Variability in Discharge Disposition Across US Trauma Centers After Treatment for High-Energy Lower Extremity Injuries

The Major Extremity Trauma Research Consortium: Development and Impact of an Orthopaedic Trauma Research Program

The Major Extremity Trauma Research Consortium (METRC) is a unique and ongoing military-civilian collaboration that resulted in the largest orthopaedic trauma research enterprise to date. The Consortium was established in September 2009 with funding from the Department of Defense. It employs a centralized data coordinating center and has grown into a network of nearly 400 investigators at 70 clinical centers. METRC conducts large multicenter clinical research studies selected and designed to improve outcomes among severely injured military and civilian patients with extremity trauma. Over the past decade, the consortium has implemented 35 such studies distributed among 19 principal investigators, enrolled more than 23,000 patients, published 61 articles, and received more than $150 million in funding from the Department of Defense, Patient Centered Outcomes Research Institute, and National Institutes of Health. This unique multidisciplinary research platform is a powerful community capable of addressing the challenging issues related to the evaluation, treatment, and recovery after severe extremity trauma. This body of work received the 2023 Elizabeth Winston Lanier Kappa Delta Award. An overview of the METRC development, organization, and research focus areas is presented.

Race and Insurance Status Disparities in Post-discharge Disposition After Hospitalization for Major Trauma

BACKGROUND

Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to examine the discharge practices among trauma centers in the US and to identify factors that may influence post-hospital disposition.

METHODS

A retrospective analysis of trauma patients using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2007-2017. Primary study outcome was hospital disposition (including long term care facility [LTC], others). Secondary outcomes included: Intensive Care Unit (ICU)-length of stay (LOS), complications, others).

RESULTS

6 899 538 patients were analyzed. Odds of LTC discharge was significantly higher for Black patients (aOR = 1.30, 95% CI:1.24-1.37), abbreviated injury score (AIS) ≥3 (aOR = 4.22, 95% CI: 4.05-4.39), and higher injury severity score (ISS) (aOR = 9.41, 95% CI:9.03-9.80). Significantly more self-pay patients were discharged home compared to other insurance types (P < .0001). Significantly longer hospital- and ICU-LOS were experienced by those who had an AIS ≥3 (hospital: 4.8 days (±7.1) vs. 7.9 (±10.1); ICU: 4.6 (±6.9) vs. 5.9 (±7.9), P < .0001) and had a high ISS (hospital: 4.5 days (±5.9) vs. 16.8 (±17.9); ICU: 3.6 (±5.0) vs. 10.2 (±11.5), P < .0001).

CONCLUSIONS

Patient race, insurance status, and injury severity were predictive of post-hospitalization care discharge. Self-pay and Black patients were less likely to be discharged to secondary care facilities. These findings have the potential to improve in-hospital patient management and predict discharge secondary care needs, and necessitate the need for future research to investigate the extent of inequalities in access to trauma 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.