomy at an urban safety net public hospital between July 2019 and December 2022. The main outcome of interest was prior emergency department visit within 3 months of index cholecystectomy. We examined patient age, sex, race, ethnicity, preferred language, insurance, and employment status. Bivariate comparisons and logistic regression were used to determine the relationship between patient factors and prior emergency department visit. RESULTS Of 508 cholecystectomy patients, 138 (27.2%) had a prior emergency department visit in the 3 months preceding their surgery. In bivariate analysis, younger age, Black race, Hispanic ethnicity, non-English preferred language, and type of insurance (P < .05) were associated with prior emergency department visit. In regression, younger age, Black race, Hispanic ethnicity, and having Medicare or being uninsured were associated with higher odds of having a prior emergency department visit. CONCLUSION More than 1 in 4 patients had an evaluation for abdominal pain within 3 months of having an urgent cholecystectomy, and these patients were more likely to be from socially disadvantaged backgrounds. Standardized evaluation pathways for abdominal pain are needed to reduce disparities from institutional or implicit bias.
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Affiliation(s)
| | | | - Sophia L Friedl
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Allison Mo
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Andrew Tran
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Hope Carrane
- Department of Surgery, The MetroHealth System, Cleveland, OH
| | - Esther S Tseng
- Department of Surgery, The MetroHealth System, Cleveland, OH. https://twitter.com/esthertsengmd
| | - Vanessa P Ho
- Department of Surgery, The MetroHealth System, Cleveland, OH; Center for Health Equity Engagement, Education, and Research, Population Health and Equity Research Institute, The MetroHealth System and Case Western Reserve University, Cleveland, OH; Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH.
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Biesboer EA, Pokrzywa CJ, Karam BS, Chen B, Szabo A, Teng BQ, Bernard MD, Bernard A, Chowdhury S, Hayudini AHE, Radomski MA, Doris S, Yorkgitis BK, Mull J, Weston BW, Hemmila MR, Tignanelli CJ, de Moya MA, Morris RS. Prospective validation of a hospital triage predictive model to decrease undertriage: an EAST multicenter study. Trauma Surg Acute Care Open 2024; 9:e001280. [PMID: 38737811 PMCID: PMC11086287 DOI: 10.1136/tsaco-2023-001280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/23/2024] [Indexed: 05/14/2024] Open
Abstract
Background Tiered trauma team activation (TTA) allows systems to optimally allocate resources to an injured patient. Target undertriage and overtriage rates of <5% and <35% are difficult for centers to achieve, and performance variability exists. The objective of this study was to optimize and externally validate a previously developed hospital trauma triage prediction model to predict the need for emergent intervention in 6 hours (NEI-6), an indicator of need for a full TTA. Methods The model was previously developed and internally validated using data from 31 US trauma centers. Data were collected prospectively at five sites using a mobile application which hosted the NEI-6 model. A weighted multiple logistic regression model was used to retrain and optimize the model using the original data set and a portion of data from one of the prospective sites. The remaining data from the five sites were designated for external validation. The area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC) were used to assess the validation cohort. Subanalyses were performed for age, race, and mechanism of injury. Results 14 421 patients were included in the training data set and 2476 patients in the external validation data set across five sites. On validation, the model had an overall undertriage rate of 9.1% and overtriage rate of 53.7%, with an AUROC of 0.80 and an AUPRC of 0.63. Blunt injury had an undertriage rate of 8.8%, whereas penetrating injury had 31.2%. For those aged ≥65, the undertriage rate was 8.4%, and for Black or African American patients the undertriage rate was 7.7%. Conclusion The optimized and externally validated NEI-6 model approaches the recommended undertriage and overtriage rates while significantly reducing variability of TTA across centers for blunt trauma patients. The model performs well for populations that traditionally have high rates of undertriage. Level of evidence 2.
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Affiliation(s)
- Elise A Biesboer
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Courtney J Pokrzywa
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Basil S Karam
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Benjamin Chen
- Department of Computer Science, University of Minnesota, Minneapolis, Minnesota, USA
| | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bi Qing Teng
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Matthew D Bernard
- Department of Surgery, Division of Acute Care Surgery, Trauma, and Surgical Crtical Care, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Andrew Bernard
- Department of Surgery, Division of Acute Care Surgery, Trauma, and Surgical Crtical Care, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | | | | | | | | | - Brian K Yorkgitis
- Department of Surgery, Division of Acute Care Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Jennifer Mull
- Department of Surgery, Division of Acute Care Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Benjamin W Weston
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mark R Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Marc A de Moya
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rachel S Morris
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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3
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Goddard SD, Jarman MP, Hashmi ZG. Societal Burden of Trauma and Disparities in Trauma Care. Surg Clin North Am 2024; 104:255-266. [PMID: 38453300 DOI: 10.1016/j.suc.2023.09.009] [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] [Indexed: 03/09/2024]
Abstract
Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.
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Affiliation(s)
- Sabrina D Goddard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA
| | - Molly P Jarman
- The Department of Surgery, Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, One Brigham Circle,1620 Tremont Street, Suite 2-016, Boston, MA 02120, USA
| | - Zain G Hashmi
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA.
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4
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Roberts SE, Rosen CB, Wirtalla CJ, Finn CB, Kaufman EJ, Reilly PM, Syvyk S, McHugh MD, Kelz RR. Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries. Am J Surg 2023; 225:1074-1080. [PMID: 36473737 PMCID: PMC10199957 DOI: 10.1016/j.amjsurg.2022.11.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/26/2022] [Accepted: 11/19/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Qualifying comorbidity sets (QCS) are tools used to identify multimorbid patients at increased surgical risk. It is unknown how the QCS framework for multimorbidity affects surgical risk in different racial groups. METHODS This retrospective cohort study included Medicare patients age ≥65.5 who underwent an emergency general surgery operation from 2015 to 2018. Our exposure was race and multimorbidity, included in our model as an interaction term. The primary outcome of the study was 30-day mortality. Secondary outcomes included routine discharge, 30-day readmission, length of stay, and complications. RESULTS In total, 163,148 patients who underwent and operation were included in this study. Of these, 13,852 (8.5%, p < 0.001) were Black, and 149,296 (91.5%, p < 0.001) were White. Black multimorbid patients had no significant differences in 30-day mortality, routine discharge or 30-day readmission when compared to White multimorbid patients after risk-adjustment. Black multimorbid patients had significantly lower odds of complications (OR 0.89, p = 0.014) compared to White multimorbid patients. CONCLUSIONS Our study of universally insured patients highlights the critical role of pre-operative health status and its association with surgical outcomes.
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Affiliation(s)
- Sanford E Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Claire B Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher J Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Caitlin B Finn
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick M Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew D McHugh
- Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, University of Pennsylvania, USA
| | - Rachel R Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA; Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Baghdadi F, Evans BA, Goodacre S, John PA, Hettiarachchi T, John A, Lyons RA, Porter A, Safari S, Siriwardena AN, Snooks H, Watkins A, Williams J, Khanom A. Building an understanding of Ethnic minority people's Service Use Relating to Emergency care for injuries: the BE SURE study protocol. BMJ Open 2023; 13:e069596. [PMID: 37185177 PMCID: PMC10151843 DOI: 10.1136/bmjopen-2022-069596] [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] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Injuries are a major public health problem which can lead to disability or death. However, little is known about the incidence, presentation, management and outcomes of emergency care for patients with injuries among people from ethnic minorities in the UK. The aim of this study is to investigate what may differ for people from ethnic minorities compared with white British people when presenting with injury to ambulance and Emergency Departments (EDs). METHODS AND ANALYSIS This mixed methods study covers eight services, four ambulance services (three in England and one in Scotland) and four hospital EDs, located within each ambulance service. The study has five Work Packages (WP): (WP1) scoping review comparing mortality by ethnicity of people presenting with injury to emergency services; (WP2) retrospective analysis of linked NHS routine data from patients who present to ambulances or EDs with injury over 5 years (2016-2021); (WP3) postal questionnaire survey of 2000 patients (1000 patients from ethnic minorities and 1000 white British patients) who present with injury to ambulances or EDs including self-reported outcomes (measured by Quality of Care Monitor and Health Related Quality of Life measured by SF-12); (WP4) qualitative interviews with patients from ethnic minorities (n=40) and focus groups-four with asylum seekers and refugees and four with care providers and (WP5) a synthesis of quantitative and qualitative findings. ETHICS AND DISSEMINATION This study received a favourable opinion by the Wales Research Ethics Committee (305391). The Health Research Authority has approved the study and, on advice from the Confidentiality Advisory Group, has supported the use of confidential patient information without consent for anonymised data. Results will be shared with ambulance and ED services, government bodies and third-sector organisations through direct communications summarising scientific conference proceedings and publications.
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Affiliation(s)
| | | | - Steve Goodacre
- School of Health and Health Related Research, University of Sheffield, Sheffield, UK
| | - Paul Anthony John
- Research and Innovation Hub, Scottish Ambulance Service, Edinburgh, UK
| | | | - Ann John
- Medical School, Swansea University, Swansea, UK
| | | | | | - Solmaz Safari
- Public Contributor, c/o Medical School, Swansea University, Swansea, UK
| | | | | | | | - Julia Williams
- School of Health and Social Work, University of Hertfordshire, Hertfordshire, UK
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Henry R, Liasidis PK, Olson B, Clark D, Gomez TH, Ghafil C, Ding L, Matsushima K, Schreiber M, Inaba K. Disparities in Care Among Gunshot Victims: A Nationwide Analysis. J Surg Res 2023; 283:59-69. [PMID: 36372028 DOI: 10.1016/j.jss.2022.10.009] [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: 03/15/2022] [Revised: 06/30/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Given the well-known healthcare disparities most pronounced in racial and ethnic minorities, trauma healthcare in underrepresented patients should be examined, as in-hospital bias may influence the care rendered to patients. This study seeks to examine racial differences in outcomes and resource utilization among victims of gunshot wounds in the United States. METHODS This is a retrospective review of the National Trauma Data Bank (NTDB) conducted from 2007 to 2017. The NTDB was queried for patients who suffered a gunshot wound not related to accidental injury or suicide. Patients were stratified according to race. The primary outcome for this study was mortality. Secondary outcomes included racial differences in resource utilization including air transport and discharge to rehabilitation centers. Univariate and multivariate analyses were used to compare differences in outcomes between the groups. RESULTS A total of 250,675 patients were included in the analysis. After regression analysis, Black patients were noted to have greater odds of death compared to White patients (odds ratio [OR] 1.14, confidence interval [CI] 1.037-1.244; P = 0.006) and decreased odds of admission to the intensive care unit (ICU) (OR 0.76, CI 0.732-0.794; P < 0.001). Hispanic patients were significantly less likely to be discharged to rehabilitation centers (Hispanic: 0.78, CI 0.715-0.856; P < 0.001). Black patients had the shortest time to death (median time in minutes: White 49 interquartile range [IQR] [9-437] versus Black 24 IQR [7-205] versus Hispanic 39 IQR [8-379] versus Asian 60 [9-753], P < 0.001). CONCLUSIONS As society carefully examines major institutions for implicit bias, healthcare should not be exempt. Greater mortality among Black patients, along with differences in other important outcome measures, demonstrate disparities that encourage further analysis of causes and solutions to these issues.
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Affiliation(s)
- Reynold Henry
- Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, Portland, Oregon.
| | - Panagiotis K Liasidis
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Blade Olson
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Damon Clark
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Tatiana Hoyos Gomez
- Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Cameron Ghafil
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Li Ding
- Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
| | - Martin Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, Portland, Oregon
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California
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7
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Roberts SE, Rosen CB, Keele LJ, Wirtalla CJ, Syvyk S, Kaufman EJ, Reilly PM, Neuman MD, McHugh MD, Kelz RR. Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients. JAMA Surg 2022; 157:1097-1104. [PMID: 36223108 PMCID: PMC9558057 DOI: 10.1001/jamasurg.2022.4959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
Importance A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department. Objective To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition. Design, Setting, and Participants This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal. Exposures Black vs White race. Main Outcomes and Measures Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition. Results A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46). Conclusions and Relevance In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.
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Affiliation(s)
- Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Claire B. Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Luke J. Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Christopher J. Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Elinore J. Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Patrick M. Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia
| | - Matthew D. McHugh
- Center for Health Outcomes & Policy Research, School of Nursing, University of Pennsylvania, Philadelphia
| | - Rachel R. Kelz
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
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Barthélemy EJ, Affana CK, Asfaw ZK, Dams-O'Connor K, Rahman J, Jones S, Ullman J, Margetis K, Hickman ZL, Dangayach NS, Giwa AO. Racial and Socioeconomic Disparities in Neurotrauma: Research Priorities in the New York Metropolitan Area through a Global Neurosurgery Paradigm. World Neurosurg 2022; 165:51-57. [PMID: 35700861 DOI: 10.1016/j.wneu.2022.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022]
Abstract
The New York Neurotrauma Consortium (NYNC) is a nascent multidisciplinary research and advocacy organization based in the New York Metropolitan Area (NYMA). It aims to advance health equity and optimize outcomes for traumatic brain and spine injury patients. Given the extensive racial, ethnic, and socioeconomic diversity of the NYMA, global health frameworks aimed at eliminating disparities in neurotrauma may provide a relevant and useful model for the informing research agendas of consortia like the NYNC. In this review, we present a comparative analysis of key health disparities in traumatic brain injury (TBI) that persist in the NYMA as well as in low- and middle-income countries (LMIC). Examples include: (a) inequitable access to quality care due to fragmentation of healthcare systems, (b) barriers to effective prehospital care for TBI, and (c) socioeconomic challenges faced by patients and their families during the subacute and chronic post-injury phases of TBI care. This review presents strategies to address each area of health disparity based on previous studies conducted in both LMIC and high-income country (HIC) settings. Increased awareness of healthcare disparities, education of healthcare professionals, effective policy advocacy for systemic changes, and fostering racial diversity of the trauma care workforce can guide the development of trauma care systems in the NYMA that are free of racial and related healthcare disparities.
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Affiliation(s)
- Ernest J Barthélemy
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA; Center for Health Equity in Surgery and Anesthesia, University of California San Francisco, San Francisco, California, USA.
| | | | - Zerubabbel K Asfaw
- Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - Kristen Dams-O'Connor
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jueria Rahman
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Department of Neurosurgery, NYC Health + Hospitals/Elmhurst, Queens, New York
| | - Salazar Jones
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Department of Neurosurgery, NYC Health + Hospitals/Elmhurst, Queens, New York
| | - Jamie Ullman
- New York Neurotrauma Consortium, Inc., New York, New York; Institute for Neurology and Neurosurgery at North Shore University Hospital
| | - Konstantinos Margetis
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - Zachary L Hickman
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Department of Neurosurgery, NYC Health + Hospitals/Elmhurst, Queens, New York
| | - Neha S Dangayach
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Al O Giwa
- New York Neurotrauma Consortium, Inc., New York, New York; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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9
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Jones DM, Connelly DW, Burgess JR. Ground Level Falls in Patients Over 60, Do Race and Socioeconomic Status Affect Outcome? Am Surg 2022; 88:2127-2131. [DOI: 10.1177/00031348221091961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Falls are a significant source of morbidity, mortality, and health care spending in the elderly. The objective was to identify whether race, insurance status, and median income by zip code were associated with discharge disposition, readmission within 90 days, or mortality within 1 year of ground-level falls in patients aged 60-90. Materials and Methods We conducted a retrospective chart review of 926 patients aged 60-90 treated for ground-level falls. We created a binomial linear regression model to identify predictors of discharge disposition, 90-day readmission, and mortality within 1 year of discharge. Results Length of stay (P < .01), having orthopedic surgery (P < .01), score on Charlson Comorbidity Index (CCI) (P < .01), increasing age (P = .014), female sex (P = .05), and admission to the ICU (P = .05) were associated with discharge to a secondary facility. Readmission within 90 days was only associated with higher scores on the CCI (P < .01). Charlson Comorbidity Index (P < .0001), hospital length of stay (P < .001), and admission to the ICU (P = .015) were associated with increased mortality at 1 year. Discussion Predictors of discharge to another facility included hospital length of stay, having orthopedic surgery, CCI scores, increasing age, female sex, and admission to the ICU. Charlson Comorbidity Index score was the only significant predictor of readmission. Predictors of mortality at 1-year post-fall included CCI score, hospital length of stay, and admission to the ICU. Race, median income by zip code, and insurance provider were not statistically significant.
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Affiliation(s)
- Da’keesha M. Jones
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Daniel W. Connelly
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jessica R. Burgess
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
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10
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de Angelis P, Kaufman EJ, Barie PS, Leahy NE, Winchell RJ, Narayan M. Disparities in Insurance Status are Associated With Outcomes But Not Timing of Trauma Care. J Surg Res 2022; 273:233-246. [PMID: 35144053 DOI: 10.1016/j.jss.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/19/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Paolo de Angelis
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York.
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Department of Surgery, Penn Medicine, Philadelphia, Pennsylvania
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Nicole E Leahy
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Robert J Winchell
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York; Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mayur Narayan
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
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Lopez R, Snair M, Arrigain S, Schold JD, Hustey F, Walker LE, Phelan MP. Sex-based differences in timely emergency department evaluations for patients with drug poisoning. Public Health 2021; 199:57-64. [PMID: 34560476 DOI: 10.1016/j.puhe.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 07/21/2021] [Accepted: 08/12/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Unintentional poisoning was the leading cause of injury-related death in the United States in 2017. Prescribed and illicit drugs are the most common cause of poisoning, and timely management in the emergency department (ED) is important. Our aim was to identify any disparities in wait times associated with sex for drug poisoning-related ED visits. STUDY DESIGN We examined ED visits using data from the 2009-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS). METHODS Drug poisoning-related visits were identified using the International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification codes. Delayed assessment was defined as wait times exceeding the recommended triage time. Weighted logistic regression was used. RESULTS The average age was 36 years (standard error = 1.1), 54% female, 87% White and 29% had delayed assessment. Most common drugs were psychotropics (45%) and opioids (32%). Adjusting for race, payment source, urgency, multiple drug types and NSAIDs, females who had poisoning by substances other than opioids had 2.1 times higher likelihood of having a delayed assessment compared with males (odds ratio [95% confidence interval]: 2.1 [1.03-4.2]), although there was no difference between sexes among visits with opioid poisoning (P = 0.27). Neither race (P = 0.23) nor payment source (P = 0.22) were associated with delayed assessment, and the sex association was consistent across these groups. CONCLUSIONS Females with non-opioid drug poisoning were more likely to have delayed assessment than men. None of the other demographic factors demonstrated a correlation. Identifying more populations vulnerable to delays in the ED can help guide the development of interventions and policies to expedite care and attenuate existing disparities.
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Affiliation(s)
- R Lopez
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - M Snair
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S Arrigain
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J D Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - F Hustey
- Center for Emergency Medicine, Emergency Services Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - M P Phelan
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA; Center for Emergency Medicine, Emergency Services Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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Dell KC, Staph J, Hillary FG. Traumatic brain injury in the homeless: health, injury mechanisms, and hospital course. Brain Inj 2021; 35:1192-1200. [PMID: 34460346 DOI: 10.1080/02699052.2021.1958009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary ObjectiveEstablished literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations.Research DesignWe leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home.Methods and ProceduresWe implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups.Main Outcomes and ResultsHomelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home.ConclusionGiven the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.
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Affiliation(s)
- Kristine C Dell
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Jason Staph
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Frank G Hillary
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States.,Department of Neurology, Hershey Medical Center, Hershey, Pennsylvania, United States
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