Factors Associated With Long-term Outcomes After Injury: Results of the Functional Outcomes and Recovery After Trauma Emergencies (FORTE) Multicenter Cohort Study

Workplace Injury and Mental Health Outcomes

Importance

Workplace injury is a widespread problem that impacts mental health and quality of life and places a substantial burden on employers and the health care system.

Objective

To determine whether mental disorder rates differ following workplace injury compared with injuries outside the workplace.

Design, Setting, and Participants

This retrospective cohort study assessed individuals hospitalized for an injury requiring surgery between January 1, 2002, and December 31, 2018, with a 2-year follow-up period using population-based administrative data in Manitoba, Canada. Analyses were completed June to July 2021. This study compared 2 cohorts: individuals with a workplace injury matched 1:5 on sex, age, geographical region, and surgical procedure code with individuals with a nonworkplace injury in the general population.

Exposure

Traumatic physical injury that required surgery with anesthetic.

Main Outcomes and Measures

The outcome of interest was a diagnosis of mental disorder (anxiety, depression, substance abuse, suicide attempt, and any mental disorder), measured 2 years prior to and following injury.

Results

In this cohort study, 7556 individuals (mean [SD] age, 44.8 [13.3] years; 5721 [75.7%] male; 4624 individuals [61.2%] with urban residence; 4545 individuals [60.1%] with low income) with a workplace injury were compared with 28 901 matches from the general population. The workplace cohort had lower rates of all mental disorders (anxiety: adjusted rate ratio [ARR], 0.82; 95% CI, 0.77-0.87; depression: ARR, 0.78; 95% CI, 0.72-0.84; substance abuse: ARR, 0.63; 95% CI, 0.55-0.72; suicide attempt: ARR, 0.28; 95% CI, 0.11-0.70; and any mental disorder: ARR, 0.82; 95% CI, 0.78-0.86; all P < .0006) before their injury and for depression (ARR, 0.89; 95% CI, 0.82-0.95) and substance abuse (ARR, 0.83; 95% CI, 0.73-0.94) after their injury. The group × care period interaction term was significant for anxiety (P < .0001) and any mental disorder (P < .0001), suggesting that individuals with workplace injuries had worse mental disorder outcomes over time than individuals with nonworkplace injuries.

Conclusions and Relevance

This cohort study found that the mental health trajectory from the preinjury to postinjury period was worse for individuals with a workplace injury compared with those injured outside the workplace. These findings suggest that there may be features unique to the workplace and/or injury claims and compensation processes that contribute to this pattern, which warrant further examination.

The impact of insurance disparities on long-term burn outcomes: A Burn Model System investigation

INTRODUCTION

Access to healthcare and insurance coverage are associated with quality of life, morbidity, and mortality outcomes. However, most studies have only focused on same-admission and short-term outcomes due to the lack of national longitudinal datalthere are limited data on this topic in the burn literature. Our aim was to determine the effect of insurance status on long-term outcomes in a national sample of burn patients.

METHODS

This retrospective study used the longitudinal Burn Model System National Database from January 1997 to December 2020. The inclusion criteria were all adult patients admitted for burn injury from participating sites. Main outcomes were the physical (PCS) and mental (MCS) health component summary scores of the Veterans RAND 12 (VR-12) score at 6, 12, and 24 months after injury. Adjusting for demographic and clinical characteristics, multivariable regression was used to examine the association between insurance status and the outcomes.

RESULTS

A total of 1809 burn patients were included. Most patients had private/commercial insurance (60.42 %), followed by Medicare (13.99 %) and Medicaid (12.77 %). The remaining 13 % were uninsured patients (self-pay or philanthropy). In adjusted analyses, Medicaid insurance was associated with worse MCS at 6 months (Coefficient -4.24, 95 % CI -6.06 - -2.41) and 12 months (Coefficient -3.62, 95 % CI -5.68 - -1.57), and worse PCS at all timepoints, compared to private/commercial insurance. Medicare insurance was associated with worse MCS scores at 12 months (Coefficient -2.86, 95 % CI -5.06 - -0.66) and worse PCS scores at all timepoints.

CONCLUSION

Having Medicaid and Medicare insurance was significantly associated with a lower health-related quality of life at long-term follow up, even after adjusting for demographics and burn injury severity.

Effects of a Virtual Trauma Clinic on admissions and length of stay for minor to moderate trauma

OBJECTIVE

To investigate the feasibility of a Virtual Trauma Clinic (VTC) for patients with minor to moderate trauma, and evaluate patient satisfaction and outcomes.

METHODS

One hundred VTC patients were matched 1:1 with historical patients from the hospital trauma registry who received conventional care. Matching was based on age ± 5 years, sex, mechanism of injury, Injury Severity Score ± 2, trauma team activation and day of week of presentation. VTC patients were sent surveys on experience and outcome measures.

RESULTS

VTC was associated with reduced average hospital length of stay for admitted patients by 1.81 days (95% CI = -2.82, -0.79; P = 0.001) and reduced hospital admissions (odds ratio 0.26; 95% CI = 0.14, 0.48; P < 0.001). There was an avoidance of 199 inpatient bed days in total, with no trauma-related readmissions within 30 days post-hospital discharge. 92% of respondents (n = 22) rated the care they received from VTC as excellent or good. Patient-reported outcome surveys showed overall improvement in functional domains but evidence of ongoing disability, with persistent issues of pain and psychological distress at 1 month post-injury.

CONCLUSION

Patients with minor to moderate trauma have ongoing care needs with high rates of pain, psychological distress and disability remaining prevalent long after discharge. VTC provided an innovative strategy for hospital avoidance with high levels of patient satisfaction and no adverse effects on safety. The overall quality of care for these patients was enhanced through the provision of standardised, patient-centred and multidisciplinary follow-up.

National analysis of health-related social needs among adult injury survivors

BACKGROUND

Despite advances in trauma care, the effects of social determinants of health continue to be a barrier to optimal health outcomes. Health-related social needs (HRSNs), now the basis of a Centers for Medicare and Medicaid Services national screening program, may contribute to poor health outcomes, inequities, and low-value care, but the impact of HRSNs among injured patients remains poorly understood at the national level.

METHODS

Using data from the nationally representative 2021 Medical Expenditure Panel Survey, injured patients were matched with uninjured controls via coarsened exact matching on age and sex. We then determined the prevalence of HRSNs based on core needs identified by Centers for Medicare and Medicaid Services: food, utilities, living situation, transportation, and personal safety. We used multivariable regression models to evaluate the association between HRSNs and health, delays in care, and emergency department visits.

RESULTS

Overall, 43% of injured patients reported one or more HRSNs. Compared with uninjured controls, injured patients were more likely to have unmet needs in all five HRSN domains (adjusted odds ratio, 1.44-2.00; p < 0.05 for all). In stratified analyses, HRSNs were highest among patients with lower income (65.1%), those who identified as Non-Hispanic Black patients (61.3%), and patients with Medicaid (66.1%). Increasing number of HRSNs was associated with worse physical and mental health ( p < 0.05). Injured patients with three or more HRSNs were also more likely to delay care because of cost (adjusted odds ratio, 3.79; 95% confidence interval, 2.29-6.27) and had greater emergency department utilization (adjusted incidence rate ratio, 1.47; 95% confidence interval, 1.16-1.87).

CONCLUSION

In this nationally representative study, nearly half of injured patients had one or more HRSNs. Greater numbers of HRSNs were associated with worse health outcomes, delayed care, and low-value care. As national screening for HRSNs is implemented, strategies to address these factors are needed and may serve to optimize health and health care utilization among injury survivors.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Hospital experience with geriatric trauma impacts long-term survival

BACKGROUND

Hospital experience measured by geriatric trauma proportion (GTP) is associated with in-hospital mortality among geriatric patients. Our goal was to determine the impact of GTP on long-term survival among older trauma patients.

METHODS

This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients admitted in Florida. GTP was calculated by dividing the number of geriatric trauma patients by the overall adult trauma volume in each hospital. Hospitals were then categorized into tertiles of GTP. Our main outcome was mortality at 30, 90, 180, and 365 days. Multivariable regression was performed to identify the association between GTP and long-term survival.

RESULTS

We included 65,763 geriatric trauma patients. As compared with hospitals in the lowest tertile, patients treated at the highest tertile were associated with lower mortality at 90 days (OR 0.90, 95%CI 0.82-0.98), 180 days (OR 0.90, 95%CI 0.83-0.97), and 365 days (OR 0.91, 95%CI 0.85-0.98).

CONCLUSIONS

Higher GTP is associated with improved long-term outcomes. However, mortality following trauma among geriatric patients continues to increase for 12 months.

The benefit of national clinical guidelines for open lower limb fractures in reducing healthcare burden: A length of inpatient stay cost-analysis

INTRODUCTION

Severe open lower limb fractures are complex and costly injuries. Studies reporting the costs associated with these injuries, the economic impact of complications, and the clinical benefit of adherence to national guidelines have been previously reported. However, the economic benefits of national guidelines and their relationship with length of inpatient stay have not been described.

METHODS

An international retrospective cohort study, using length of stay as a proxy for in-hospital economic impact, comparing the duration of inpatient stay in countries with national guidelines and those without.

RESULTS

In a cohort of 2641 patients from 16 countries, length of stay was 17 % lower in countries with national guidelines, equivalent to 2-3 fewer inpatient days per patient. This difference was primarily driven by a lower incidence of deep infection observed in countries with national clinical guidelines.

CONCLUSION

The presence of national guidelines for the management of severe lower limb injuries is associated with both improved clinical outcomes and reduced length of stay and therefore healthcare burden. Whilst application and adoption of national guidelines is not without challenges, their implementation is associated with significant clinical and economic benefits.

Randomized clinical trial of peer integrated collaborative care intervention after physical injury

Objectives

The goal of the current study was to assess the effectiveness of a peer integrated collaborative care intervention for postinjury outcomes.

Methods

Injury survivors ≥18 years of age were screened for post-traumatic stress disorder (PTSD) symptoms and severe postinjury concerns; screen-positive patients were randomized to the intervention versus enhanced usual care control conditions. The collaborative care intervention included peer support and care management. The intervention also included evidence-based pharmacotherapy and psychotherapeutic elements targeting PTSD. The COVID-19 pandemic interrupted recruitment between March and June 2020; in response to the COVID-19 pandemic, the peer component of the intervention went from in-person to virtual delivery. The primary outcomes were PTSD symptoms assessed with the Diagnostic and Statistical Manual of Mental Disorders fourth edition PTSD checklist, any severe postinjury concerns, and emergency department/inpatient utilization followed over the 12 months postinjury. Secondary outcomes included patient satisfaction with emotional healthcare.

Results

A total of 450 patients were randomized to the intervention (n=225) and control (n=225) conditions; 124 patients (28%) were recruited and completed all study assessments prior to the onset of the COVID-19 pandemic, while 326 patients (72%) were recruited after and/or had one or more study follow-ups occur postpandemic onset. Mixed model regression revealed no statistically significant comparisons for any of the primary outcomes. In exploratory models that examined the impact of COVID-19, significantly improved PTSD symptoms were present at 3 months pre-COVID-19 relative to post-COVID-19. Intervention patients consistently demonstrated higher satisfaction with emotional aspects of healthcare (F(5,1652)=2.87, p=0.01).

Conclusions

The intervention demonstrated no significant improvements in primary outcomes in the intent-to-treat sample. The peer integrated collaborative care intervention contributed to higher patient satisfaction with the emotional aspects of healthcare.

Level of evidence

Level II, randomized clinical trial.

Trial registration number

NCT03569878.

Firearm injury survivors report extreme high risk for poor physical and mental health outcomes early after hospital discharge necessitating multidisciplinary care

Background

Up to 20-40% of survivors of any traumatic injury develop post-traumatic stress disorder (PTSD) or depression after injury. Firearm injury survivors may be at even higher risk for adverse outcomes. We aimed to characterize PTSD and depression risk, pain symptoms, and ongoing functional limitations in firearm injury survivors early after hospital discharge.

Methods

Firearm injury survivors seen in the Trauma Quality of Life (TQOL) outpatient follow-up clinic 1-2 weeks after discharge were invited to participate in a survey assessing both mental and physical health outcomes. The survey included the Brief Pain Inventory (BPI), the Injured Trauma Survivor Screen (ITSS), the Beck Depression Inventory (BDI), the PTSD Checklist for DSM-5 (PCL-5), and the 12-item Short Form Survey Physical Health component (SF-12).

Results

306 patients were seen in the TQOL Clinic, and 175 responded to the survey. The mean age was 32 years (SD=12), 81% were male, and 79% were black. On the ITSS, 69% and 48% of patients screened risk positive for PTSD and depression, respectively. Patients reported mild depression symptoms with an average BDI score of 14.3 (SD=11.8) and elevated PTSD symptoms with an average PCL-5 score of 43.8 (SD=12.8). Patients with severe BPI scores were more likely to screen positive for depression and PTSD. Respondents scored >2 SD below the US national average on the SF-12 for physical quality of life (M=28.7). 12% of patients were at risk across all four domains of pain, PTSD, depression, and physical function.

Conclusion

Early after discharge, over two-thirds of firearm injury survivors were at risk for the development of PTSD, nearly half were at risk of depression, and physical function was significantly decreased. Trauma centers need to prioritize early, outpatient multidisciplinary care to treat and prevent the development of poor chronic physical and mental health for firearm injury survivors.

Level of evidence

III.

Development and validation of early prediction models for new-onset functional impairment of patients with trauma at hospital discharge

BACKGROUND

Early identification of individuals at risk of functional impairment after trauma is crucial for the timely clinical decision-making and intervention to improve reintegration into the society. This study aimed to develop and validate models for predicting new-onset functional impairment after trauma using predictors that are routinely collected within 2 days of hospital admission.

METHODS

In this multicenter retrospective cohort study of acute care hospitals in Japan, we identified adult patients with trauma with independence in carrying out activities of daily living before hospitalization, treated in the intensive or high-dependency care unit, and survived for at least 2 days between April 2008 and September 2023. The primary outcome was functional impairment defined as Barthel Index ≤60 at hospital discharge. In the internal validation data set (between April 2008 and August 2022), using the routinely collected 129 candidate predictors within 2 days of admission, we trained and tuned the four conventional and machine learning models with repeated random subsampling cross-validation. We measured the performance of these models in the temporal validation data set (between September 2022 and September 2023). We also computed the importance of each predictor variable in our model.

RESULTS

We identified 8,529 eligible patients. Functional impairment at discharge was observed in 41% of the patients (n = 3,506/8,529). In the temporal validation data set, all four models showed moderate discrimination ability, with areas under the curve above 0.79, and extreme gradient boosting showing the best performance (0.83). In the variable importance analyses, age was the most important predictor, followed by consciousness, severity score, cervical spinal cord injury, mild dementia, and serum albumin level at admission.

CONCLUSION

We successfully developed early prediction models for patients with trauma with new-onset functional impairment at discharge that achieved high predictive performance using routinely collected data within 2 days of hospital admission.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Reducing barriers through education: A scoping review calling for structured disability curricula in surgical training programs

BACKGROUND

Patients with disabilities face widespread barriers to accessing surgical care given inaccessible health systems, resulting in poor clinical outcomes and perpetuation of health inequities. One barrier is the lack of education, and therefore awareness, among trainees/providers, of the need for reasonable accommodations for surgical patients with disabilities.

METHODS

We conducted a scoping review of the literature on the current state of disabilities curricula in medical education and graduate residency curriculum.

RESULTS

While the literature does demonstrate a causal link between reasonable accommodation training and positive patient-provider relationships and improved clinical outcomes, in practice, disability-focused curricula are rare and often limited in time and to awareness-based didactic courses in medical education and surgical training.

CONCLUSIONS

The absence of structured curricula to educate on anti-ableism and care for patients with disabilities promotes a system of structural "ableism." Expanding disability curricula for medical students and trainees may be an opportunity to intervene and promote better surgical care for all patients.

Predictors of healthy days at home: Benchmarking long-term outcomes in geriatric trauma

BACKGROUND

Quality benchmarking has recently evolved from a historical focus on short-term morbidity and mortality as the key metrics to assessing long-term outcomes. Long-term quality metrics have been shown to provide a more complete assessment of geriatric trauma care. Among these metrics, patients' average number of healthy days at home (HDAH) proports to be a useful administrative claims-based marker of patient functional status. Our goal was to determine the predictors of HDAH among injured older adults.

METHODS

Medicare inpatient claims (2014-2015) were used to identify all geriatric trauma patients. Patients' number of HDAH was measured from the date of discharge and calculated as the total sum of patients' time during that period less any time spent in the hospital or emergency department, step-down/rehabilitation/nursing care, home health, or after death within a 365-period after index admission. Controlling for demographic, injury severity, and hospital-level characteristics, multivariable regression analyses were performed to identify the factors associated with increased HDAH.

RESULTS

We included 772,109 geriatric trauma patients. The mean age was 82.15 years (SD, 8.49 years), 68.3% were female, and 91.6% were White. The median HDAH was 351 days (interquartile range, 351-355 days). After adjusted analysis, age, Black race, Charlson Comorbidity Index (CCI), and care at a level 3/nontrauma center were associated with fewer HDAH within 365 days after discharge.

CONCLUSION

This study suggests that higher level trauma centers provide more HDAH after index admission for injured older adults. Future studies should focus on correlating HDAH with more granular but less readily accessible quality of life metrics.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; III.

A scoping review of hospital-based geriatric-centered interventions on trauma surgery services

BACKGROUND

Millions of older adults (≥65) present to emergency departments for injury annually. As the population increases, so will the number of older adults admitted for trauma. Although treatment guidelines for older adults who sustain trauma exist, the evidence for quality improvement is limited. The purpose of this scoping review was to identify hospital-based geriatric-centered interventions that improve care for older adults admitted to trauma services.

METHODS

We searched MEDLINE, EMBASE, and CINAHL to identify studies related to geriatric-centered interventions on trauma surgery services (1993-2023). Five reviewers screened studies for full-text review based on these inclusion criteria: (1) older injured adults and/or their caregivers; (2) hospital-based clinical interventions directed to geriatric trauma patients (e.g., frailty assessments, geriatric co-management, triage criteria); and (3) measuring outcomes associated with geriatric trauma. We used the Donabedian quality improvement framework to categorize interventions as structures or processes.

RESULTS

Of 2243 abstracts, 66 studies met the criteria for full-text review, and 47 were included in the analysis. Most (64%) were single-site retrospective cohort studies at Level 1 trauma centers. The most frequent interventions (not mutually exclusive) included geriatric-centered teams (26%), geriatric consultation (23%), interdisciplinary rounds (17%), and medication review (11%). The most frequently measured clinical outcomes were length of stay (47%), discharge location (26%), and in-hospital mortality (21%). Two studies (4%) measured outcomes beyond 3 months. Patient-reported outcomes were rarely included (4%), and caregiver-specific outcomes were not measured.

CONCLUSIONS

This scoping review demonstrates the variability in the types of geriatric-centered interventions on trauma surgery services and their associated outcome measures. Furthermore, this review highlights evidence gaps in existing long-term, post-discharge outcomes and patient-/caregiver-reported outcomes. Given the increasing demand for high-quality geriatric trauma care, our findings emphasize the need for evidence-based national standards for geriatric trauma care and targeted study of outcomes germane to older adults and their caregivers.

Firearm Injury, It's Not Just Physical: The Adverse Impact on Patient-Reported Socioeconomic, Mental Health, and Quality-of-Life Outcomes

Background: The burden of firearm injury (FI) extends beyond hospitalization; however, literature focuses mostly on short-term physical outcomes. This study aimed to assess changes in patient-reported outcomes following firearm-related trauma. We hypothesized long-term patient-reported socioeconomic, mental health, and quality-of-life (QoL) outcomes are worse post-FI compared to pre-FI.Methods: This was a retrospective study where a phone survey was conducted with FI survivors admitted between January 2017 and August 2022 at a level 1 trauma center. Survey questions assessed demographics, socioeconomics, and mental and physical health pre-FI vs ≥ 6 months post-FI; the McNemar test was used for comparisons. The PROMIS-29 + 2v2.1 NIH validated instrument was used to assess long-term QoL. Standardized NIH PROMIS T-scores were calculated using the HealthMeasures Scoring Service.Results: Of 204 eligible FI survivors, 71 were successfully contacted and 38 surveyed. Respondents were male (86.8%), Black (76%), and aged 18-29 (55.3%), and 68.4% had high school level education. Post-FI, patients were more likely to be unemployed (55.2% vs 13.2%, P < .001) and report increased mental health needs (84.2% vs 21%, P < .001) compared to pre-FI. Most (73.7%) also reported lasting physical disability. Similarly, the PROMIS instrument demonstrated largely worse health-related QoL scores post-FI, particularly high anxiety/fear (T-score 60.2, SE 3.1, CI 54.6-66.3, Table 2), pain resulting in life interference (T-score 60.0, SE 2.3, CI 55.7-63.9), and worse physical function (T-score 42.5, SE 3.0, CI 38.2-46.9).Conclusions: Firearm injury survivors had more unemployment and worse mental health post-FI compared to pre-FI. Firearm injury survivors also reported significantly worse health-related QoL metrics including pain, anxiety, and physical function 6 months following their trauma. These long-term patient-reported outcomes are a framework to build future outpatient resources.Level of Evidence: IV.

Health service use in major trauma survivors: A population-based cohort study from Ontario, Canada

BACKGROUND

Little is known about how major trauma survivors access health services in the years following their injury. Our study sought to characterize patterns of health services use in trauma survivors following discharge from a provincial trauma center and to identify sociodemographic factors associated with service utilization.

METHODS

We conducted a population-based retrospective case-control study using linked administrative data on trauma survivors' population-based controls between April 1, 2011, and March 31, 2021. For each major trauma survivor, we matched four cases based on age and sex. The primary outcome was the composite rate (sum) of health service use episodes including outpatient visits to family physicians and specialists, emergency department visits, and acute care hospital admissions during the 5-year period following discharge from the trauma center. We used multivariate regression to compute rate ratios comparing the rates of health service use in trauma survivors versus controls and to assess for associations between sociodemographic variables and health services use.

RESULTS

The study cohort consisted of a total of 273,406 individuals: 55,060 trauma survivors and 218,346 controls. Trauma survivors were predominately males (71%) with a median age of 46 years (interquartile range, 26-65 years). Health service use in trauma survivors peaked within a year of hospital discharge but remained increased throughout the follow-up period. Trauma survivorship was associated with a 56% increase in overall health services use (adjusted rate ratio, 1.56; 95% confidence interval, 1.55-1.57), including an 88% increase in hospital admissions (adjusted rate ratio, 1.88; 95% confidence interval, 1.85-1.92). Male sex and rural residence were associated with a reduced overall use of health services but greater use of emergency department services.

CONCLUSION

Major trauma survivors have long-term health services needs that persist for years after discharge from the trauma center. Future research should focus on the understanding why trauma survivors have prolonged health services requirements and ensure that care needs are aligned with service delivery.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Understanding and Assisting the Recovery of Non-English-Speaking Trauma Survivors: Assessment of the NESTS Pathway

BACKGROUND

Spanish-speaking trauma and burn patients have unique needs in their postdischarge care navigation. The confluence of limited English proficiency, injury recovery, mental health, socioeconomic disadvantages, and acute stressors after hospital admission converge to enhance patients' vulnerability, but their specific needs and means of meeting these needs have not been well described.

STUDY DESIGN

This prospective, cross-sectional survey study describes the results of a multi-institutional initiative devised to help Spanish-speaking trauma and burn patients in their care navigation after hospitalization. The pathway consisted of informational resources, intake and follow-up surveys, and multiple points of contact with a community health worker who aids in accessing community resources and navigating the healthcare system.

RESULTS

From January 2022 to November 2023, there were 114 patients identified as eligible for the Non-English-Speaking Trauma Survivors pathway. Of these, 80 (70.2%) were reachable and consented to participate, and 68 were approached in person during their initial hospitalization. After initial screening, 60 (75.0%) eligible patients had a mental health, social services, or other need identified via our survey instrument. During the initial consultation with the community health worker, 48 of 60 patients with any identified need were connected to a resource (80%). Food support was the most prevalent need (46, 57.5%). More patients were connected to mental health resources (16) than reported need in this domain (7).

CONCLUSIONS

The Non-English-Speaking Trauma Survivors pathway identified the specific needs of Spanish-speaking trauma and burn patients in their recovery, notably food, transportation, and utilities. The pathway also addressed disparities in postdischarge care by connecting patients with community resources, with particular improvement in access to mental healthcare.

Taking action to achieve health equity and eliminate healthcare disparities within acute care surgery

Addressing disparities is crucial for enhancing population health, ensuring health security, and fostering resilient health systems. Disparities in acute care surgery (trauma, emergency general surgery, and surgical critical care) have been well documented and the magnitude of inequities demand an intentional, organized, and effective response. As part of its commitment to achieve high-quality, equitable care in all aspects of acute care surgery, the American Association for the Surgery of Trauma convened an expert panel at its eigty-second annual meeting in September 2023 to discuss how to take action to work towards health equity in acute care surgery practice. The panel discussion framed contemporary disparities in the context of historic and political injustices, then identified targets for interventions and potential action items in health system structure, health policy, the surgical workforce, institutional operations and quality efforts. We offer a four-pronged approach to address health inequities: identify, reduce, eliminate, and heal disparities, with the goal of building a healthcare system that achieves equity and justice for all.

The impact of frailty on long-term functional outcomes in severely injured geriatric patients

BACKGROUND

The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients.

METHODS

We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site.

RESULTS

We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations.

CONCLUSION

Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services.

Beyond surviving: A scoping review of collaborative care models to inform the future of postdischarge trauma care

ABSTRACT

Trauma centers demonstrate an impressive ability to save lives, as reflected by inpatient survival rates of more than 95% in the United States. Nevertheless, we fail to allocate sufficient effort and resources to ensure that survivors and their families receive the necessary care and support after leaving the trauma center. The objective of this scoping review is to systematically map the research on collaborative care models that have been put forward to improve trauma survivorship. Of 833 articles screened, we included 16 studies evaluating eight collaborative care programs, predominantly in the United States. The majority of the programs offered care coordination and averaged 9 months in duration. Three fourths of the programs incorporated a mental health provider within their primary team. Observed outcomes were diverse: some models showed increased engagement (e.g., Center for Trauma Survivorship, trauma quality-of-life follow-up clinic), while others presented mixed mental health outcomes and varied results on pain and health care utilization. The findings of this study indicate that collaborative interventions may be effective in mental health screening, posttraumatic stress disorder and depression management, effective referrals, and improving patient satisfaction with care. A consensus on core elements and cost-effectiveness of collaborative care models is necessary to set the standard for comprehensive care in posttrauma recovery.

Return to Work One Year after Moderate to Severe Traumatic Injury in a Working Age Population

Background/Objectives: Physical trauma may cause long-term disabilities. The importance of place of residence in the return to work after injuries is little researched. The primary aims of this study were to describe return to work or school (RTW) at 6 and 12 months after moderate to severe traumatic injury and to investigate demographic and injury-related predictors for RTW with an initial focus on geographic centrality of residency. The secondary aim was to investigate the association between RTW and functioning. Methods: A prospective cohort study conducted at two Norwegian trauma centres. Inclusion criteria: age 18 to 70 years, at least a two-day hospital stay and a New Injury Severity Score > 9. Information about centrality, demographics, injuries, and return to work were collected. Associations between possible predictors and RTW were assessed using binary logistic regression. Results: Of the 223 participants, 68% had returned to work after 6 months and 77% after 12 months. Twelve-month RTW was 89% after thorax/abdomen injuries, 78% after extremity/spine injuries and 73% after head injuries. More central residency was a significant predictor for RTW in univariable but only within the extremity/spine injury subgroup in multivariable analysis. Negative factors were age, having a blue-collar job, number of injuries and rehabilitation complexity. Function 12 months post-injury was associated with RTW in the multivariable model. Conclusions: RTW after one year was high in all major trauma groups. Demographic and injury-related factors were more important predictors of RTW than centrality of residency. Blue-collar workers and patients with multiple injuries and high rehabilitation complexity should be given special attention to support RTW.

The cross-sectional and longitudinal interconnectedness of physical, psychological and role functioning following physical trauma: A network analysis

OBJECTIVE

Surviving physical trauma can have a large impact on one's daily life. Patients are at increased risk for poor physical health, psychological complaints, and problems in role functioning - which is often experienced simultaneously. The present study explores the interconnectedness of physical, psychological, and role functioning during the first two years post-injury, both cross-sectionally and longitudinally from a network perspective.

METHODS

3785 trauma patients (Mage = 64.2 years, SDage = 18.9 years, 50.5% female) completed questionnaires on physical, psychological, and role functioning across six measurement occasions during the first two years post-injury. The Injury Severity Score (ISS) was retrieved from the local trauma registry. Mixed graphical network models and cross-lagged network models were estimated to examine which items of recovery played a central role and were mostly related to other items in cross-sectional and longitudinal networks respectively.

RESULTS

The cross-sectional networks showed especially strong interconnections between impairments of physical and role functioning and also within post-traumatic stress symptoms. The longitudinal networks extended these results by showing that pain, impaired mobility, limitations in self-care, anxiety/depressive symptoms, and several post-traumatic stress symptoms were strong predictors for impairments in functioning at later stages of recovery.

CONCLUSION

Our findings showed that impairments in physical, psychological, and role functioning experienced by trauma patients are largely intertwined across the two years following injury. Monitoring physical impairments and psychological complaints early in recovery might help to more promptly provide the best fitting aftercare for trauma patients, which can improve recovery on the long-term.

International variation in injury burden and comparative outcomes: How injury looks like in different parts of the world

Injury is reported as one of the leading causes of morbidity and mortality globally. However, its burden stays under-reported in low- and middle-income countries, which prevents understanding of the true distribution and impact of injury worldwide. This dearth of data not only includes the burden of trauma-associated mortality but also involves the identification of long-term patient-reported outcomes after injury. High-income countries have shown that the development of trauma registries can achieve proper data collection, the findings from which can ultimately decrease trauma-associated morbidity and mortality. Expanding such an initiative to low-resource settings with high injury proportions can aid in understanding the long-term outcomes of post-trauma patients, identifying the factors that continue to contribute to its injury burden, and developing strategies catered to reducing it. Here, we discuss the variation in the global injury burden and go a step beyond mortality to highlight the importance of capturing long-term patient-reported outcomes post-trauma. We describe the process of developing trauma registries in high-income countries and extrapolate the findings from this experience to set up similar registries in resource-limited settings. Lastly, we demonstrate the feasibility and initial impact of using its data on identifying predictors of in-hospital mortality and determining long-term patient-reported outcomes in the context of low-resource settings. Through these findings, we share the outlook of an evolved trauma care system in both high- and low-income regions with reduced morbidity and mortality globally.

The Relationship Between Body Mass Index and Long-Term Outcomes Following Traumatic Injury

INTRODUCTION

Little is known about the relationship between body mass index (BMI), a function of mass and height (masskg/height2m) and long-term outcomes among traumatic injury survivors. In this prospective cohort study, we investigate the relationship between BMI and long-term health outcomes in the trauma population.

METHODS

Adult trauma survivors with an injury severity score ≥9 admitted to one of three level 1 trauma centers, from January 1, 2015 to December 31, 2022, were surveyed via telephone between 6 and 12 mo postinjury. Participants were stratified into one of five groups by BMI at the time of trauma: L-BMI (BMI <18.5), N-BMI (BMI 18.5-24.9), H1-BMI (BMI 25-29.9), H2-BMI (BMI 30-34.9), and H3-BMI (BMI ≥35); N-BMI was used as the referent. Mental and physical health-related quality of life scores, pain, new functional limitations, and hospital readmissions were evaluated. Univariate and multivariate analyses were used to compare outcomes between study groups.

RESULTS

3830 patients were included. Of those, 124 were L-BMI (3.2%), 1495 N-BMI (39%), 1318 H1-BMI (34.4%), 541 H2-BMI (14.1%), and 352 H3-BMI (9.2%). L-BMI was associated with adverse physical (b = -3.13, CI = -5.71 to -0.55, P = 0.017) and mental health (b = -3.17, CI = -5.87 to -0.46, P = 0.022) outcomes 6-12 mo postinjury compared to the referent. H1-BMI and H2-BMI had higher odds of wo`rse physical outcomes (b = -1.47, CI = -2.42 to -0.52, P = 0.002; b = -3.11, CI = - 4.33 to -1.88, P ≤ 0.001, respectively) and chronic pain (adjusted odds ratio (aOR) = 1.24, CI = 1.04-1.47, P = 0.016; aOR = 1.52, CI = 1.21-1.90, P ≤ 0.001, respectively). Patients with H3-BMI had higher odds of worse physical outcomes compared to N-BMI (b = -4.82, CI = -6.28 to -3.37, P ≤ 0.001), chronic pain (aOR = 2.11, CI = 1.61-2.78, P ≤ 0.001), all-cause hospital readmissions (aOR = 1.62, CI = 1.10-2.34, P = 0.013), and new functional limitations (aOR = 1.39, CI = 1.08-1.79, P = 0.01).

CONCLUSIONS

BMI variance above or below N-BMI is associated with worse long-term outcomes following traumatic injury.

Implementation of a perioperative registry in Ethiopia to enhance surgical quality improvement

BACKGROUND

Despite a glaring need and proven efficacy, prospective surgical registries are lacking in low- and middle-income countries. The objective of this study was to design and implement a comprehensive prospective perioperative registry in a low-income country.

METHODS

This study was conducted at Hawassa University Comprehensive Specialized Hospital in Hawassa, Ethiopia. Design of the registry occurred from June 2021 to May 2022 and pilot implementation from May 2022 to May 2023. All patients undergoing elective or emergent general surgery were included. Following one year, operability and fidelity of the registry were analyzed by assessing capture rate, incidence of missing data, and accuracy.

RESULTS

A total of 67 variables were included in the registry including demographics, preoperative, operative, post-operative, and 30-day data. Of 440 eligible patients, 226 (51.4%) were successfully captured. Overall incidence of missing data and accuracy was 5.4% and 90.2% respectively. Post pilot modifications enhanced capture rate to 70.5% and further optimized data collection processes.

CONCLUSION

The establishment of a low-cost electronic prospective perioperative registry in a low-income country represents a significant step forward in enhancing surgical care in under-resourced settings. The initial success of this registry highlights the feasibility of such endeavors when strong partnerships and local context are at the center of implementation. Continuous efforts to refine this registry are ongoing, which will ultimately lead to enhanced surgical quality, research output, and expansion to other sites.

Long-term functional outcomes in polytrauma: a fundamentally new approach is needed in prediction

PURPOSE

Modern trauma care has reduced mortality but poor long-term outcomes with low follow-up rates are common with limited recommendations for improvements. The aim of this study was to describe the impact of severe injury on the health-related quality of life, specifically characterise the non-responder population and to identify modifiable predictors of poorer outcomes.

METHODS

Five-year (2012-2016) prospective cohort study was performed at a level 1 trauma centre. Baseline Short-Form Health Survey (SF36) was collected at admission, and at 6 and 12 months postinjury together with demographics, injury mechanism and severity, psychosocial wellbeing, and return to work capacity.

RESULTS

Of the 306 consecutive patients [age 52 ± 17 years, male 72%, ISS 21 (17, 29), mortality 5%], 195 (64%) completed questionnaires at baseline, and at 12 months. Preinjury physical health scores were above the general population (53.1 vs. 50.3, p < 0.001) and mental health component was consistent with the population norms (51.7 vs. 52.9, p = 0.065). One year following injury, both physical health (13.2, 95% CI 14.8, 11.6) and mental health scores (6.0, 95% CI 8.1, 3.8) were significantly below age- and sex-adjusted preinjury baselines. Non-responders had similar ISS but with a lower admission GCS, and were more likely to be younger, and without comorbidities, employment, or university education.

CONCLUSION

Contrary to their better than population norm preinjury health status, polytrauma patients remain functionally impaired at least 1 year after injury. The identified high risk for non-responding group needs more focused efforts for follow-up. A fundamentally different approach is required in polytrauma research which identify modifiable predictors of poor long-term outcomes.

Recovering from physical trauma in late life, a struggle to recapture autonomy: A grounded theory study

AIM

The study aimed to explore the experiences of care and recovery among older patients treated for physical trauma.

DESIGN

A qualitative study with a constructivist grounded theory design.

METHODS

Fifteen in-depth interviews with older adults recovering from physical trauma were conducted and analysed between 2019 and 2023, in accordance with grounded theory methodology.

RESULTS

The findings show that for older patients who suffered physical trauma, the core category was the strive to recapture autonomy. This was achieved by means of Adaptation, Reflection and Interactions, which constitute the three main categories. Recovery involves facing and navigating various new life challenges, such as increased dependency on others, managing difficult symptoms and adapting in various ways to everyday life. The recovery process was influenced by fear, hope and the attitude towards new challenges.

CONCLUSION

Older adults being cared for after a traumatic event have a difficult path to recovery ahead of them. Dealing with increased unwanted dependency on others was a main concern for the participants. Undertreated symptoms can lead to undesired isolation, delayed recovery and further increase unwanted dependency. On the other hand, hope, which was defined as having a positive approach to life and longing for the future, was a strong accelerating factor in the recovery process.

IMPACT

As a result of this study, we have established that older patients experience the initial period after trauma as difficult and that support in the initial phase can be helpful when returning home. As healthcare services are under increasing pressure because of an ageing population, this study contributes by addressing an understudied population and clarifying their concerns.

REPORTING METHOD

Reporting adheres to the COREQ (COnsolidated criteria for REporting Qualitative research) Checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors

INTRODUCTION

Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury.

METHODS

Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission ​≥ ​3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors.

RESULTS

2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR ​= ​1.57; 95% CI ​= ​1.21, 2.03), and worse SF-12 mental (mean Δ ​= ​-1.43; 95% CI ​= ​-2.79, -0.09) and physical scores (mean Δ ​= ​-2.61; 95% CI ​= ​-3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group.

CONCLUSIONS

Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.

Financial toxicity part II: A practical guide to measuring and tracking long-term financial outcomes among acute care surgery patients

ABSTRACT

Acute care surgery (ACS) patients are frequently faced with significant long-term recovery and financial implications that extend far beyond their hospitalization. While major injury and emergency general surgery (EGS) emergencies are often viewed solely as acute moments of crisis, the impact on patients can be lifelong. Financial outcomes after major injury or emergency surgery have only begun to be understood. The Healthcare Economics Committee from the American Association for the Surgery of Trauma previously published a conceptual overview of financial toxicity in ACS, highlighting the association between financial outcomes and long-term physical recovery. The aims of second-phase financial toxicity review by the Healthcare Economics Committee of the American Association for the Surgery of Trauma are to (1) understand the unique impact of financial toxicity on ACS patients; (2) delineate the current limitations surrounding measurement domains of financial toxicity in ACS; (3) explore the "when, what and how" of optimally capturing financial outcomes in ACS; and (4) delineate next steps for integration of these financial metrics in our long-term patient outcomes. As acute care surgeons, our patients' recovery is often contingent on equal parts physical, emotional, and financial recovery. The ACS community has an opportunity to impact long-term patient outcomes and well-being far beyond clinical recovery.

The invisible scars: Unseen financial complications worsen every aspect of long-term health in trauma survivors

BACKGROUND

Trauma survivors are susceptible to experiencing financial toxicity (FT). Studies have shown the negative impact of FT on chronic illness outcomes. However, there is a notable lack of data on FT in the context of trauma. We aimed to better understand prevalence, risk factors, and impact of FT on trauma long-term outcomes.

METHODS

Adult trauma patients with an Injury Severity Score (ISS) ≥9 treated at Level I trauma centers were interviewed 6 months to 14 months after discharge. Financial toxicity was considered positive if patients reported any of the following due to the injury: income loss, lack of care, newly applied/qualified for governmental assistance, new financial problems, or work loss. The Impact of FT on Patient Reported Outcome Measure Index System (PROMIS) health domains was investigated.

RESULTS

Of 577 total patients, 44% (254/567) suffered some form of FT. In the adjusted model, older age (odds ratio [OR], 0.4; 95% confidence interval [95% CI], 0.2-0.81) and stronger social support networks (OR, 0.44; 95% CI, 0.26-0.74) were protective against FT. In contrast, having two or more comorbidities (OR, 1.81; 95% CI, 1.01-3.28), lower education levels (OR, 1.95; 95% CI, 95%, 1.26-3.03), and injury mechanisms, including road accidents (OR, 2.69; 95% CI, 1.51-4.77) and intentional injuries (OR, 4.31; 95% CI, 1.44-12.86) were associated with higher toxicity. No significant relationship was found with ISS, sex, or single-family household. Patients with FT had worse outcomes across all domains of health. There was a negative linear relationship between the severity of FT and worse mental and physical health scores.

CONCLUSION

Financial toxicity is associated with long-term outcomes. Incorporating FT risk assessment into recovery care planning may help to identify patients most in need of mitigative interventions across the trauma care continuum to improve trauma recovery. Further investigations to better understand, define, and address FT in trauma care are warranted.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Health-Related Quality of Life in severely injured patients in Finland: an observational cohort study of 325 patients with 1-year follow-up

BACKGROUND

Major trauma has a significant effect on Health-Related Quality of Life (HR-QoL). It is unclear, however, which factors most affect HR-QoL. This study aims to evaluate HR-QoL after severe injury in Finland and determine how different injury patterns and patient-related factors, such as level of education and socioeconomic group, are associated with HR-QoL. We also assess how well different injury scoring systems associate with HR-QoL.

METHODS

We retrospectively analyzed 325 severely injured trauma patients (aged ≥ 18 years, New Injury Severity Score, (NISS) ≥ 16, and alive at 1 year after injury) treated in the Intensive Care Unit (ICU) or High Dependence Unit (HDU) of Tampere University Hospital (TAUH) from 2013 through 2016. HR-QoL was assessed with the EQ-5D-3L questionnaire completed during ICU stay and 1 year after injury. HR-QOL index values and reported problems were further compared with Finnish population norms.

RESULTS

The severity of the injury (measured by ISS and NISS) had no significant association with the decrease in HR-QoL. Length of ICU stay had a weak negative correlation with post-injury HR-QoL and a weak positive correlation with the change in HR-QoL. The largest mean decrease in HR-QoL occurred in patients with spinal cord injury (Spine AIS ≥ 4) (-0.338 (SD 0.136)), spine injury in general (Spine AIS ≥ 2 (-0.201 (SD 0.279)), and a lower level of education (-0.157 (SD 0.231)). Patient's age, sex, or socioeconomic status did not seem to associate with smaller or greater changes in HR-QoL.

CONCLUSIONS

After serious injury, many patients have permanent disabilities which reduce HR-QoL. Injury scoring systems intended for assessing the risk for death did not seem to associate with HR-QoL and are not, therefore, a meaningful way to predict the future HR-QoL of a severely injured patient. Recovery from the injury seems to be weaker in poorer educated patients and patients with spinal cord injury, and these patients may benefit from targeted additional measures. Although there were significant differences in baseline HR-QoL levels between different socioeconomic groups, recovery from injury appears to be similar, which is likely due to equal access to high-quality trauma care.

Exploring the Long-Term Disability Outcomes in Trauma Patients: Study Protocol

Objectives

Post-discharge patient-reported outcomes from trauma registries can be used to measure trauma care quality. However, studies reflecting the Asian experience are limited. Therefore, we aim to develop a digital trauma registry to prospectively capture patient-reported outcomes (PROs) at one-, three-, six-, and twelve-months post-injury in Pakistan.

Methods

We will use a cohort study design to develop a digital trauma registry at two tertiary care facilities (Aga Khan University Hospital & Jinnah Postgraduate Medical Center) in Karachi, Pakistan. The registry will include all admitted adult trauma patients (≥18 years). Data collection will be digital using tablets, with mortality, level of disability, and functional status, quality of life being the outcomes. Telephonic interviews will be conducted with the patients and caregivers for follow-up data collection.

Discussion

The high disability burden following accidental trauma imposes a significant burden and cost on individuals and society. Therefore, the trauma registry would fill this gap by capturing post-discharge long-term PROs. It will provide the injured patient's post-discharge situation, challenges, and future directions for incorporating long-term PROs in low-resource settings. Including long-term measures in routine follow-ups will provide insights into physical, social, and policy barriers and help advance injury care research.

Feasibility of using an automated call service to collect quality of life and functional outcome data in trauma patients

Objectives

Following up trauma patients after discharge, to evaluate their subsequent quality of life and functional outcomes, is notoriously difficult, time consuming, and expensive. Automated systems are a conceptually attractive solution. We prospectively assessed the feasibility of using a series of automated phone calls administered by Emmi Patient Engagement to survey trauma patients after discharge.

Methods

Recruitment into the study was incorporated into the patient discharge process by nursing staff. For this pilot, we included trauma patients discharging home and who were able to answer phone calls. A script was created to evaluate the Extended Glasgow Outcome Scale and the EuroQol EQ-5D to assess functional status and quality of life, respectively. Call attempts were made at 6 weeks, 3 months, 6 months, and 1 year after discharge.

Results

A total of 110 patients initially agreed to participate. 368 attempted patient encounters (calls or attempted calls) took place, with 104 (28.3%) patients answering a least one question in the study. 21 unique patients (19.1% of those enrolled) completed 27 surveys.

Conclusions

Automated, scripted phone calls to survey patients after discharge are not a feasible way of collecting functional and quality of life data.

Level of evidence

Level II/prospective.

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION

Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population.

METHODS

Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes.

RESULTS

Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012).

CONCLUSIONS

Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Can Baseline Patient Clinical and Demographic Characteristics Predict Response to Early Posttraumatic Stress Disorder Interventions After Physical Injury?

OBJECTIVE

A growing evidence base supports stepped care interventions for the early treatment of posttraumatic stress disorder (PTSD) after physical injury. Few investigations have examined the characteristics of patients who do and do not respond to these interventions.

METHOD

This investigation was a secondary analysis that used previously collected data from three randomized clinical trials of stepped care interventions (patient N = 498). The study hypothesized that a subgroup of patients would manifest persistent PTSD symptoms regardless of randomization to intervention or control conditions, and that characteristics present at the time of baseline injury hospitalization could distinguish patients who would develop persistent symptoms from potential treatment responders. Regression analyses identified baseline patient clinical and demographic characteristics that were associated with persistent PTSD symptoms over the 6-months post-injury. Additional analyses identified treatment attributes of intervention patients who were and were not likely to demonstrate persistent symptoms.

RESULTS

A substantial subgroup of patients (n = 222, 44.6%) demonstrated persistent PTSD symptoms over time. Greater numbers of pre-injury trauma, pre-injury PTSD symptoms, elevated early post-injury PTSD symptoms, unemployment, and non-White race identified patients with persistent symptoms. Patients with ≥3 of these baseline risk characteristics demonstrated diminished treatment responses when compared to patients with <3 characteristics. Intervention patients with ≥3 risk characteristics were less likely to engage in treatment and required greater amounts of interventionist time.

CONCLUSIONS

Injured trauma survivors have readily identifiable characteristics at the time of hospitalization that can distinguish responders to PTSD stepped care interventions versus patients who may be treatment refractory.

Using PROM(I)S to measure health-related quality of life in patients with a bone fracture: An observational cohort study

INTRODUCTION

The incidence of patients with fractures is increasing and so is the impact on health care systems and society. To improve patient care, measurement of disabilities and impaired health experiences after traumatic musculoskeletal injuries are important. Next to objective clinical parameters, PROM(I)S can be used to map health domains important to patients. We aimed to objectify different aspects of (health-related) quality of life in fracture patients, including the ability to participate in social roles and activities using PROMIS among other PROMs.

METHODS

An observational cohort study was performed in which health-related quality of life in fracture patients was measured. Patients aged 18 year and older either treated conservatively or surgically between November 2020 and June 2022 were included. Participants were followed for a maximum of one year and completed the following PROMs: PROMIS-CAT physical function, PROMIS-CAT pain interference, PROMIS-CAT ability to participate in social roles and activities and LEFS or QDASH. We applied a univariate linear mixed model to evaluate significance of improvement.

RESULTS

Seven hundred-forty six patients with a mean age of 54.4 years were included. Mean PROMIS scores were structurally inferior in the lower extremity (LE) fracture group in comparison with the upper extremity (UE) fracture group. For "PROMIS physical function", UE fracture patients performed better and showed physical progression earlier. For "PROMIS pain interference", UE fracture patients experienced fewer limitations, but it took longer to experience improvement in this group. For "PROMIS ability to participate in social roles", significant improvement was only seen in the UE fracture group at one year follow up.

CONCLUSION

Upper -and lower extremity fractures can have a significant impact on physical function and social health. Patients with UE fractures tend to have fewer limitations compared to LE fracture patients. Physical function and pain interference is most impaired shortly after the injury in all fracture patients and show significant changes over time, social health improves less over time. Moment of measurement should be based on type of fracture and can differ between individual patients, but when generic measures and outcomes are desirable, PROMIS questionnaires can potentially be used measurement.

Prevalence and levels of disability post road traffic orthopaedic injuries in Rwanda

Background

Prolonged disability resulting from road traffic injuries (RTIs) contributes significantly to morbidity and disease burden. A good understanding of the prevalence and the level of disability of orthopaedic injuries in developing countries is crucial for improvement; however, such data are currently lacking in Rwanda.

Objectives

To determine the prevalence and levels of disability of 2 years post-road traffic orthopaedic injuries in Rwanda.

Method

A multicentre, cross-sectional study from five Rwandan referral hospitals of 368 adult RTI victims' sustained from accidents in 2019. Between 02 June 2022, and 31 August 2022, two years after the injury, participants completed the World Health Organization Disability Assessment Schedule (WHODAS 2.0) Questionnaire for the degree of impairment and the Upper Extremity Functional Scale and Lower-Extremity Functional Scale forms for limb functional evaluation. Descriptive, inferential statistics Chi-square and multinomial regression models were analysed using R Studio.

Results

The study's mean age of the RTOI victims was 37.5 (±11.26) years, with a sex ratio M: F:3: 1. The prevalence of disability following road traffic orthopedic injury (RTOI) after 2 years was 36.14%, with victims having WHODAS score > 25.0% and 36.31% were still unable to return to their usual activities. Age group, Severe Kampala Trauma Score and lack of rehabilitation contributed to disability. The most affected WHODAS domains were participation in society (33%) and life activities (28%).

Conclusion

The prevalence and levels of disability because of RTOI in Rwanda are high, with mobility and participation in life being more affected than other WHODAS domains. Middle-aged and socio-economically underprivileged persons are the most affected.

Contribution

This study showed that a good rehabilitation approach and economic support for the RTI victims would decrease their disabilities in Rwanda.

A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory

OBJECTIVES

To explore trauma patients' experiences of the long-term recovery pathway during 18 months following hospital discharge.

DESIGN

Longitudinal qualitative study.

SETTING AND PARTICIPANTS

Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge.

METHOD

The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically.

RESULTS

Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress.

CONCLUSIONS AND IMPLICATIONS

The patients' experiences from this study establish knowledge of several challenges in the trauma population's recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients' health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.

Insurance Not Socioeconomic Status is Associated With Access to Postacute Care After Injury: A Multicenter Cohort Study

INTRODUCTION

Access to postacute care services in rehabilitation or skilled nursing facilities is essential to return trauma patients to their preinjury functional level but is often hindered by systemic barriers. We sought to study the association between the type of insurance, socioeconomic status (SES) measures, and postacute care utilization after injury.

METHODS

Adult trauma patients with an Injury Severity Score (ISS) ≥9 admitted to one of three Level I trauma centers were contacted 6-12 mo after injury to gather long-term functional and patient-centered outcome measures. In addition to SES inquiry specifically focused on education and income levels, patients were asked to subjectively categorize their perceived SES (p-SES) as high, mid-high, mid-low, or low. Insurance and income data were retrieved from trauma registries. Multivariable regression models were built to determine the association between type of insurance, SES, and discharge disposition after adjusting for patient and injury characteristics and hospitalization events.

RESULTS

A total of 1373 patients were included, of which 44% were discharged to postacute care facilities. The median age (IQR) was 65 (46, 76) years, 56% of patients were male, 11% were on Medicaid, 68% had attained education higher than high school, 27% had low income, and 29% reported a low/mid-low p-SES. Medicaid patients were less likely to be discharged to postacute care compared to privately insured (OR [95% CI]: 0.41 [0.29-0.58]) and Medicare patients (OR [95% CI]: 0.29 [0.16-0.50]). The latter relationship was true across p-SES categories. P-SES, income and educational level were not associated with discharge destination.

CONCLUSIONS

Insurance status, specifically having Medicaid, can pose a barrier to access to postacute care services in the trauma patient population across patients of all SES. Initiatives and policies that aim at reducing these access disparities are warranted.

Emergency Department and Inpatient Utilization Reductions and Cost Savings Associated With Trauma Center Mental Health Intervention: Results From a 5-year Longitudinal Randomized Clinical Trial Analysis

OBJECTIVE

To identify and refer patients at high risk for the psychological sequelae of traumatic injury, the American College of Surgeons Committee on Trauma now requires that trauma centers have in-place protocols. No investigations have documented reductions in utilization and associated potential cost savings associated with trauma center mental health interventions.

BACKGROUND

The investigation was a randomized clinical trial analysis that incorporated novel 5-year emergency department (ED)/inpatient health service utilization follow-up data.

METHODS

Patients were randomized to a mental health intervention, targeting the psychological sequelae of traumatic injury (n = 85) versus enhanced usual care control (n = 86) conditions. The intervention included case management that coordinated trauma center-to-community care linkages, psychotropic medication consultation, and psychotherapy elements. Mixed model regression was used to assess intervention and control group utilization differences over time. An economic analysis was also conducted.

RESULTS

Over the course of the 5-year intervention, patients demonstrated significant reductions in ED/inpatient utilization when compared with control patients [ F (19,3210) = 2.23, P = 0.009]. Intervention utilization reductions were greatest at 3 to 6 months (intervention 15.5% vs control 26.7%, relative risk = 0.58, 95% CI: 0.34, 1.00) and 12 to 15 months (intervention 16.5% vs control 30.6%, relative risk = 0.54, 95% CI: 0.32, 0.91) postinjury time points. The economic analysis suggested potential intervention cost savings.

CONCLUSIONS

Mental health intervention is associated with significant reductions in ED and inpatient utilization, as well as potential cost savings. These findings could be productively integrated into future American College of Surgeons Committee on Trauma policy discussions.

Do hospital-based emergency Medicaid programs benefit trauma centers? A mixed-methods analysis

INTRODUCTION

Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization, which can offset patient costs of care, increase access to postdischarge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement and characterize incentives for HPE participation among hospitals and TCs. We hypothesized that there would be financial, operational, and mission-based incentives.

METHODS

We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semistructured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8).

RESULTS

Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE, 77 (21%) of which are TCs. As of early 2015, 100% of TCs had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II TCs. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue ( b = 6.74, p < 0.001) and decreased uncompensated care costs ( b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included reduction of hospital bad debt, improved patient satisfaction, and community benefit in access to care.

CONCLUSION

Hospital Presumptive Eligibility programs not only are a promising pathway for long-term insurance coverage for trauma patients but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program.

LEVEL OF EVIDENCE

Economic And Value Based Evaluations; Level II.

Stepped collaborative care versus American College of Surgeons Committee on Trauma required screening and referral for posttraumatic stress disorder: Clinical trial protocol

BACKGROUND

Each year in the US, approximately 1.5-2.5 million individuals are so severely injured that they require inpatient hospital admissions. The American College of Surgeons Committee on Trauma (College) now requires that trauma centers have in place protocols to identify and refer hospitalized patients at risk injury psychological sequelae. Literature review revealed no investigations that have identified optimal screening, intervention, and referral procedures in the wake of the College requirement.

METHODS

The single-site pragmatic trial investigation will individually randomize 424 patients (212 intervention and 212 control) to a brief stepped care intervention versus College required mental health screening and referral control conditions. Blinded follow-up interviews at 1-, 3-, 6-, and 12-months post-injury will assess the symptoms of PTSD and related comorbidity for all patients. The emergency department information exchange (EDIE) will be used to capture population-level automated emergency department and inpatient utilization data for the intent-to-treat sample. The investigation aims to test the primary hypotheses that intervention patients will demonstrate significant reductions in PTSD symptoms and emergency department/inpatient utilization when compared to control patients. The study incorporates a Rapid Assessment Procedure-Informed Clinical Ethnography (RAPICE) implementation process assessment.

CONCLUSIONS

The overarching goal of the investigation is to advance the sustainable delivery of high-quality trauma center mental health screening, intervention, and referral procedures for diverse injury survivors. An end-of-study policy summit will harness pragmatic trial data to inform the capacity for US trauma centers to implement high-quality acute care mental health screening, intervention and referral services for diverse injured patient populations.

TRIAL REGISTRATION

Clinicaltrials.govNCT05632770.

Functional and Radiographic Outcomes of Open Proximal Femoral Fractures Caused by Gunshot Wounds in Yemen: A Prospective Cohort Study

Background

Open proximal femoral fractures caused by gunshot wounds are rare but devastating injuries that pose considerable challenges for prognosis and management. The aim of this study was to evaluate the functional and radiographic outcomes of patients with open proximal femoral fractures caused by gunshot wounds treated at 3 Level-I trauma centers in Yemen and to identify the factors that influence them.

Methods

We prospectively enrolled 174 patients with open proximal femoral fractures caused by gunshot wounds. The fractures were classified according to the Gustilo-Anderson and OTA/AO systems. The primary outcome measures were fracture union, infection, and functional outcomes. The secondary outcome measures were the Harris hip score (HHS) and the Short Form-36 (SF-36) health survey score. We performed multivariable logistic regression modeling to identify the predictors of complications and poor functional outcomes.

Results

The overall rate of fracture union was 87%. The complication rates were 18% for infection, 13% for nonunion, 23% for reoperation, 12% for delayed union, 4% for osteonecrosis, 6% for heterotopic ossification, and 2% for amputation. The mean HHS at the final follow-up was 78.4, and the mean SF-36 score was 67.3.

Conclusions

Open proximal femoral fractures caused by gunshot wounds are associated with high rates of complications and poor functional outcomes in Yemen. Early debridement, appropriate fixation, infection control, and adequate soft-tissue coverage are essential for achieving satisfactory results. The type of wound, the type of fracture, and the type of definitive fixation are significant predictors of the outcomes. Future studies should compare different fixation methods and evaluate the long-term outcomes and complications of these injuries.

Level of Evidence

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Patient-Reported Outcomes Following Severe Abdominal Trauma: A Secondary Analysis of the Damage Control Laparotomy Trial

INTRODUCTION

Little is known about patient-reported outcomes (PROs) following abdominal trauma. We hypothesized that patients undergoing definitive laparotomy (DEF) would have better PROs compared to those treated with damage control laparotomy (DCL).

METHODS

The DCL Trial randomized DEF versus DCL in abdominal trauma. PROs were measured using the European Quality of Life-5 Dimensions-5 Levels (EQ-5D) questionnaire at discharge and six months postdischarge (1 = perfect health, 0 = death, and <0 = worse than death) and Posttraumatic Stress Disorder (PTSD) Checklist-Civilian. Unadjusted Bayesian analysis with a neutral prior was used to assess the posterior probability of achieving minimal clinically important difference.

RESULTS

Of 39 randomized patients (21 DEF versus 18 DCL), 8 patients died (7 DEF versus 1 DCL). Of those who survived, 28 completed the EQ-5D at discharge (12 DEF versus 16 DCL) and 25 at 6 mo (12 DEF versus 13 DCL). Most patients were male (79%) with a median age of 30 (interquartile range (IQR) 21-42), suffered blunt injury (56%), and were severely injured (median injury severity score 33, IQR 21 - 42). Median EQ-5D value at discharge was 0.20 (IQR 0.06 - 0.52) DEF versus 0.31 (IQR -0.03 - 0.43) DCL, and at six months 0.51 (IQR 0.30 - 0.74) DEF versus 0.50 (IQR 0.28 - 0.84) DCL. The posterior probability of minimal clinically important difference DEF versus DCL at discharge and six months was 16% and 23%, respectively.

CONCLUSIONS

Functional deficits for trauma patients persist beyond the acute setting regardless of laparotomy status. These deficits warrant longitudinal studies to better inform patients on recovery expectations.

Effects of prior injury on long term patient reported outcomes after trauma

BACKGROUND

Trauma is an episodic, chronic disease with substantial, long-term physical, psychological, emotional, and social impacts. However, the effect of recurrent trauma on these long-term outcomes remains unknown. We hypothesized that trauma patients with a history of prior traumatic injury (PTI) would have poorer outcomes 6 months (6mo) after injury compared with patients without PTI.

METHODS

Adult trauma patients admitted at an urban, academic, Level I trauma center were screened for inclusion (October 2020 to November 2021). Enrolled patients were administered the PROMIS-29 instrument, the primary care post-traumatic stress disorder screen, and standardized questions about prior trauma hospitalization, substance use, employment, and living situation at baseline and 6mo after injury. Assessment data was merged with clinical registry data, and outcomes were compared with respect to PTI.

RESULTS

Of 3,794 eligible patients, 456 completed baseline assessments and 92 completed 6mo surveys. Between those with or without PTI, there were no differences at 6mo after injury in the proportion of patients reporting poor function in social participation, anxiety, depression, fatigue, pain interference, or sleep disturbance. Prior traumatic injury patients reported poor physical function less often than patients without PTI (10 [27.0%] vs. 33 [60.0%], p = 0.002). After controlling for age, gender, race, injury mechanism, and Injury Severity Score, PTI correlated with a fourfold decrease in poor physical function risk (adjusted odds ratio, 0.243; 95% confidence interval, 0.081-0.733; p = 0.012) in the multivariable logistic regression model.

CONCLUSION

Compared with patients suffering their first injury, trauma patients with PTI have better self-reported physical function after a subsequent injury and otherwise equivalent outcomes across a range of HRQoL domains at 6mo. There remains substantial room for improvement to mitigate the long-term challenges faced by trauma patients and to facilitate their societal reintegration, regardless of the number of times they are injured.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Patient Experiences of Acute and Postacute Care After Trauma

INTRODUCTION

Traumatic injury can transform a healthy, independent individual into a patient with complex health needs. Little is known about how injured patients understand their health and healthcare needs during postacute recovery, limiting our ability to optimize care. This multiple-methods study explored injured patients' experiences of care up to 30 days after discharge.

METHODS

Injured adults admitted to an urban, Level I trauma center August 1, 2019-November 30, 2020 were sampled purposively to balance blunt and penetrating injuries. Patient experience and health status were assessed at baseline and 30 days postdischarge using the Quality of Trauma Care Patient-Reported Experience Measure. Fifteen qualitative interviews were conducted with a purposive subset and analyzed using qualitative content analysis.

RESULTS

Of 67 participants (76% male, 73% Black, 51% penetrating, median age 34 years), 37 completed follow-up surveys. Quality of acute care was rated 9-10/10 by 81% of the sample for acute and 65% for postacute care (P = 0.09). Thirty percent described fair or poor mental health, but only mental health concerns were addressed for only 2/3. Pain control was inadequate in 31% at baseline and for 46% at follow-up (P = 0.09). Qualitative analysis revealed general satisfaction with acute care but challenges in recovery with unmet needs for communication and care coordination.

CONCLUSIONS

Trauma patients appreciated the quality of their acute care experiences but identified opportunities for improvement in prognostic communication, pain management, and mental health support. Unmet mental and physical care needs persist at least 1 month after hospital discharge and reinforce the need for interventions that optimize postacute trauma care.

Loss of independence after traumatic injury: A patient-centered study

BACKGROUND

Patient-reported outcomes of postdischarge functional status can provide insight into patient recovery experiences not typically reflected in trauma registries. Injuries may be characterized by a long-term loss of independence. We sought to examine factors predictive of patient-reported, postdischarge loss of independence in trauma patients.

METHODS

Trauma patients admitted to 1 of 3 level I trauma centers were contacted by phone between 6 to 12 months after hospital discharge to complete the Revised Trauma Quality of Life survey. Loss of independence was defined as a new need for assistance with at least one activity of daily living or transition to living in an institutional setting. Patients with severe traumatic brain injury or spinal cord injury were excluded. Multivariable logistic regression analyses were performed to identify predictors of loss of independence.

RESULTS

801 patients were included. The median age was 65 (interquartile range: 46-76) years, 46.1% were female, and the median Injury Severity Score was 9 (interquartile range: 9-13). Two hundred seventy-one patients (33.8%) experienced a loss of independence, most commonly requiring assistance walking up stairs. The main predictors of loss of independence were persistent daily pain (odds ratio: 3.83, 95% confidence interval: [2.90-5.04], P < .001), length of hospital stay (odds ratio: 1.04, 95% confidence interval: [1.01-1.09], P = .021) and income below the national median (odds ratio: 1.46, 95% confidence interval: [1.12-1.91], P = .006). Perceived social support (odds ratio: 0.75, 95% confidence interval: [0.66-0.85], P < .001) was protective against loss of independence.

CONCLUSION

Injury is associated with a relatively high rate of long-term loss of independence. Ensuring adequate social support systems for patients postdischarge may help them regain functional independence after injury.

Development of a Machine Learning-Based Prescriptive Tool to Address Racial Disparities in Access to Care After Penetrating Trauma

Importance

The use of artificial intelligence (AI) in clinical medicine risks perpetuating existing bias in care, such as disparities in access to postinjury rehabilitation services.

Objective

To leverage a novel, interpretable AI-based technology to uncover racial disparities in access to postinjury rehabilitation care and create an AI-based prescriptive tool to address these disparities.

Design, Setting, and Participants

This cohort study used data from the 2010-2016 American College of Surgeons Trauma Quality Improvement Program database for Black and White patients with a penetrating mechanism of injury. An interpretable AI methodology called optimal classification trees (OCTs) was applied in an 80:20 derivation/validation split to predict discharge disposition (home vs postacute care [PAC]). The interpretable nature of OCTs allowed for examination of the AI logic to identify racial disparities. A prescriptive mixed-integer optimization model using age, injury, and gender data was allowed to "fairness-flip" the recommended discharge destination for a subset of patients while minimizing the ratio of imbalance between Black and White patients. Three OCTs were developed to predict discharge disposition: the first 2 trees used unadjusted data (one without and one with the race variable), and the third tree used fairness-adjusted data.

Main Outcomes and Measures

Disparities and the discriminative performance (C statistic) were compared among fairness-adjusted and unadjusted OCTs.

Results

A total of 52 468 patients were included; the median (IQR) age was 29 (22-40) years, 46 189 patients (88.0%) were male, 31 470 (60.0%) were Black, and 20 998 (40.0%) were White. A total of 3800 Black patients (12.1%) were discharged to PAC, compared with 4504 White patients (21.5%; P < .001). Examining the AI logic uncovered significant disparities in PAC discharge destination access, with race playing the second most important role. The prescriptive fairness adjustment recommended flipping the discharge destination of 4.5% of the patients, with the performance of the adjusted model increasing from a C statistic of 0.79 to 0.87. After fairness adjustment, disparities disappeared, and a similar percentage of Black and White patients (15.8% vs 15.8%; P = .87) had a recommended discharge to PAC.

Conclusions and Relevance

In this study, we developed an accurate, machine learning-based, fairness-adjusted model that can identify barriers to discharge to postacute care. Instead of accidentally encoding bias, interpretable AI methodologies are powerful tools to diagnose and remedy system-related bias in care, such as disparities in access to postinjury rehabilitation care.

Injury-related emergency department visits and unplanned readmissions are associated with worse long-term mental and physical health

BACKGROUND

The risk factors for unplanned emergency department (ED) visits and readmission after injury and the impact of these unplanned visits on long-term outcomes are not well understood. We aim to: 1) describe the incidence of and risk factors for injury-related ED visits and unplanned readmissions following injury and, 2) explore the relationship between these unplanned visits and mental and physical health outcomes 6-12 months post-injury.

METHODS

Trauma patients with moderate-to-severe injury admitted to one of three Level-I trauma centers were asked to complete a phone survey to assess mental and physical health outcomes at 6-12 months. Patient reported data on injury-related ED visits and readmissions was collected. Multivariable regression analyses were performed controlling for sociodemographic and clinical variables to compare subgroups.

RESULTS

Of 7,781 eligible patients, 4675 were contacted and 3,147 completed the survey and were included in the analysis. 194 (6.2%) reported an unplanned injury-related ED visit and 239 (7.6%) reported an injury-related readmission. Risk factors for injury-related ED visits included: younger age, Black race, a lower level of education, Medicaid insurance, baseline psychiatric or substance abuse disorder and penetrating mechanism. Risk factors for unplanned injury-related readmission included younger age, male sex, Medicaid insurance, substance abuse disorder, greater injury severity and penetrating mechanism of injury. Injury-related ED visits and readmissions were associated with significantly higher rates of PTSD, chronic pain and new injury-related functional limitations in addition to lower SF-12 mental and physical composite scores.

CONCLUSIONS

Injury-related ED visits and unplanned readmissions are common after hospital discharge following treatment of moderate-severe injury and are associated with worse mental and physical health outcomes.

History repeats itself: Impact of mental illness on violent reinjury and hospital reencounters among female victims of interpersonal violence

BACKGROUND

Violence-related reinjury impacts both patients and health care systems. Mental illness (MI) is prevalent among violently injured individuals. The relationship between preexisting MI and violent reinjury among women has not been fully characterized. Our objective was to determine if risk of hospital reencounter-violent reinjury and all-cause-was associated with preexisting MI at time of index injury among female victims of violence.

METHODS

All females (15-100 + years) presenting to a level I trauma center with violent injury (2002-2019) surviving to discharge were included (N = 1,056). Exposure was presence of preexisting MI. The primary outcome was hospital reencounters for violent reinjury and all-cause within one year (through 2020). The secondary outcome was the development of a new MI within one year of index injury. Odds of reencounter and development of new MI for those with and without preexisting MI were compared with multivariable logistic regression, stratified for interaction when appropriate.

RESULTS

There were 404 women (38%) with preexisting MI at time of index injury. Approximately 11% of patients with preexisting MI experienced violent reinjury compared to 5% of those without within 1 year ( p < 0.001). Specifically, those with MI in the absence of concomitant substance use had more than three times the odds of violent reinjury (adjusted Odds Ratio, 3.52 (1.57, 7.93); p = 0.002). Of those with preexisting MI, 64% had at least one reencounter for any reason compared to 46% of those without ( p < 0.001 ) . Odds of all-cause reencounter for those with preexisting MI were nearly twice of those without (adjusted Odds Ratio, 1.81 [1.36, 2.42]; p < 0.0001).

CONCLUSION

Among female victims of violence, preexisting MI is associated with a significantly increased risk of hospital reencounter and violent reinjury within the first year after index injury. Recognition of this vulnerable population and improved efforts at addressing MI in trauma patients is critical to ongoing prevention efforts to reduce violent reinjury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.