Factors Influencing Nonadherence to Recommended Postdischarge Follow-Up After Trauma

Risk Factors for Missed Follow-up Appointments among Facial Trauma Patients

A retrospective case-control study was performed to characterize the rate of missed follow-up appointments after facial trauma and identify associated risk factors.Follow-up appointments for facial trauma over a 3-month period at a single, safety net hospital were analyzed. Appointment-specific, sociodemographic, trauma, and management data were compared between cases (missed appointments) and controls (attended appointments). Univariate testing and multivariable logistic regression were employed.A total of 116 cases and 259 controls were identified, yielding a missed appointment rate of 30.9% (116/375). Missed appointments were significantly associated with initial clinic appointments compared to return visits (odds ratio [OR] 2.21 [1.38-3.54]), afternoon visits compared to morning (OR 3.14 [1.94-5.07]), lack of private health insurance (OR 2.91 [1.68-5.18]), and presence of midface fractures (OR 2.04 [1.28-3.27]). Missed appointments were negatively associated with mandible fractures (OR 0.56 [0.35-0.89]), surgical management (OR 0.48 [0.30-0.77]), and the presence of nonremovable hardware (OR 0.39 [0.23-0.64]). Upon multivariable logistic regression, missed appointments remained independently associated with afternoon visits (adjusted OR [aOR] 1.95 [1.12-3.4]), lack of private health insurance (aOR 2.73 [1.55-4.8]), and midface fractures (aOR 2.09 [1.21-3.59]).Nearly one-third of facial trauma patients missed follow-up appointments, with the greatest risk among those with afternoon appointments, lacking private health insurance, and with midface fractures.

A comparison of the psychometric properties of a person-administered vs. automated screening tool for posttraumatic stress disorder (PTSD) in traumatically injured patients

BACKGROUND

The American College of Surgeons Committee on Trauma (ACS-CoT) mandated that trauma centers have mental health screening and referral protocols in place by 2023. This study compares the Injured Trauma Survivor Screen (ITSS) and the Automated Electronic Medical Record (EMR) Screen to assess their performance in predicting risk for posttraumatic stress disorder (PTSD) within the same sample of trauma patients to inform trauma centers' decision when selecting a tool to best fit their current clinical practice.

METHODS

This was a secondary analysis of three prospective cohort studies of traumatically injured patients (N = 255). The ITSS and Automated EMR Screen were compared using receiver operating characteristic curves to predict risk of subsequent PTSD development. PTSD diagnosis at 6-month follow-up was assessed using the Clinician Administered PTSD Scale for DSM-5.

RESULTS

Just over half the sample screened positive on the ITSS (57.7%), while 67.8% screened positive on the Automated EMR Screen. The area under the curve (AUC) for the two screens was not significantly different (ITSS AUC = 0.745 versus Automated EMR Screen AUC = 0.694, p = 0.21), similar performance in PTSD risk predication within the same general trauma population. The ITSS and Automated EMR Screen had similar sensitivities (86.5%, 89.2%), and specificities (52.5%, 40.9%) respectively at their recommended cut-off points.

CONCLUSION

Both screens are psychometrically comparable. Therefore, trauma centers considering screening tools for PTSD risk to comply with the ACS-CoT 2023 mandate should consider their local resources and patient population. Regardless of screen selection, screening must be accompanied by a referral process to address the identified risk.

Risk factors for loss to follow-up after traumatic injury: An updated view of a chronic problem

BACKGROUND

Loss to follow-up after traumatic injury occurs at rates of up to 47%. However, the most recent data are over a decade old, and recent changes in traumatic injury patterns necessitate an updated assessment of risk factors for loss to follow-up after trauma.

METHODS

We conducted a retrospective chart review of trauma admissions from January 1, 2018 to December 31, 2021. Categorical variables were compared using χ2 analyses, and continuous variables were analyzed using Mann-Whitney Wilcoxon tests. Multivariable logistic regression was used to adjust for relevant factors identified on unadjusted analysis.

RESULTS

Among 3,034 patients, overall loss to follow-up was 36.9%. Non-White patients, patients who underwent operations or non-surgical procedures, and patients discharged to rehabilitation facilities were more likely to have follow-up appointments within 30 days. Patients with substance use disorder and, among White patients, those with public insurance had higher loss to follow-up rates. Having a follow-up appointment scheduled with a primary care provider was the single most significant factor associated with attending a follow-up appointment.

CONCLUSION

Social determinants of health, such as insurance status and substance use disorder, are associated with loss of follow-up after trauma. Primary care appointments are associated with the highest attendance rates, supporting that all patients should be offered primary care appointments after traumatic injury.

Effect of Standardized Reminder Calls on Trauma Patient No-Show Rate

BACKGROUND

Most patients who sustain a traumatic injury require outpatient follow-up. A common barrier to outpatient postadmission care is patient failure to follow-up. One of the most significant factors resulting in failure to follow-up is age more than 35 years. Recent work has shown that follow-up telephone calls reduce readmission rates. Our aim was to decrease no-show appointments by 10% in 12 months.

STUDY DESIGN

The electronic medical records at our level I and II trauma centers were queried for all outpatient appointments for trauma between July 1, 2020, and June 9, 2021, and whether the patient attended their follow-up appointment. Patients with visits scheduled after August 1, 2021, received 24- and 48-hour previsit reminder calls. Patients with visits scheduled between July 1, 2020, and August 1, 2021, did not receive previsit calls. Both groups were compared using multivariable direct logistic regression models.

RESULTS

A total of 1,822 follow-up opportunities were included in the study. During the pre-implementation phase, there was a no-show rate of 30.9% (329 of 1,064 visits). Postintervention, a 12.2% reduction in overall no-show rate occurred. A statistically significant 11.2% decrease (p < 0.001) was seen in elderly patients. Multivariate analysis showed standardized calls resulted in significantly decreased odds of failing to keep an appointment (adjusted odds ratio = 0.610, p < 0.001).

CONCLUSIONS

Reminder calls led to a 12.2% reduction in no-show rate and were an independent predictor of a patient's likelihood of attending their appointment. Other predictors of attendance included insurance status and abdominal injury.

Diagnostic Workup and Therapeutic Intervention of Hiatal Hernias Discovered as Incidental Findings on Computed Tomography

BACKGROUND

Computed tomography imaging routinely detects incidental findings; most research focuses on malignant findings. However, benign diseases such as hiatal hernia also require identification and follow-up. Natural language algorithms can help identify these non-malignant findings.

METHODS

Imaging of adult trauma patients from 2010 to 2020 who underwent CT chest/abdomen/pelvis was evaluated using an open-source natural language processor to query for hiatal hernias. Patients who underwent subsequent imaging, endoscopy, fluoroscopy, or operation were retrospectively reviewed.

RESULTS

1087(10.6%) of 10 299 patients had incidental hiatal hernias: 812 small (74.7%) and 275 moderate/large (25.3%). 224 (20.7%) had subsequent imaging or endoscopic evaluation. Compared to those with small hernias, patients with moderate/large hernias were older (66.3 ± 19.4 vs 79.6 ± 12.6 years, P < .001) and predominantly female (403[49.6%] vs 199[72.4%], P < .001). Moderate/large hernias were not more likely to grow (small vs moderate/large: 13[7.6%] vs 8[15.1%], P = .102). Patients with moderate/large hernias were more likely to have an intervention or referral (small vs moderate/large: 6[3.5%] vs 7[13.2%], P = .008). No patients underwent elective or emergent hernia repair. Three patients had surgical referral; however, only one was seen by a surgeon. One patient death was associated with a large hiatal hernia.

CONCLUSIONS

We demonstrate a novel utilization of natural language processing to identify patients with incidental hiatal hernia in a large population, and found a 10.6% incidence with only 1.2%. (13/1087) of these receiving a referral for follow-up. While most incidental hiatal hernias are small, moderate/large and symptomatic hernias have high risk of loss-to-follow-up and need referral pipelines to improve patient outcomes.

Long-term survival after major trauma: a retrospective nationwide cohort study from the National Health Insurance Research Database

BACKGROUND

Most trauma-related studies are focused on short-term survival and complications within the index admission, and the long-term outcomes beyond discharge are mainly unknown. The purpose of this study was to analyze the data from the National Health Insurance Research Database (NHIRD) and to assess the long-term survival of major trauma patients after being discharged from the index admission.

MATERIAL AND METHODS

This retrospective, observational study included all patients with major trauma (injury severity score ≥16) in Taiwan from 2003 to 2007, and a 10-year follow-up was conducted on this cohort. Patients aged 18-70 who survived the index admission were enrolled. Patients who survived less than one year after discharge (short survival, SS) and those who survived for more than one year (long survival, LS) were compared. Variables, including preexisting factors, injury types, and short-term outcomes and complications, were analyzed, and the 10-year Kaplan-Meier survival analysis was conducted.

RESULTS

In our study, 9896 patients were included, with 2736 in the SS group and 7160 in the LS group. Age, sex, comorbidities, low income, cardiopulmonary resuscitation event, prolonged mechanical ventilation, prolonged ICU length of stay (LOS), and prolonged hospital LOS were identified as the independent risk factors of SS. The 10-year cumulative survival for major trauma patients was 63.71%, and the most mortality (27.64%) occurred within the first year after discharge.

CONCLUSION

27.64% of patients would die one year after being discharged from major trauma. Major trauma patients who survived the index admission still had significantly worse long-term survival than the general population, but the curve flattened and resembled the general population after one year.

Post-Trauma Discharge Instructions: Are We Dropping the Ball?

INTRODUCTION

Complex follow-up plans for polytrauma patients are compiled at the end of hospitalization into discharge instructions. We sought to identify how often patient discharge instructions incorrectly communicated specialist recommendations. We hypothesized that patients with more complex hospitalizations would have more discharge instruction errors (DI-errors).

METHODS

We reviewed adult trauma inpatients (March 2017-March 2018), excluding those who left against medical advice or were expected to follow up outside our system. Complex hospitalizations were represented using injury severity (ISS), hospital length of stay (LOS), intensive care unit length of stay (iLOS), and number of consultants (NC). We recorded the type of consultant (surgical or nonsurgical), and consultant recommendations for follow-up. DI-errors were defined as either follow-up necessary but omitted or follow-up not necessary yet present on the instructions. Patients with DI-errors were compared to patients without DI-errors. Groups were compared using Wilcoxon rank sum or chi-square (alpha <.05).

RESULTS

We included 392 patients (median age 45 [IQR 26-58], ISS 14 [10-21], LOS 6 [3-11]). 55 patients (14%) had DI-errors. Factors associated with DI-errors included the total number of consultants and use of nonsurgical consultants. ISS, LOS, iLOS, were not associated with DI-errors.

CONCLUSION

Common measures of admission complexity were not associated with DI-errors, although the number and type of consultants were associated with DI-errors. Non-surgical specialty consultant recommendations were more likely to be omitted. It is crucial for patients to receive accurate discharge instructions, and systematic processes are needed to improve communication with the patients at discharge.

Transitional care programs for trauma patients: A scoping review

BACKGROUND

Transitional care programs establish comprehensive outpatient care after hospitalization. This scoping review aimed to define participant characteristics and structure of transitional care programs for injured adults as well as associated readmission rates, cost of care, and follow-up adherence.

METHODS

We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews standard. Information sources searched were Medline, the Cochrane Library, CINAHL, and Scopus Plus with Full Text. Eligibility criteria were systematic reviews, clinical trials, and observational studies of transitional care programs for injured adults in the United States, published in English since 2000. Two independent reviewers screened all full texts. A data charting process extracted patient characteristics, program structure, readmission rates, cost of care, and follow-up adherence for each study.

RESULTS

A total of 10 studies described 9 transitional care programs. Most programs (60%) were nurse/social-worker-led post-discharge phone call programs that provided follow-up reminders and inquired regarding patient concerns. The remaining 40% of programs were comprehensive interdisciplinary case-coordination transitional care programs. Readmissions were reduced by 5% and emergency department visits by 13% among participants of both types of programs compared to historic data. Both programs improved follow-up adherence by 75% compared to historic data.

CONCLUSION

Transitional care programs targeted at injured patients vary in structure and may reduce overall health care use.

Health disparities in orthopedic trauma: a qualitative study examining providers' perspectives on barriers to care and recovery outcomes

Social workers involved in interdisciplinary orthopedic trauma care can benefit from the knowledge of providers' perspectives on healthcare disparities in this field. Using qualitative data from focus groups conducted on 79 orthopedic care providers at three Level 1 trauma centers, we assessed their perspectives on orthopedic trauma healthcare disparities and discussed potential solutions. Focus groups originally aimed to detect barriers and facilitators of the implementation of a trial of a live video mind-body intervention to aid in recovery in orthopedic trauma care settings (Toolkit for Optimal Recovery-TOR). We used the Socio-Ecological Model to analyze an emerging code of "health disparities" during data analysis to determine at which levels of care these disparities occurred. We identified factors related to health disparities in orthopedic trauma care and outcomes at the Individual (Education- comprehension, health-literacy; Language Barriers; Psychological Health- emotional distress, alcohol/drug use, learned helplessness; Physical Health- obesity, smoking; and Access to Technology), Relationship (Social Support Network), Community (Transportation and Employment Security), and Societal level (Access- safe/clean housing, insurance, mental health resources; Culture). We discuss the implications of the findings and provide recommendations to address these issues, with a specific focus on their relevance to the field of social work in health care.

Factors influencing participation in psychosocial programming among orthopaedic trauma patients with PTSD

INTRODUCTION

Post Traumatic Stress Disorder (PTSD) commonly occurs following acute trauma. Post-injury outcomes are negatively impacted by PTSD. Trauma Recovery Services (TRS) programming was developed at our institution in 2013 to provide psychosocial programming that increases patient satisfaction with care and ability to return to work and decreases PTSD symptoms. We sought to identify factors that influence patients' decision to participate in programming.

METHODS

Over a 3-year period at a single, urban level 1 trauma center, 172 patients over the age of 18 screened positive for PTSD on the validated PTSD checklist for DSM-5 (PCL-5) screening tool. Demographic, socioeconomic, injury, and medical comorbidity information was collected. Variables were initially compared in a univariate manner via Chi-squared, Fisher exact, t-test, or Mann-Whitney U, as appropriate. Variables that had a p-value <0.2 on univariate analysis were entered into a backward stepwise logistic regression model to identify independent predictors of participation in TRS programming.

RESULTS

Mean age was 37.8 years. 70.1% of patients were male. The most common mechanisms of injury were gunshot wound (33.7%), motor vehicle crash (19.0%), and burn. 33.5% of patients participated in TRS programming. Nine predictors had p<.2 on univariate analysis and were entered into the stepwise regression model. Four predictors remained in the final model. Patients with private insurance (RR=2.2, p=.038), high school diploma or greater (RR=1.53, p=.002; Table 1), and PCL-5 score greater than 50 were more likely to participate in TRS programming (RR=1.42, p=.046). Patients who live 20 or more minutes away by car from TRS were less likely to participate in programming (RR=0.47, p=.065).

DISCUSSION

Patients with more severe PTSD, higher levels of education, and private insurance were more likely to participate in TRS programming. Participation in TRS and similar psychosocial programs may be improved by minimizing the participant's potential commute to the program location.

Risk factors for loss to follow up of pelvis and acetabular fractures

INTRODUCTION

Pelvic and acetabular fracture incidence is increasing worldwide for more than four decades. There is currently no evidence examining risk factors for loss to follow up in patients with these injuries.

METHODS

Patients presenting with pelvic and/or acetabular fractures at our institution between 2015 and 2020 were included. Demographic, injury, treatment, and follow up information was included. Excluded patients were those who sustained a pathologic fracture, has a course of treatment prior to transfer to our centre, or expired prior to discharge.

RESULTS

446 patients, 263 with a pelvic ring injury, 172 with an acetabular fracture, and 11 with combined injuries were identified. 271 (61%) of patients in our cohort followed up in Orthopaedic clinic (p = 0.016). With an odds ratio of 2.134, gunshot wound mechanism of injury was the largest risk factor for loss to follow up (p = 0.031) followed by male sex (OR= 1.859) and surgery with general trauma surgery (OR=1.841). The most protective risk factors for follow up with Orthopaedic surgery were operatively treated pelvic and acetabular fractures (OR=0.239) and Orthopaedic Surgery as the discharging service (OR=0.372).

DISCUSSION

Numerous risk factors exist for loss to follow up including male sex, ballistic mechanism, and discharging service. Investigation into interventions to improve follow up in these patients are warranted.

Trauma System Support to Facilitate Recovery

SUMMARY

Trauma is a major public health issue. Orthopaedic trauma surgeons are skilled in the acute management of musculoskeletal injury; however, formal training and resources have not been devoted to optimizing recovery after trauma. Recovery entails addressing the biomedical aspects of injury, as well as the psychological and social factors. The purposes of this study were to describe existing programs and resources within trauma centers, developed to promote psychosocial recovery. Supporting research data will be referenced, and potential barriers to program implementation will be discussed. The American College of Surgeons has mandated screening and treatment for mental illness after trauma, which will raise the bar to highlight the importance of these social issues, likely enabling providers to develop new programs and other resources within their systems. Provider education will promote the informing of patients and families, with the intent of enhancing the efficiency and scope of recovery.

Barriers to accessing follow up care in post-hospitalized trauma patients in Moshi, Tanzania: A mixed methods study

Disproportionately high injury rates in Sub-Saharan Africa combined with limited access to care in both the acute injury phase and for injury patients requiring continued care after hospital discharge remains a challenge. We aimed to characterize barriers to transportation and access to care in a cohort of post-hospitalized injury patients in Moshi, Tanzania. This was a mixed-methods study of a prospective cohort of trauma registry patients presenting to Kilimanjaro Christian Medical Center between August 2018 and January 2020. We conducted standardized patient/family surveys and in-depth interviews at a 2-week follow up visit after hospital discharge, and focus groups with healthcare providers. Quantitative results were analyzed using descriptive statistics and multivariable logistic regression using R statistical software. Qualitative results were analyzed using thematic analysis through an iterative process using NVivo software. A total of 1,365 patients were enrolled in the trauma registry, with 169 patients followed up at 2 weeks. Over half of patients at follow-up, 101 (59.8%), reported challenges in traveling. The majority of patients were male (80.3%). Difficulty in traveling since injury was associated with female gender (aOR 5.85 [95% CI 1.20-33.59]) and a need for non-family members escorts for travel (aOR 7.10 [95% CI 1.43-41.66]). Those who reported assault or fall as the mechanism of injury as compared to road traffic injury and had health insurance were less likely to report challenges in traveling (aOR 0.19 [95% CI 0.03-0.90]), 0.11 [95% CI 0.01-0.61], 0.14 [95% 0.02-0.80]). Transportation barriers that emerged from qualitative data included inability to use regular means of transportation, financial challenges, physical barriers, rigid compliance to physician orders, access to healthcare, and social support barriers. Our findings demonstrate several areas to address transportation barriers for post-injury patients in Tanzania. Educational interventions such as clarification of doctors' orders of strict bedrest, provision of vouchers to support financial challenges and alternate means of transportation given physical barriers and reliance on social support may address some of these barriers.

Treating trauma more effectively: A review of psychosocial programming

IMPORTANCE

Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation.

OBSERVATIONS

Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented.

CONCLUSIONS AND RELEVANCE

The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.

Lost in Follow-Up: Predictors of Patient No-Shows to Clinic Follow-Up After Abdominal Injury

BACKGROUND

The aim of this study is to evaluate risk factors for non-attendance to post-discharge, hospital follow-up appointments for traumatically injured patients who underwent exploratory laparotomy.

METHODS

This is a retrospective chart review of patients who underwent exploratory laparotomy for traumatic abdominal injury at an urban, Midwestern, level I trauma center with clinic follow-up scheduled after discharge. Clinically, relevant demographic characteristics, patients' distance from hospital, and the presence of staples, sutures, and drains requiring removal were collected. Descriptive statistics of categorical variables were calculated as totals and percentages and compared with a chi-squared test or Fisher's exact when appropriate.

RESULTS

The sample included 183 patients who were largely assaultive trauma survivors (68%), male (80%), and black (53%) with a mean age of 35.4 ± 14.9 years. Overall, 18.5% no-showed for their follow-up appointment. On multivariate analysis for clinic no-show; length of stay (odds ratio = 0.92 [0.84-0.99], P = 0.04) and the need for suture, staple, or drain removal were protective for clinic attendance (odds ratio = 5.59 [1.07-7.01], P = 0.04). Overall, 12 patients (6.4%) were readmitted. Forty patients (18.3%) had their follow-up in the emergency department (ED). On multivariate regression of risk factors for ED visits, the only statistically significant factors (P < 0.05) were clinic appointment no-show (OR = 2.81) and self-pay insurance (OR = 4.78).

CONCLUSIONS

Abdominal trauma patients are at high risk of no-show for follow-up appointments and no-show visits are associated with ED visits. Future work is needed evaluating interventions to improve follow-up.

"What Are My Injuries?" Health Literacy and Patient Comprehension of Trauma Care and Injuries

BACKGROUND

Trauma patients often have complex injuries treated by multidisciplinary providers with wide-ranging expertise. We hypothesized that trauma patients would frequently incorrectly identify both their injuries and care teams. We also hypothesized that low health literacy level would be correlated with low levels of comprehension about injuries or care teams.

MATERIALS AND METHODS

We performed a prospective study of adult trauma inpatients >18 years. Participants were surveyed to report on 1) injured body regions 2) their care teams, and 3) health literacy via a validated survey. Self-reported injuries and care teams were compared to the patient's medical record. We also studied whether health literacy was associated with patient knowledge of injuries and care teams.

RESULTS

Fifty participants were surveyed; thirty-two percent could not identify ≥50% of their injuries. Patients reliably identified injuries to the head, but injuries to other body areas were often misidentified. Forty-two percent of patients were not able to identify ≥50% of their medical teams, and 28% could not identify ≥75% of their medical teams. Patients often did not recognize teams such as nutrition, physical/occupationalt, or social work as part of their care. Thirteen participants reported adequate health literacy. Health literacy was not related to participant knowledge of injuries or care teams (both P = 0.9).

CONCLUSION

Many trauma inpatients were unable to correctly identify their injuries and care teams despite a range of self-reported health literacy scores.