The Social Vulnerability Index and Long-term Outcomes after Traumatic Injury

Examining the role of social vulnerability, neighborhood characteristics, and geospatial patterns of firearm-related injuries and clinical outcomes in Milwaukee county

BACKGROUND

Previous work has shown socioenvironmental factors can influence firearm injury. Milwaukee County, Wisconsin is a diverse midwestern county with historic disinvestment in marginalized communities yielding stark segregation along racial and ethnic lines. It is also one of the many U.S. counties burdened by surging firearm injuries. The differences among communities within Milwaukee County provides a unique opportunity to explore the intersection of socioenvironmental factors that may affect clinical outcomes and geospatial patterns of firearm injury.

METHODS

The trauma registry from the regional adult level 1 trauma center was queried for patients who sustained a firearm-related injury from 2015 to 2022 (N = 2402). The Social Vulnerability Index (SVI) ranking was derived using patient residence addresses to evaluate its association with traumatic injury clinical outcomes (i.e., in-hospital mortality, length of hospital stay, ICU or ventilator treatment, or injury severity score) and risk screening results for alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and depression. We evaluated hotspots of firearm injury density over time for patient residences and injury locations and distances between locations. A spatially lagged regression model tested the association between firearm injury density and SVI domains, alcohol outlet types, and park coverage.

RESULTS

Most firearm injury patients were younger, male, racial or ethnic minorities from disadvantaged neighborhoods (SVI total; M = 0.86, SD = 0.15). SVI was not associated with any clinical outcomes. Of those screened, 12.9% screened positive for AUD and 44.5% screened at risk for PTSD, depression, or both. Hotspot analysis indicated consistent concentrations of firearm injury density. There were no differences in clinical outcomes between those injured inside or outside the home. Census tracts with lower socioeconomic status, greater off-premises and lower on-premises alcohol outlet density were associated with greater firearm injury density.

CONCLUSIONS

In Milwaukee County, firearm injury patients are injured in and often return to the same disadvantaged neighborhoods that may hamper recovery. Results replicate and expand previous work and implicate specific socioenvironmental factors for intervention and prevention of firearm injury.

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.

Area deprivation index and social vulnerability index in Milwaukee County: Impact on hospital outcomes after traumatic injuries

BACKGROUND

Predisposing factors for traumatic injuries are complex and variable. Neighborhood environments may influence injury mechanism or outcomes. The Social Vulnerability Index (SVI) identifies areas at risk for emergencies; Area Deprivation Index (ADI) measures socioeconomic disadvantage. The objective was to assess the impact of SVI or ADI on hospital length of stay (LOS) and mortality for injured patients to determine whether SVI or ADI indicated areas where injury prevention may be most impactful.

METHODS

Adult patients who resided in Milwaukee County and were treated for injuries from 2015 to 2022 at a level I trauma center were included. Patients' addresses were geocoded and merged with 2020 state-level SVI and ADI measures. SVI ranks census tracts 0-100 from least to most vulnerable. ADI ranks census block groups 1-10 from least to most disadvantaged. ADI and SVI rankings were converted to deciles. Statistical analyses included descriptive statistics, chi-square tests, and regression models for LOS and in-hospital mortality, adjusted for either SVI or ADI within separate models, age, sex, race or ethnicity, mechanism of injury (MOI), injury severity score (ISS).

RESULTS

14,542 patients were included; 63 % were male. Mean total hospital LOS was 6.4 ± 9.8 days, and in-hospital mortalities occurred in 5.2 % of patients. Based on SVI and ADI, 5,280 (36 %) patients resided in high vulnerability areas and 5,576 (39 %) lived in highly disadvantaged areas, respectively. After adjusting for patient factors, SVI deciles #6, 9, 10 were associated with increased hospital LOS, and SVI decile #5 was associated with in-hospital mortality (OR = 2.22, 95 %CI:1.06-4.63; p = 0.034). When adjusted for ADI, the 7th-10th deciles were associated with increased hospital LOS. Greater age and ISS were associated with increased hospital LOS and mortality when adjusted for SVI and ADI.

CONCLUSIONS

SVI and ADI identified a similar proportion of patients in high vulnerability or disadvantaged areas. Higher SVI and ADI deciles were associated with longer hospital LOS, and only the 5th SVI decile was associated with in-hospital mortality. Highly disadvantaged or vulnerable areas may have a longer LOS, but SVI and ADI have limited influence on trauma mortality. Continued research on neighborhood and community factors and trauma outcomes is needed.

The 340B Program and oral specialty drugs for advanced prostate cancer

INTRODUCTION

Expensive oral specialty drugs for advanced prostate cancer can be associated with treatment disparities. The 340B program allows hospitals to purchase medications at discounts, generating savings that can improve care of the socioeconomically disadvantaged. This study assessed the effect of hospital 340B participation on advanced prostate cancer.

METHODS

The authors performed a retrospective cohort study of Medicare beneficiaries with advanced prostate cancer from 2012 to 2019. The primary outcome was use of an oral specialty drug. Secondary outcomes included monthly out-of-pocket costs and treatment adherence. We evaluated the effects of 1) hospital 340B participation, 2) a regional measure vulnerability, the social vulnerability index (SVI), and 3) the interaction between hospital 340B participation and SVI on outcomes.

RESULTS

There were 2237 and 1100 men who received care at 340B and non-340B hospitals. There was no difference in specialty drug use between 340B and non-340B hospitals, whereas specialty drug use decreased with increased SVI (odds ratio, 0.95, p = .038). However, the interaction between hospital 340B participation and SVI on specialty drug use was not significant. Neither 340B participation, SVI, or their interaction were associated with out-of-pocket costs. Although hospital 340B participation and SVI were not associated with treatment adherence, their interaction was significant (p = .020). This demonstrated that 340B was associated with better adherence among socially vulnerable men.

CONCLUSIONS

The 340B program was not associated with specialty drug use in men with advanced prostate cancer. However, among those who were started on therapy, 340B was associated with increased treatment adherence in more socially vulnerable men.

The Effect of Social Vulnerability on Perioperative Tonsillectomy Outcomes in Children

OBJECTIVE

To determine if children with greater social vulnerability are more likely to experience a prolonged oxygen requirement (POR) following adenotonsillectomy to inform the need for overnight monitoring prior to discharge.

METHODS

A previously published prospective study assessing children observed overnight following adenotonsillectomy for obstructive sleep-disordered breathing was reanalyzed including social vulnerability index (SVI). The outcome was POR beyond 3 h following extubation. Logistic regression was used to assess the association of SVI components with POR. SVI components were assessed as quartiles of cohort values. Final adjusted models included race, asthma, Down syndrome, and pre-operative SpO2.

RESULTS

A total of 462 children had SVI data available and were included. 354 (76.6%) were > = 3 years of age. Overall, 351 (76%) did not have a POR. The median overall SVI percentile was 26.5 (Q1 10.4, Q3 60.1). When categorized by SVI quartiles, there was a statistically significant difference with POR for overall SVI percentile (p = 0.007), SVI household composition percentile (p = 0.033), and median SVI housing/transportation percentile (p = 0.005). Individuals with an overall SVI in the 4th quartile (greatest vulnerability) were 2.63 times more likely to experience a POR than those in the 1st quartile (lowest social vulnerability) in adjusted logistic regression (95% OR CI 1.23-5.62; p = 0.01).

CONCLUSIONS

There is a significant association between greater neighborhood-level social vulnerability and a POR following adenotonsillectomy. We propose that a child's SVI be considered when planning for the perioperative course following adenotonsillectomy.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2449-2454, 2024.

Social Vulnerability Index and Survivorship after Colorectal Cancer Resection

BACKGROUND

Race and socioeconomic status incompletely identify patients with colorectal cancer (CRC) at the highest risk for screening, treatment, and mortality disparities. Social vulnerability index (SVI) was designed to delineate neighborhoods requiring greater support after external health stressors, summarizing socioeconomic, household, and transportation barriers by census tract. SVI is implicated in lower cancer center use and increased complications after colectomy, but its influence on long-term prognosis is unknown. Herein, we characterized relationships between SVI and CRC survival.

STUDY DESIGN

Patients undergoing resection of stage I to IV CRC from January 2010 to May 2023 within an academic health system were identified. Clinicopathologic characteristics were abstracted using institutional National Cancer Database and NSQIP. Addresses from electronic health records were geocoded to SVI. Overall survival and cancer-specific survival were compared using Kaplan-Meier and Cox proportional hazards methods.

RESULTS

A total of 872 patients were identified, comprising 573 (66%) patients with colon tumor and 299 (34%) with rectal tumor. Patients in the top SVI quartile (32%) were more likely to be Black (41% vs 13%, p < 0.001), carry less private insurance (39% vs 48%, p = 0.02), and experience greater comorbidity (American Society of Anesthesiologists physical status III: 86% vs 71%, p < 0.001), without significant differences by acuity, stage, or CRC therapy. In multivariable analysis, high SVI remained associated with higher all-cause (hazard ratio 1.48, 95% CI 1.12 to 1.96, p < 0.01) and cancer-specific survival mortality (hazard ratio 1.71, 95% CI 1.10 to 2.67, p = 0.02).

CONCLUSIONS

High SVI was independently associated with poorer prognosis after CRC resection beyond the perioperative period. Acknowledging needs for multi-institutional evaluation and elaborating causal mechanisms, neighborhood-level vulnerability may inform targeted outreach in CRC care.

Using the Social Vulnerability Index to Analyze Statewide Health Disparities in Cholecystectomy

INTRODUCTION

Addressing the effects of social determinants of health in surgery has become a national priority. We evaluated the utility of the Social Vulnerability Index (SVI) in determining the likelihood of receiving cholecystectomy for cholecystitis in Texas.

METHODS

A retrospective study of adults with cholecystitis in the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Data Public Use Data File from 2016 to 2019. Patients were stratified into SVI quartiles, with the lowest quartile as low vulnerability, the middle two as average vulnerability, and the highest as high vulnerability. The relative risk (RR) of undergoing surgery was calculated using average vulnerability as the reference category and subgroup sensitivity analyses.

RESULTS

A total of 67,548 cases were assessed, of which 48,603 (72.0%) had surgery. Compared with the average SVI groups, the low vulnerability groups were 21% more likely to undergo cholecystectomy (RR = 1.21, 95% confidence interval [CI] 1.18-1.24), whereas the high vulnerability groups were 9% less likely to undergo cholecystectomy (RR = 0.91, 95% CI 0.88-0.93). The adjusted model showed similar results (RR = 1.05, 95% CI 1.04-1.06 and RR = 0.97, 95% CI 0.96-0.99, for low and high vulnerability groups, respectively). These results remained significant after stratifying for age, sex, ethnicity, and insurance status. However, the differences between low, average, and high vulnerability groups diminished in rural settings, with lower surgery rates in all groups.

CONCLUSIONS

Patients with higher SVI were less likely to receive an elective cholecystectomy. SVI is an effective method of identifying social determinants impacting access to and receipt of surgical care.

Factors Associated With Diagnostic Delay in Axial Spondyloarthritis: Impact of Clinical Factors and Social Vulnerability

OBJECTIVE

Patients with axial spondyloarthritis (axSpA) often experience significant delay between symptom onset and diagnosis for reasons that are incompletely understood. We investigated associations between demographic, medical, and socioeconomic factors and axSpA diagnostic delay.

METHODS

We identified patients meeting modified New York criteria for ankylosing spondylitis (AS) or 2009 Assessment of Spondyloarthritis International Society criteria for axSpA in the Mass General Brigham health care system between December 1990 and October 2021. We determined the duration of diagnostic delay, defined as the duration of back pain symptoms reported at diagnosis, as well as disease manifestations and specialty care prior to diagnosis from the electronic health record. We obtained each patient's Social Vulnerability Index (SVI) by mapping their address to the US Centers for Disease Control SVI Atlas. We examined associations among disease manifestations, SVI, and diagnostic delay using ordinal logistic regression.

RESULTS

Among 554 patients with axSpA who had a median diagnostic delay of 3.8 years (interquartile range 1.1-10), peripheral arthritis (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.45-0.93) and older age at symptom onset (OR 0.83, 95% CI 0.78-0.88 per five years) were associated with shorter delay. AS at diagnosis (OR 1.85, 95% CI 1.30-2.63), a history of uveitis prior to diagnosis (OR 2.77, 95% CI 1.73-4.52), and higher social vulnerability (defined as national SVI 80th to 99th percentiles; OR 1.99, 95% CI 1.06-3.84) were associated with longer diagnostic delay.

CONCLUSION

Older age at back pain onset and peripheral arthritis were associated with shorter delay, whereas uveitis was associated with longer diagnostic delay. Patients with higher socioeconomic vulnerability had longer diagnostic delay independent of clinical factors.

Social vulnerability adversely affects emergency-department utilization but not patient-reported outcomes after total joint arthroplasty

INTRODUCTION

Multiple studies demonstrate social deprivation is associated with inferior outcomes after total hip (THA) and total knee (TKA) arthroplasty; its effect on patient-reported outcomes is debated. The primary objective of this study evaluated the relationship between social vulnerability and the PROMIS-PF measure in patients undergoing THA and TKA. A secondary aim compared social vulnerability between patients who required increased resource utilization or experienced complications and those who didn't.

MATERIALS AND METHODS

A retrospective review of 537 patients from March 2020 to February 2022 was performed. The Centers for Disease Control Social Vulnerability Index (SVI) were used to quantify socioeconomic disadvantage. The cohort was split into THA and TKA populations; univariate and multivariate analyses were performed to evaluate primary and secondary outcomes. Statistical significance was assessed at p < 0.05.

RESULTS

48.6% of patients achieved PROMIS-PF MCID at 1-year postoperatively. Higher levels of overall social vulnerability (0.40 vs. 0.28, p = 0.03) were observed in TKA patients returning to the ED within 90-days of discharge. Increased overall SVI (OR = 9.18, p = 0.027) and household characteristics SVI (OR = 9.57, p = 0.015) were independent risk factors for 90-day ED returns after TKA. In THA patients, increased vulnerability in the household type and transportation dimension was observed in patients requiring 90-day ED returns (0.51 vs. 0.37, p = 0.04).

CONCLUSION

Despite an increased risk for 90-day ED returns, patients with increased social vulnerability still obtain good 1-year functional outcomes. Initiatives seeking to mitigate the effect of social deprivation on TJA outcomes should aim to provide safe alternatives to ED care during early recovery.

The Impact of Social Determinants of Health on Outcomes and Complications After Total Knee Arthroplasty: An Analysis of Neighborhood Deprivation Indices

BACKGROUND

Social determinants of health (SDOH) are important factors in the delivery of orthopaedic care. The purpose of this study was to investigate the relationship between outcomes following total knee arthroplasty (TKA) and both the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI).

METHODS

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was utilized to identify TKA cases for inclusion. Demographic characteristics and medical history were documented. The SVI, its subthemes, and the ADI were analyzed. Outcome data included length of stay, discharge disposition, postoperative change in the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR), 90-day incidences of emergency department (ED) visits, readmission, death, deep venous thrombosis (DVT) and/or pulmonary embolism (PE), periprosthetic fracture, implant failure, periprosthetic joint infection (PJI), and all-cause reoperation. Database cross-referencing was completed to document aseptic and septic revisions beyond 90 days postoperatively. Bivariate quartile-stratified and multivariable analyses were used to associate deprivation metrics with outcomes.

RESULTS

A total of 19,321 TKA cases met inclusion criteria. Baseline patient characteristics varied among the SVI and/or ADI quartiles, with patients of non-White race and with a greater number of comorbidities noted in higher deprivation quartiles. Higher SVI and/or ADI quartiles were correlated with an increased rate of discharge to a skilled nursing facility (p < 0.05). A higher SVI and/or ADI quartile was associated with increased incidences of ED visits and readmissions postoperatively (p < 0.05). DVT and/or PE and long-term aseptic revision were the complications most strongly associated with higher deprivation metrics. Upon multivariable analysis, greater length of stay and greater incidences of ED visits, readmissions, DVT and/or PE, and aseptic revision remained significantly associated with greater deprivation based on multiple metrics.

CONCLUSIONS

Greater deprivation based on multiple SVI subthemes, the composite SVI, and the ADI was significantly associated with increased length of stay, non-home discharge ED visits, and readmissions. The SVI and the ADI may be important considerations in the perioperative assessment of patients who undergo TKA.

LEVEL OF EVIDENCE

Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Social determinants of health in pediatric trauma: Associations with injury mechanisms and outcomes in the context of the COVID-19 pandemic

BACKGROUND

Relationships between social determinants of health and pediatric trauma mechanisms and outcomes are unclear in context of COVID-19.

METHODS

Children <16 years old injured between 2016 and 2021 from ten pediatric trauma centers in Florida were included. Patients were stratified by high vs. low Social Vulnerability Index (SVI). Injury mechanisms studied were child abuse, ATV/golf carts, and firearms. Mechanism incidence trends and mortality were evaluated by interrupted time series and multivariable logistic regression.

RESULTS

Of 19,319 children, 68% and 32% had high and low SVI, respectively. Child abuse increased across SVI strata and did not change with COVID. ATV/golf cart injuries increased after COVID among children with low SVI. Firearm injuries increased after COVID among children with high SVI. Mortality was predicted by injury mechanism, but was not independently associated with SVI, race, or COVID.

CONCLUSION

Social vulnerability influences pediatric trauma mechanisms and COVID effects. Child abuse and firearm injuries should be targeted for prevention.

The interruption of romosozumab treatment during COVID lockdown among US post-menopausal women enrolled in Medicare

PURPOSE

To evaluate the impact of the COVID lock-down on treatment interruptions of romosozumab, a first in class biologic therapy, administered by healthcare providers once monthly.

METHODS

We used Medicare data from 1/1/2017 to 9/30/2021 to identify women age ≥65 initiating romosozumab between 4/1/2019 and 6/30/2021. Patient demographics, provider specialty, and baseline comorbidities were identified. Romosozumab dispensations were grouped into five 6-month periods based on the dispensing date from FDA licensure to the end of the data (Period 1 to 5). "Treatment interruption" was defined as any interval gap between 2 dispensations >60 days. The numbers of treatment interruption event were aggregated per period per patient. Mixed effect Poisson regression with patient-level random effects was performed, including an interaction term between Period and number of prior doses.

RESULTS

There were 12,216 romosozumab new users identified. A total of 2724 treatment interruption events were identified among 2229 romosozumab users. After adjustment, comparing with the period immediately before the lockdown (Period 2: 2019-10-1-2020-3-30), the IRRs (95 % CI) for treatment interruption were 0.49 (0.29, 0.81), 1.65 (1.48, 1.85), 1.79 (1.60, 2.01), and 1.67 (1.49, 1.87) for periods 1, 3, 4, and 5, respectively, per 1 prior dose change (p < 0.01 for all IRRs), where Periods 3, 4, and 5 were post-lockdown.

CONCLUSION

Compared to the pre-COVID period, the lockdown negatively impacted the continuity of romosozumab treatment among Medicare beneficiaries. Prioritizing in-time assistance for patients receiving a provider-administered parenteral therapy is critical when patients' in-person access to their provider is compromised.

Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality

Importance

Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used.

Objective

To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors.

Design, Setting, and Participants

This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022.

Exposures

Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI.

Main Outcomes and Measures

Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression.

Results

A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05).

Conclusions and Relevance

The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.

Public Insurance and Single-Guardian Households Are Associated with Diagnostic Delay in Slipped Capital Femoral Epiphysis

BACKGROUND

Extensive literature documents the adverse sequelae of delayed diagnosis of slipped capital femoral epiphysis (SCFE), including worsening deformity and surgical complications. Less is known about predictors of delayed diagnosis of SCFE, particularly the effects of social determinants of health. The purpose of this study was to evaluate the impact of insurance type, family structure, and neighborhood-level socioeconomic vulnerability on the delay of SCFE diagnosis.

METHODS

We reviewed medical records of patients who underwent surgical fixation for stable SCFE at a tertiary pediatric hospital from 2002 to 2021. We abstracted data on demographic characteristics, insurance status, family structure, home address, and symptom duration. We measured diagnostic delay in weeks from the date of symptom onset to diagnosis. We then geocoded patient addresses to determine their Census tract-level U.S. Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI), using U.S. Census and American Community Survey data. We performed 3 separate logistic regression models to examine the effects of (1) insurance status, (2) family structure, and (3) SVI on a delay of ≥12 weeks (reference, <12 weeks). We adjusted for age, sex, weight status, number of siblings, and calendar year.

RESULTS

We identified 351 patients with SCFE; 37% (129) had a diagnostic delay of ≥12 weeks. In multivariable logistic regression models, patients with public insurance were more likely to have a delay of ≥12 weeks than patients with private insurance (adjusted odds ratio [OR], 1.83 [95% confidence interval (CI), 1.12 to 2.97]; p = 0.015) and patients from single-guardian households were more likely to have a delay of ≥12 weeks than patients from multiguardian households (adjusted OR, 1.95 [95% CI, 1.11 to 3.45]; p = 0.021). We did not observe a significant increase in the odds of delay among patients in the highest quartile of overall SVI compared with patients from the lower 3 quartiles, in both the U.S. comparison (adjusted OR, 1.43 [95% CI, 0.79 to 2.58]; p = 0.24) and the Massachusetts comparison (adjusted OR, 1.45 [95% CI, 0.79 to 2.66]; p = 0.23).

CONCLUSIONS

The delay in diagnosis of SCFE remains a concern, with 37% of patients with SCFE presenting with delay of ≥12 weeks. Public insurance and single-guardian households emerged as independent risk factors for diagnostic delay. Interventions to reduce delay may consider focusing on publicly insured patients and those from single-guardian households.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Racial, Ethnic, and Socioeconomic Disparities in Out-of-Hospital Pain Management for Patients With Long Bone Fractures

STUDY OBJECTIVE

To evaluate racial and ethnic disparities in out-of-hospital analgesic administration, accounting for the influence of clinical characteristics and community socioeconomic vulnerability, among a national cohort of patients with long bone fractures.

METHODS

Using the 2019-2020 ESO Data Collaborative, we retrospectively analyzed emergency medical services (EMS) records for 9-1-1 advanced life support transport of adult patients diagnosed with long bone fractures at the emergency department. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for out-of-hospital analgesic administration by race and ethnicity, accounting for age, sex, insurance, fracture location, transport time, pain severity, and scene Social Vulnerability Index. We reviewed a random sample of EMS narratives without analgesic administration to identify whether other clinical factors or patient preferences could explain differences in analgesic administration by race and ethnicity.

RESULTS

Among 35,711 patients transported by 400 EMS agencies, 81% were White, non-Hispanic, 10% were Black, non-Hispanic, and 7% were Hispanic. In crude analyses, Black, non-Hispanic patients with severe pain were less likely to receive analgesics compared with White, non-Hispanic patients (59% versus 72%; Risk Difference: -12.5%, 95% CI: -15.8% to -9.9%). After adjustment, Black, non-Hispanic patients remained less likely to receive analgesics compared with White, non-Hispanic patients (aOR:0.65, 95% CI:0.53 to 0.79). Narrative review identified similar rates of patients declining analgesics offered by EMS and analgesic contraindications across racial and ethnic groups.

CONCLUSIONS

Among EMS patients with long bone fractures, Black, non-Hispanic patients were substantially less likely to receive out-of-hospital analgesics compared with White, non-Hispanic patients. These disparities were not explained by differences in clinical presentations, patient preferences, or community socioeconomic conditions.

Multidisciplinary Optimal Outcomes Reporting and Team Clinic Retention in Isolated Nonsyndromic Cleft Palate

OBJECTIVE

Optimal Outcomes Reporting was recently introduced to categorize outcomes after cleft palate repair. We seek to propose an expanded version of Optimal Outcomes Reporting and to determine if correlation exists between the expanded outcomes and persistence with team care follow-up through age 9.

DESIGN

Retrospective cohort study.

SETTING

Cleft team at large pediatric hospital.

PATIENTS

Patients with isolated nonsyndromic cleft palate (n = 83) born from 2001-2012.

MAIN OUTCOME MEASURES

Patients who continued to present at age 5 or greater were assessed for optimal outcomes. Optimal outcomes were: surgery - no fistula or velopharyngeal insufficiency; otolaryngology - no obstructive sleep apnea or signs of chronic middle ear disease; audiology - no hearing loss; speech-language pathology - no assessed need for speech therapy.

RESULTS

Of the 83 patients identified, 41 were assessed for optimal outcomes. Optimal outcome in any discipline was not associated with follow-up through age 9 (0.112 ≤ p ≤ 0.999). For all disciplines, the group with suboptimal outcomes had a higher proportion of patients from geographic areas in the most disadvantaged quartile of social vulnerability index, with the strongest association in the group with suboptimal speech outcome (OR 6.75, 95% CI 0.841-81.1).

CONCLUSIONS

Optimal outcomes and retention in team clinic were not statistically significantly associated, but clinically relevant associations were found between patients in the most disadvantaged quartile of social vulnerability and their outcomes. A patient-centered approach, including caregiver education about long-term care for patients with cleft palate, would allow for enhanced resource utilization to improve retention for patients of concern.

Incidence of and Factors Associated With Recurrent Firearm Injury Among Patients Presenting to St. Louis Trauma Centers, 2010 to 2019 : A Cohort Study

BACKGROUND

Firearm injuries are a public health crisis in the United States.

OBJECTIVE

To examine the incidence and factors associated with recurrent firearm injuries and death among patients presenting with an acute (index), nonfatal firearm injury.

DESIGN

Multicenter, observational, cohort study.

SETTING

Four adult and pediatric level I trauma hospitals in St. Louis, Missouri, 2010 to 2019.

PARTICIPANTS

Consecutive adult and pediatric patients (n = 9553) presenting to a participating hospital with a nonfatal acute firearm injury.

MEASUREMENTS

Data on firearm-injured patient demographics, hospital and diagnostic information, health insurance status, and death were collected from the St. Louis Region-Wide Hospital-Based Violence Intervention Program Data Repository. The Centers for Disease Control and Prevention (CDC) Social Vulnerability Index was used to characterize the social vulnerability of the census tracts of patients' residences. Analysis included descriptive statistics and time-to-event analyses estimating the probability of experiencing a recurrent firearm injury.

RESULTS

We identified 10 293 acutely firearm-injured patients of whom 9553 survived the injury and comprised the analytic sample. Over a median follow-up of 3.5 years (IQR, 1.5 to 6.4 years), 1155 patients experienced a recurrent firearm injury including 5 firearm suicides and 149 fatal firearm injuries. Persons experiencing recurrent firearm injury were young (25.3 ± 9.5 years), predominantly male (93%), Black (96%), and uninsured (50%), and resided in high social vulnerability regions (65%). The estimated risk for firearm reinjury was 7% at 1 year and 17% at 8 years.

LIMITATIONS

Limited data on comorbidities and patient-level social determinants of health. Inability to account for recurrent injuries presenting to nonstudy hospitals.

CONCLUSION

Recurrent injury and death are frequent among survivors of firearm injury, particularly among patients from socially vulnerable areas. Our findings highlight the need for interventions to prevent recurrence.

PRIMARY FUNDING SOURCE

Emergency Medicine Foundation-AFFIRM and Missouri Foundation for Health.

Community-Level Social Vulnerability and Patterns of Adolescent Injury

Objective

To describe adolescent injuries by the community-level social vulnerability, focusing on injuries related to interpersonal violence.

Background

The Center for Disease Control and Prevention's social vulnerability index (SVI) is a tool used to characterize community-level vulnerability.

Methods

Injured adolescent trauma patients (13-17 years old) cared for at a large Level I trauma center over a 10-year period were identified. Injuries were classified by intent as either intentional or unintentional. Census tract level SVI was calculated by composite score and for 4 subindex scores (socioeconomic, household composition/disability, minority/language, housing type/transportation). Patients were stratified by SVI quartile with the lowest quartile designated as low-, the middle two quartiles as average-, and the highest quartile as high vulnerability. The primary outcome was odds of intentional injury. Demographic and injury characteristics were compared by SVI and intent. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI.

Results

A total of 1993 injured adolescent patients (1676 unintentional and 317 intentional) were included. The composite SVI was higher in the intentional injury cohort (mean, SD: 66.7, 27.8 vs. 50.5, 30.2; P < 0.001) as was each subindex SVI. The high SVI cohort comprised 31% of the study population, 49% of intentional injuries, and 51% of deaths. The high SVI cohort had significantly increased unadjusted (odds ratio, 4.5; 95% confidence interval, 3.0-6.6) and adjusted (odds ratio, 1.8; 95% confidence interval, 1.6-2.8) odds of intentional injury.

Conclusions

Adolescents living in the highest SVI areas experience significantly higher odds of intentional injury. SVI and SVI subindex details may provide direction for community-level interventions to decrease the impact of violent injury among adolescents.

Quality care is equitable care: a call to action to link quality to achieving health equity within acute care surgery

Health equity is defined as the sixth domain of healthcare quality. Understanding health disparities in acute care surgery (defined as trauma surgery, emergency general surgery and surgical critical care) is key to identifying targets that will improve outcomes and ensure delivery of high-quality care within healthcare organizations. Implementing a health equity framework within institutions such that local acute care surgeons can ensure equity is a component of quality is imperative. Recognizing this need, the AAST (American Association for the Surgery of Trauma) Diversity, Equity and Inclusion Committee convened an expert panel entitled 'Quality Care is Equitable Care' at the 81st annual meeting in September 2022 (Chicago, Illinois). Recommendations for introducing health equity metrics within health systems include: (1) capturing patient outcome data including patient experience data by race, ethnicity, language, sexual orientation, and gender identity; (2) ensuring cultural competency (eg, availability of language services; identifying sources of bias or inequities); (3) prioritizing health literacy; and (4) measuring disease-specific disparities such that targeted interventions are developed and implemented. A stepwise approach is outlined to include health equity as an organizational quality indicator.