1
|
Bell F, Crabtree R, Wilson C, Miller E, Byrne R. Ambulance service recognition of health inequalities and activities for reduction: An evidence and gap map of the published literature. Br Paramed J 2024; 9:47-57. [PMID: 38946737 PMCID: PMC11210581 DOI: 10.29045/14784726.2024.6.9.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Background Emergency medical services (EMS) are often patients' first point of contact for urgent and emergency care needs. Patients are triaged over the phone and may receive an ambulance response, with potential conveyance to the hospital. A recent scoping review suggested disparities in EMS patient care in the United States. However, it is unknown how health inequalities impact EMS care in other developed countries and how inequalities are being addressed. Objectives This rapid evidence map of published literature aims to map known health inequalities in EMS patients and describe interventions reducing health inequalities in EMS patient care. Methods The search strategy consisted of EMS synonyms and health inequality synonyms. The MEDLINE/PubMed database was searched from 1 January 2010 to 26 July 2022. Studies were included if they described empirical research exploring health inequalities within ambulance service patient care. Studies were mapped on to the EMS care interventions framework and Core20PLUS5 framework. Studies evaluating interventions were synthesised using the United Kingdom Allied Health Professions Public Health Strategic Framework. Results The search strategy yielded 771 articles, excluding duplicates, with two more studies added from hand searches. One hundred studies met the inclusion criteria after full-text review. Inequalities in EMS patient care were predominantly situated in assessment, treatment and conveyance, although triage and response performance were also represented. Studies mostly explored EMS health inequalities within ethnic minority populations, populations with protected characteristics and the core issue of social deprivation. Studies evaluating interventions reducing health inequalities (n = 5) were from outside the United Kingdom and focused on older patients, ethnic minorities and those with limited English proficiency. Interventions included community paramedics, awareness campaigns, dedicated language lines and changes to EMS protocols. Conclusions Further UK-based research exploring health inequalities of EMS patients would support ambulance service policy and intervention development to reduce health inequality in urgent and emergency care delivery.
Collapse
Affiliation(s)
- Fiona Bell
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0003-4503-1903
| | | | - Caitlin Wilson
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0002-9854-4289
| | - Elisha Miller
- NIHR Coordinating Centre ORCID iD: https://orcid.org/0000-0003-4729-8572
| | | |
Collapse
|
2
|
Mabry CD, Davis B, Sutherland M, Robertson R, Carger J, Wyrick D, Collins T, Porter A, Kalkwarf K. Progressive Reduction in Preventable Mortality in a State Trauma System Using Continuous Preventable Mortality Review to Drive Provider Education: Results of Analyzing 1,979 Trauma Deaths from 2015 to 2022. J Am Coll Surg 2024; 238:426-434. [PMID: 38149781 DOI: 10.1097/xcs.0000000000000935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND The state legislature codified and funded the Arkansas Trauma System (ATS) in 2009. Quarterly preventable mortality reviews (PMRs) by the ATS began in 2015 and were used to guide state-wide targeted education to reduce preventable or potentially preventable (P/PP) deaths. We present the results of this PMR-education initiative from 2015 to 2022. STUDY DESIGN The ATS uses a statistical sampling model of the Arkansas Trauma Registry to select ~40% of the deaths for quarterly review, reflecting the overall the Arkansas Trauma Registry mortality population. A multispecialty PMR committee reviews the medical records from prehospital care to death, and hospital and regional advisory council reviews for each death. The PMR committee assigns opportunities for improvement (OFIs), cause(s) of death, and the likelihood of preventability for each case. Education to improve trauma care includes annual state-wide trauma meetings, novel classes targeted at level III/IV trauma center hospital providers, trauma evidence-based guidelines, and PMR "pearls." RESULTS We reviewed 1,979 deaths with 211 (10.6%) deaths judged to be P/PP deaths. There was a progressive decrease in P/PP deaths and OFIs for P/PP deaths. Five OFI types targeted by education accounted for 72% of the 24 possible OFI types in the P/PP cases, and 94% of the "contributory OFIs." Reductions in "delay in treatment" resulted in the most rapid decrease in P/PP deaths. CONCLUSIONS Using ongoing PMR studies to target provider education led to a reduction in P/PP deaths and OFIs for P/PP deaths. Focusing on education designed to improve preventable mortality can result in a substantial decrease in P/PP deaths by 43% (14% to 8%) for trauma systems.
Collapse
Affiliation(s)
- Charles D Mabry
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | - Benjamin Davis
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | - Michael Sutherland
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL (Sutherland)
| | - Ronald Robertson
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - Deidre Wyrick
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
- Division of Pediatric Surgery and Section of Pediatric Critical Care Medicine, Department of Surgery, University of Arkansas College of Medicine and Arkansas Children's Hospital, Little Rock, AR (Wyrick)
| | - Terry Collins
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| | - Austin Porter
- Department of Health Policy and Management, Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences and Arkansas Department of Health, Little Rock, AR (Porter)
| | - Kyle Kalkwarf
- From the Department of Surgery, College of Medicine (Mabry, Davis, Robertson, Wyrick, Collins, Kalkwarf) University of Arkansas for Medical Sciences, Little Rock, AR
| |
Collapse
|
3
|
Goddard SD, Jarman MP, Hashmi ZG. Societal Burden of Trauma and Disparities in Trauma Care. Surg Clin North Am 2024; 104:255-266. [PMID: 38453300 DOI: 10.1016/j.suc.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Trauma imposes a significant societal burden, with injury being a leading cause of mortality worldwide. While numerical data reveal that trauma accounts for millions of deaths annually, its true impact goes beyond these figures. The toll extends to non-fatal injuries, resulting in long-term physical and mental health consequences. Moreover, injury-related health care costs and lost productivity place substantial strain on a nation's economy. Disparities in trauma care further exacerbate this burden, affecting access to timely and appropriate care across various patient populations. These disparities manifest across the entire continuum of trauma care, from prehospital to in-hospital and post-acute phases. Addressing these disparities and improving access to quality trauma care are crucial steps toward alleviating the societal burden of trauma and enhancing equitable patient outcomes.
Collapse
Affiliation(s)
- Sabrina D Goddard
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA
| | - Molly P Jarman
- The Department of Surgery, Center for Surgery and Public Health, Harvard Medical School, Harvard T.H. Chan School of Public Health, Brigham and Women's Hospital, One Brigham Circle,1620 Tremont Street, Suite 2-016, Boston, MA 02120, USA
| | - Zain G Hashmi
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 622, Birmingham, AL 35294, USA.
| |
Collapse
|
4
|
Scrushy M, Lunardi N, Sakran JV. Trauma Demographics and Injury Prevention. Surg Clin North Am 2024; 104:243-254. [PMID: 38453299 DOI: 10.1016/j.suc.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Traumatic injury is a leading cause of death in the United States. Risk of traumatic injury varies by sex, age, geography, and race/ethnicity. Understanding the nuances of risk for a particular population is essential in designing, implementing, and evaluating injury prevention initiatives.
Collapse
Affiliation(s)
- Marinda Scrushy
- Department of General Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Nicole Lunardi
- Department of General Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins Hospital, 1800 Orleans Street, Sheikh Zayed Tower / Suite 6107A, Baltimore, MD 21287, USA.
| |
Collapse
|
5
|
Scott KA, Elliott KC, Lincoln J, Flynn MA, Hill R, Hall DM. Rural health and rural industries: Opportunities for partnership and action. J Rural Health 2024; 40:401-405. [PMID: 37669228 PMCID: PMC10912364 DOI: 10.1111/jrh.12791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/07/2023]
Affiliation(s)
- Kenneth A. Scott
- National Institute for Occupational Safety and Health, Denver, Colorado, USA
| | - K. C. Elliott
- National Institute for Occupational Safety and Health, Anchorage, Alaska, USA
| | - Jennifer Lincoln
- National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | - Michael A. Flynn
- National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | - Ryan Hill
- National Institute for Occupational Safety and Health, Spokane, Washington, USA
| | - Diane M. Hall
- Office of Rural Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
6
|
Oami T, Abe T, Nakada TA, Imaeda T, Aizimu T, Takahashi N, Yamao Y, Nakagawa S, Ogura H, Shime N, Umemura Y, Matsushima A, Fushimi K. Association between hospital spending and in-hospital mortality of patients with sepsis based on a Japanese nationwide medical claims database study. Heliyon 2024; 10:e23480. [PMID: 38170111 PMCID: PMC10758802 DOI: 10.1016/j.heliyon.2023.e23480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Background The effect of hospital spending on the mortality rate of patients with sepsis has not yet been fully elucidated. We hypothesized that hospitals that consume more medical resources would have lower mortality rates among patients with sepsis. Methods This retrospective study used administrative data from 2010 to 2017. The enrolled hospitals were divided into quartiles based on average daily medical cost per sepsis case. The primary and secondary outcomes were the average in-hospital mortality rate of patients with sepsis and the effective cost per survivor among the enrolled hospitals, respectively. A multiple regression model was used to determine the significance of the differences among hospital categories to adjust for baseline imbalances. Results Among 997 hospitals enrolled in this study, the crude in-hospital mortality rates were 15.7% and 13.2% in the lowest and highest quartiles of hospital spending, respectively. After adjusting for confounding factors, the highest hospital spending group demonstrated a significantly lower in-hospital mortality rate than the lowest hospital spending group (coefficient = -0.025, 95% confidence interval [CI] -0.034 to -0.015; p < 0.0001). Similarly, the highest hospital spending group was associated with a significantly higher effective cost per survivor than the lowest hospital spending group (coefficient = 77.7, 95% CI 73.1 to 82.3; p < 0.0001). In subgroup analyses, hospitals with a small or medium number of beds demonstrated a consistent pattern with the primary test, whereas those with a large number of beds or academic affiliations displayed no association. Conclusions Using a nationwide Japanese medical claims database, this study indicated that hospitals with greater expenditures were associated with a superior survival rate and a higher effective cost per survivor in patients with sepsis than those with lower expenditures. In contrast, no correlations between hospital spending and mortality were observed in hospitals with a large number of beds or academic affiliations.
Collapse
Affiliation(s)
- Takehiko Oami
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Toshikazu Abe
- Health Services Research and Development Center, University of Tsukuba, Tsukuba, Japan
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Taro Imaeda
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tuerxun Aizimu
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasuo Yamao
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Nakagawa
- Department of Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Asako Matsushima
- Department of Emergency and Critical Care, Nagoya City University Graduate School of Medical Sciences, Aichi, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medical and Dental Sciences, Tokyo, Japan
| |
Collapse
|
7
|
Hwang B, Jeong T, Jo J. Relationships between trauma death, disability, and geographic factors: a systematic review. Clin Exp Emerg Med 2023; 10:426-437. [PMID: 37525580 PMCID: PMC10790073 DOI: 10.15441/ceem.23.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 08/02/2023] Open
Abstract
OBJECTIVE Trauma is a global health problem. The causes of trauma-related deaths are diverse and may depend in part on socioeconomic and geographical factors; however, there have been few studies addressing such relationships. The aim of this study was to investigate the relationships between trauma and geographical factors in order to support policy recommendations to reduce trauma-related deaths and disability. METHODS In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched international and Korean databases to retrieve relevant literature published between 2000 and 2020. RESULTS Thirty-two studies showed a positive relationship between the outcomes of major trauma and geographical factors. The study investigated regional factors including economic factors such as size of urban areas, gross domestic product, and poverty rate, as well as hospital parameters, such as presence of trauma centers and number of hospital beds. There was a tendency toward higher mortality rates in rural and low-income areas, and most of the studies reported that the presence of trauma centers reduced trauma-related mortality rates. CONCLUSION Our study showed that geographic factors influence trauma outcomes. The findings suggest geographical considerations be included in care plans to reduce death and disability caused by trauma.
Collapse
Affiliation(s)
- Bona Hwang
- Korea Disease Control and Prevention Agency, Cheongju, Korea
| | - Taewook Jeong
- Department of Emergency Medical Technology, Seojeong University, Yanju, Korea
| | - Jiyeon Jo
- Chungcheongbukdo Public Health Policy Institute, Cheongju, Korea
- Korea Paramedic Education Research Society, Seoul, Korea
| |
Collapse
|
8
|
Cho NY, Mabeza RM, Bakhtiyar SS, Richardson S, Ali K, Tran Z, Benharash P. National trends and resource associated with recurrent penetrating injury. PLoS One 2023; 18:e0280702. [PMID: 37967100 PMCID: PMC10650986 DOI: 10.1371/journal.pone.0280702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 08/22/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND While recurrent penetrating trauma has been associated with long-term mortality and disability, national data on factors associated with reinjury remain limited. We examined temporal trends, patient characteristics, and resource utilization associated with repeat firearm-related or stab injuries across the US. METHODS This was a retrospective study using 2010-2019 Nationwide Readmissions Database (NRD). NRD was queried to identify all hospitalizations for penetrating trauma. Recurrent penetrating injury (RPI) was defined as those returned for a subsequent penetrating injury within 60 days. We quantified injury severity using the International Classification of Diseases Trauma Mortality Prediction model. Trends in RPI, length of stay (LOS), hospitalization costs, and rate of non-home discharge were then analyzed. Multivariable regression models were developed to assess the association of RPI with outcomes of interest. RESULTS Of an estimated 968,717 patients (28.4% Gunshot, 71.6% Stab), 2.1% experienced RPI within 60 days of the initial injury. From 2010 to 2019, recurrent gunshot wounds increased in annual incidence while that of stab cohort remained stable. Patients experiencing recurrent gunshot wounds were more often male (88.9 vs 87.0%, P<0.001), younger (30 [23-40] vs 32 [24-44] years, P<0.001), and less commonly insured by Medicare (6.5 vs 11.2%, P<0.001) compared to others. Those with recurrent stab wounds were younger (36 [27-49] vs 44 [30-57] years, P<0.001), less commonly insured by Medicare (21.3 vs 29.3%, P<0.001), and had lower Elixhauser Index Comorbidities score (2 [1-3] vs 3 [1-4], P<0.001) compared to others. After risk adjustment, RPI of both gunshot and stab was associated with significantly higher hospitalization costs, a shorter time before readmission, and increased odds of non-home discharge. CONCLUSION The trend in RPI has been on the rise for the past decade. National efforts to improve post-discharge prevention and social support services for patients with penetrating trauma are warranted and may reduce the burden of RPI.
Collapse
Affiliation(s)
- Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Shannon Richardson
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
| |
Collapse
|
9
|
Breeding T, Ngatuvai M, Rosander A, Maka P, Davis J, Knowlton LM, Hoops H, Elkbuli A. Trends in disparities research on trauma and acute care surgery outcomes: A 10-year systematic review of articles published in The Journal of Trauma and Acute Care Surgery. J Trauma Acute Care Surg 2023; 95:806-815. [PMID: 37405809 DOI: 10.1097/ta.0000000000004067] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
ABSTRACT This is a 10-year review of The Journal of Trauma and Acute Care Surgery (JTACS) literature related to health care disparities, health care inequities, and patient outcomes. A retrospective review of articles published in JTACS between January 1, 2013, and July 15, 2022, was performed. Articles screened included both adult and pediatric trauma populations. Included articles focused on patient populations related to trauma, surgical critical care, and emergency general surgery. Of the 4,178 articles reviewed, 74 met the inclusion criteria. Health care disparities related to gender (n = 10), race/ethnicity (n = 12), age (n = 14), income status (n = 6), health literacy (n = 6), location and access to care (n = 23), and insurance status (n = 13) were described. Studies published on disparities peaked in 2016 and 2022 with 13 and 15 studies respectively but dropped to one study in 2017. Studies demonstrated a significant increase in mortality for patients in rural geographical regions and in patients without health insurance and a decrease in patients who were treated at a trauma center. Gender disparities resulted in variable mortality rates and studied factors, including traumatic brain injury mortality and severity, venous thromboembolism, ventilator-associated pneumonia, firearm homicide, and intimate partner violence. Under-represented race/ethnicity was associated with variable mortality rates, with one study demonstrating increased mortality risk and three finding no association between race/ethnicity and mortality. Disparities in health literacy resulted in decreased discharge compliance and worse long-term functional outcomes. Studies on disparities in JTACS over the last decade primarily focused on location and access to health care, age, insurance status, and race, with a specific emphasis on mortality. This review highlights the areas in need of further research and funding in the Journal of Trauma and Acute Care Surgery regarding health care disparities in trauma aimed at interventions to reduce disparities in patient care, ensure equitable care, and inform future approaches targeting health care disparities. LEVEL OF EVIDENCE Systematic Review; Level IV.
Collapse
Affiliation(s)
- Tessa Breeding
- From the Kiran Patel College of Allopathic Medicine (T.B., M.N.), NOVA Southeastern University, Fort Lauderdale, Florida; Arizona College of Osteopathic Medicine, Midwestern University (A.R.), Glendale, Arizona; John A. Burns School of Medicine (P.M.), Honolulu, Hawaii; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (J.D.), The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Trauma and Surgical Critical Care, Department of Surgery (L.M.K.), Stanford University Medical Center, Palo Alto, California; Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (H.H.), Oregon Health & Sciences University, Portland, Oregon; Division of Trauma and Surgical Critical Care, Department of Surgery (A.E.), and Department of Surgical Education (A.E.), Orlando Regional Medical Center, Orlando, Florida
| | | | | | | | | | | | | | | |
Collapse
|
10
|
Gallaher J, An S, Varela C, Schneider A, Charles A. The Bidirectionality of Global Surgical Research: The Utility of the Malawi Trauma Score in the United States Trauma Population. J Surg Res 2023; 291:459-465. [PMID: 37523896 DOI: 10.1016/j.jss.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION Trauma scoring systems provide valuable risk stratification of injured patients. Trauma scoring systems developed in resource-limited settings, such as the Malawi Trauma Score (MTS), are based on readily available clinical information. This study sought to test the performance of the MTS in a United States trauma population. MATERIALS AND METHODS We analyzed the United States National Trauma Data Bank during 2017-2020. MTS uses alertness score: alert, responds to verbal or painful stimuli, or unresponsive (AVPU), age, sex, presence of a radial pulse, and primary anatomic injury location. MTS and an age-adjusted version reflective of the US age distribution, was evaluated for its performance in predicting crude mortality in the National Trauma Data Bank using receiver operating characteristic analysis. We utilized logistic regression to model the odds ratio of death at a particular MTS cutoff. RESULTS A total of 3,833,929 patients were included. The mean age was 49.3 y (sandard deviation 24.4), with a male preponderance (61.1%). Crude mortality was 3.4% (n = 131,452/3,833,929). The area under the curve for the MTS in predicting mortality was 0.87 (95% CI 0.87, 0.88). The area under the curve for a cutoff of 15 was 0.83 (95% CI 0.83, 0.83). An MTS of 15 higher had an odds ratio of death of 46.5 (95% CI 45.9, 47.1), compared to those with a score of 14 or lower. CONCLUSIONS MTS has excellent performance as a predictor of mortality in a US trauma population. MTS is simple to calculate and can be estimated in the prehospital setting or the emergency department. Consequently, it may have utility as a triage tool in both high-income trauma systems and resource-limited settings.
Collapse
Affiliation(s)
- Jared Gallaher
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Selena An
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Andrew Schneider
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony Charles
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Kamuzu Central Hospital, Lilongwe, Malawi
| |
Collapse
|
11
|
Medrano NW, Villarreal CL, Price MA, Bixby PJ, Bulger EM, Eastridge BJ. Access to trauma center care: A statewide system-based approach. J Trauma Acute Care Surg 2023; 95:242-248. [PMID: 37158782 DOI: 10.1097/ta.0000000000004002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Timely access to specialized trauma care is a vital element in patient outcome after severe and critical injury requiring the skills of trauma teams in levels I and II trauma centers to avoid preventable mortality. We used system-based models to estimate timely access to care. METHODS Trauma system models consisted of ground emergency medical services, helicopter emergency medical services, and designated levels I to V trauma centers were constructed for five states. These models incorporated geographic information systems along with traffic data and census block group data to estimate population access to trauma care within the "golden hour." Trauma systems were further analyzed to identify the optimal location for an additional level I or II trauma center that would provide the greatest increase in access. RESULTS The population of the states studied totaled 23 million people, of which 20 million (87%) had access to a level I or II trauma center within 60 minutes. Statewide-specific access ranged from 60% to 100%. Including levels III to V trauma centers, access within 60 minutes increased to 22 million (96%), ranging from 95% to 100%. The addition of a levels I and II trauma center in an optimized location in each state would provide timely access to a higher trauma capability for an additional 1.1 million, increasing total access to approximately 21.1 million people (92%). CONCLUSION This analysis demonstrates that nearly universal access to trauma care is present in these states when including levels I to V trauma centers. However, concerning gaps remain in timely access to levels I and II trauma centers. This study provides an approach to determine more robust statewide estimates of access to care. It highlights the need for a national trauma system, one in which all components of state-managed trauma systems are assembled in a national data set to accurately identify gaps in care. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
Affiliation(s)
- Nicolas W Medrano
- From the Coalition for National Trauma Research (N.W.M., C.L.V., M.A.P., P.J.B.), San Antonio, Texas; Department of Surgery (E.M.B.), University of Washington, Seattle, Washington; and Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas
| | | | | | | | | | | |
Collapse
|
12
|
Salhi RA, Iyengar S, da Silva Bhatia B, Smith GC, Heisler M. How do current police practices impact trauma care in the prehospital setting? A scoping review. J Am Coll Emerg Physicians Open 2023; 4:e12974. [PMID: 37229183 PMCID: PMC10204184 DOI: 10.1002/emp2.12974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 04/08/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Objective In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement. Methods PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion. Results Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level. Conclusions Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.
Collapse
Affiliation(s)
- Rama A. Salhi
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Sonia Iyengar
- University of Michigan Medical SchoolAnn ArborMichiganUSA
| | | | - Graham C. Smith
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Washtenaw/Livingston Medical Control AuthorityAnn ArborMichiganUSA
| | - Michele Heisler
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
| |
Collapse
|
13
|
Peters GA, Ordoobadi AJ, Panchal AR, Cash RE. Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings. PREHOSP EMERG CARE 2023; 27:162-169. [PMID: 34913821 DOI: 10.1080/10903127.2021.2018076] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Rural prehospital care settings are underrepresented in the out-of-hospital cardiac arrest (OHCA) literature. This study aimed to describe treatment patterns and the odds of a favorable patient outcome (e.g., return of spontaneous circulation (ROSC) or being presumptively alive at the end of the incident) among rural OHCA patients in the U.S. METHODS Using the 2018 National Emergency Medical Services Informational System (NEMSIS) dataset, we analyzed OHCA incidents where an emergency medical services (EMS) unit provided cardiopulmonary resuscitation (CPR) and either terminated the resuscitation or completed transport. We excluded traumatic injuries, pediatric patients, and incidents with response time >60 minutes. The primary outcome was ROSC at any time during the EMS incident. The secondary outcome was a binary end-of-event indicator previously described for use in NEMSIS to estimate longer-term outcomes. Multivariable logistic regression was performed for each outcome measure comparing rural, suburban, and urban settings while controlling for key factors. RESULTS A total of 64,489 OHCA incidents were included, with 5,601 (8.9%) in rural settings. Among the full sample of OHCA incidents, ROSC was achieved in 20,578 (33.6%) cases, including 29.2% in rural settings and 34.1% in urban or suburban settings (p < 0.001). Advanced life support units responded to 95.3% of all calls, and a greater proportion of rural OHCA incidents were managed by basic life support units (7.4% vs. 4.2%, p < 0.001). Rural OHCA incidents had longer response times (7.5 vs. 5.9 minutes, p < 0.001), and rural patients were less likely to receive epinephrine (69.3% vs. 73.3%, p < 0.001). Further, EMS clinicians in rural areas were more likely to use mechanical CPR (29.5% vs. 27.6%, p < 0.01) and were less likely to perform advanced airway management (48.5% vs. 54.2%, p < 0.001). Rural patients had lower odds of achieving ROSC than urban patients after controlling for other factors (OR 0.81, 95% CI: 0.75-0.87). Rural patients also had lower odds of having a positive end-of-event outcome (i.e., presumptively alive) after controlling for other factors (OR 0.86, 95% CI: 0.79-0.93). CONCLUSION In this national sample of EMS-treated OHCAs, rural patients had lower odds of a favorable outcome (e.g., ROSC or presumptively alive) compared to those in urban settings.
Collapse
Affiliation(s)
- Gregory A Peters
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Ashish R Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.,National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
14
|
Sen-Crowe B, Sutherland M, McKenney M, Elkbuli A. Nationwide Analysis of the Distribution of Level 1 and Level 2 Trauma Centers Per Population Growth and Motor Vehicle Collision Injuries/Fatalities Utilizing Geographic Information Systems Mapping Technology: Toward Optimizing Access to Trauma Care. Ann Surg 2023; 277:e418-e427. [PMID: 34029229 DOI: 10.1097/sla.0000000000004953] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma centers (TCs) improve patient outcomes. Few investigations detail the US geographical distribution of Level 1 and 2 TCs (L1TCs, L2TCs) regarding motor vehicle collision (MVC) injuries/fatalities. OBJECTIVE We utilized Geographic Information Systems mapping to investigate the distribution of L1TCs and L2TCs in relation to population growth, MVC injuries, and MVC fatalities at the county and regional level to identify any disparities in access to trauma care. METHODS A cross-sectional analysis of L1TC and L2TC distribution, MVC injuries/fatalities, and population growth from 2010 to 2018. Information was gathered at the county and region level for young adults (aged 15-44), middle-aged adults (45-64), and elderly (≥65). RESULTS A total of 263 L1TCs across 46 states and 156 counties and 357 L2TCs across 44 states and 255 counties were identified. The mean distance between L1TCs and L2TCs is 28.3 miles and 31.1 miles, respectively. Seven counties were identified as being at-risk, all in the Western and Southern US regions that experienced ≥10% increase in population size, upward trends in MVC injuries, and upward trends MVC fatalities across all age groups. CONCLUSIONS Seven US counties containing ≤2 ACSCOT-verified and/or state-designated L1TCs or L2TCs experienced a 10% increase in population, MVC injuries, and MVC fatalities across young, middle-aged and elderly adults from 2010 to 2018. This study highlights chronic disparities in access to trauma care for MVC patients. Evaluation of state limitations regarding the distribution of L1TCs and L2TCs, frequent evaluation of local and regional trauma care needs, and strategic interventions to improve access to trauma care may improve patient outcomes for heavily burdened counties.
Collapse
Affiliation(s)
- Brendon Sen-Crowe
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; and
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; and
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; and.,University of South Florida, Tampa, FL
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL; and
| |
Collapse
|
15
|
Hispanic Farmers Experience Shorter EMS Response Times but Longer Emergency Department Length of Stay Following Occupational Injuries. World J Surg 2022; 46:2872-2881. [PMID: 36161352 DOI: 10.1007/s00268-022-06729-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Agriculture has the highest rate of fatal injuries by sector. Hispanic workers also experience more fatal work injuries than every other minority group combined. Pre-hospital and initial trauma evaluation represent an important marker to understand the impact of a trauma system. We sought to investigate whether Hispanic agricultural workers in the United States (US) experience disparities following traumatic occupational injuries in terms of pre-hospital and emergency department care. METHODS We retrospectively analyzed the National Trauma Data Bank from 2012-2016 to understand differences between Hispanic and non-Hispanic farmers in Emergency Medical Services (EMS) response and transport times (minutes), transport mode, transfer rates, presentation to University or Level I trauma hospitals, Injury Severity Scores (ISS), length of stay (LOS) in the emergency department (ED, minutes) or hospital (days), need for the operating room (OR), admittance to the Intensive Care Unit (ICU), and mortality. RESULTS A total of 6,161 farmers were included in our analyses (median age 47 years, females 7.0%). Multivariable analyses indicate differences regarding EMS response, EMS transport, and LOS in the ED. Rates of admission to the ICU, surgical operations, days on a ventilator, discharge from the hospital with supportive care, and mortality did not differ between groups. CONCLUSIONS Non-Hispanic patients have longer median EMS response and total transport times. Hispanic patients have longer median LOS in the ED. However, the lack of significant differences in management variables other than EMS times and ED LOS indicate an equitable delivery of trauma care once patients were transferred from the ED.
Collapse
|
16
|
Trinidad S, Kotagal M. Social determinants of health as drivers of inequities in pediatric injury. Semin Pediatr Surg 2022; 31:151221. [PMID: 36347129 DOI: 10.1016/j.sempedsurg.2022.151221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A child's social determinants of health (SDH), including their neighborhood environment, insurance status, race and ethnicity, English language proficiency and geographic location, all significantly impact their risk of injury and outcomes after injury. Children from socioeconomically disadvantaged neighborhoods experience overall higher rates of injury and different types of injuries, including higher rates of motor vehicle-, firearm-, and violence-related injuries. Similarly, children with public insurance or no insurance, as a proxy for lower socioeconomic status, experience higher rates of injuries including firearm-related injuries and non-accidental trauma, with overall worse outcomes. Race and associated racism also impact a child's risk of injury and care received after injury. Black children, Hispanic children, and those from other minority groups disproportionately experience socioeconomic disadvantage with sequelae of injury risk as described above. Even after controlling for socioeconomic status, there are still notable disparities with further evidence of racial inequities and bias in pediatric trauma care after injury. Finally, where a child lives geographically also significantly impacts their risk of injury and available care after injury, with differences based on whether a child lives in a rural or urban area and the degree of state laws regarding injury prevention. There are clear inequities based on a child's SDH, most predominantly in a child's risk of injury and the types of injuries they experience. These injuries are preventable and the SDH provide potential upstream targets in injury prevention efforts.
Collapse
Affiliation(s)
- Stephen Trinidad
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children...s Hospital Medical Center, Cincinnati, Ohio.
| | - Meera Kotagal
- Assistant Professor, Division of General and Thoracic Surgery, Director, Trauma Services, Director, Pediatric Surgery Global Health Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2023, Cincinnati, OH 45229, United States.
| |
Collapse
|
17
|
Peterman N, Smith EJ, Liang E, Yeo E, Kaptur B, Naik A, Arnold PM, Hassaneen W. Geospatial evaluation of disparities in neurosurgical access in the United States. J Clin Neurosci 2022; 105:109-114. [PMID: 36148727 DOI: 10.1016/j.jocn.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 08/15/2022] [Accepted: 09/02/2022] [Indexed: 11/25/2022]
Abstract
When neurosurgical care is needed, the distance to a facility staffed with a neurosurgeon is critical. This work utilizes geospatial analysis to analyze access to neurosurgery in the Medicare population and relevant socioeconomic factors. Medicare billing and demographic data from 2015 to 2019 were combined with national National Provider Identifier (NPI) registry data to identify the average travel distance to reach a neurosurgeon as well as the number of neurosurgeons in each county. This was merged with U.S. Census data to capture 23 socioeconomic attributes. Moran's I statistic was calculated across counties. Socioeconomic variables were compared using ANOVA. Hotspots with the highest neurosurgeon access were predominantly located in the Mid-Atlantic region, central Texas, and southern Montana. Coldspots were found in the Great Plains, Midwest, and Southern Texas. There were statistically significant differences (p < 0.05) between high- and low-access counties, including: stroke prevalence, poverty, median household income, and total population density. There were no statistically significant differences in most races or ethnicities. Overall, there exist statistically significant clusters of decreased neurosurgery access within the United States, with varying sociodemographic characteristics between access hotspots and coldspots.
Collapse
Affiliation(s)
| | | | - Edward Liang
- Carle Illinois College of Medicine, Urbana, IL, USA
| | - Eunhae Yeo
- Carle Illinois College of Medicine, Urbana, IL, USA
| | | | - Anant Naik
- Carle Illinois College of Medicine, Urbana, IL, USA
| | - Paul M Arnold
- Carle Illinois College of Medicine, Urbana, IL, USA; Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA
| | - Wael Hassaneen
- Carle Illinois College of Medicine, Urbana, IL, USA; Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA.
| |
Collapse
|
18
|
Invited Commentary: Financial Vulnerability of Trauma Centers: Where Are the Data? J Am Coll Surg 2022; 235:435-437. [PMID: 35972162 DOI: 10.1097/xcs.0000000000000219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
19
|
Zogg CK, Becher RD, Dalton MK, Hirji SA, Davis KA, Salim A, Cooper Z, Jarman MP. Defining Referral Regions for Inpatient Trauma Care: The Utility of a Novel Geographic Definition. J Surg Res 2022; 275:115-128. [PMID: 35272088 PMCID: PMC9038698 DOI: 10.1016/j.jss.2021.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Geographic variation is an inherent feature of the US health system. Despite efforts to account for geographic variation in trauma system strengthening, it remains unclear how trauma "regions" should be defined. The objective of this study is to evaluate the utility of a novel definition of Trauma Referral Regions (TRR) for assessing geographic variation in inpatient trauma across the age span of hospitalized trauma patients. METHODS Using 2016-2017 State Inpatient Databases, we assessed the extent of geographic variability in three common metrics of hospital use (localization index, market share index, net patient flow) among TRRs and, as a comparison, trauma regions alternatively defined based on Hospital Referral Regions, Hospital Service Areas, and counties. RESULTS A total of 860,593 admissions from 102 TRRs, 127 Hospital Referral Regions, 884 Hospital Service Areas, and 583 counties were included. Consistent with expectations for distinct trauma regions, TRR presented with high average localization indices (mean [standard deviation]: 83.4 [11.7%]), low market share indices (mean [standard deviation]: 11.9 [7.0%]), and net patient flows close to 1.00. Similar results were found among stratified pediatric, adult, and older adult patients. Associations between TRRs and variations in important demographic features (e.g., travel time by road to the nearest Level I or II Trauma Center) suggest that while indicative of standalone trauma regions, TRRs are also able to simultaneously capture critical variations in regional trauma care. CONCLUSIONS TRRs offer a standalone set of geographic regions with minimal variation in common metrics of hospital use, minimal geographic clustering, and preserved associations with important demographic factors. They provide a needed, valid means of assessing geographic variation among trauma systems.
Collapse
Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut; Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts.
| | | | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Sameer A Hirji
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | | | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
20
|
Wohlgemut JM, Ramsay G, Bekheit M, Scott NW, Watson AJM, Jansen JO. Emergency general surgery: impact of distance and rurality on mortality. BJS Open 2022; 6:6573396. [PMID: 35466374 PMCID: PMC9035437 DOI: 10.1093/bjsopen/zrac032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/13/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There is debate about whether the distance from hospital, or rurality, impacts outcomes in patients admitted under emergency general surgery (EGS). The aim of this study was to determine whether distance from hospital, or rurality, affects the mortality of emergency surgical patients admitted in Scotland. METHODS This was a retrospective population-level cohort study, including all EGS patients in Scotland aged 16 years or older admitted between 1998 and 2018. A multiple logistic regression model was created with inpatient mortality as the dependent variable, and distance from hospital (in quartiles) as the independent variable of interest, adjusting for age, sex, co-morbidity, deprivation, admission origin, diagnosis category, operative category, and year of admission. A second multiple logistic regression model was created with a six-fold Scottish Urban Rural Classification (SURC) as the independent variable of interest. Subgroup analyses evaluated patients who required operations, emergency laparotomy, and inter-hospital transfer. RESULTS Data included 1 572 196 EGS admissions. Those living in the farthest distance quartile from hospital had lower odds of mortality than those in the closest quartile (OR 0.829, 95 per cent c.i. 0.798 to 0.861). Patients from the most rural areas (SURC 6) had higher odds of survival than those from the most urban (SURC 1) areas (OR 0.800, 95 per cent c.i. 0.755 to 0.848). Subgroup analysis showed that these effects were not observed for patients who required emergency laparotomy or transfer. CONCLUSION EGS patients who live some distance from a hospital, or in rural areas, have lower odds of mortality, after adjusting for multiple covariates. Rural and distant patients undergoing emergency laparotomy have no survival advantage, and transferred patients have higher mortality.
Collapse
Affiliation(s)
- Jared M. Wohlgemut
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - George Ramsay
- General Surgical Department, Aberdeen Royal Infirmary, Aberdeen, UK,Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mohamed Bekheit
- General Surgical Department, Aberdeen Royal Infirmary, Aberdeen, UK,Department of Surgery, Elkabbary Hospital, Alexandria, Egypt
| | - Neil W. Scott
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | | | - Jan O. Jansen
- Correspondence to: Jan O. Jansen, Division of Trauma & Acute Care Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, Alabama 35294, USA (e-mail: )
| |
Collapse
|
21
|
Jarman MP, Jin G, Weissman JS, Ash AS, Tjia J, Salim A, Haider A, Cooper Z. Association of Trauma Center Designation With Postdischarge Survival Among Older Adults With Injuries. JAMA Netw Open 2022; 5:e222448. [PMID: 35294541 PMCID: PMC8928003 DOI: 10.1001/jamanetworkopen.2022.2448] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 01/12/2022] [Indexed: 01/14/2023] Open
Abstract
Importance Trauma centers improve outcomes for young patients with serious injuries. However, most injury-related hospital admissions and deaths occur in older adults, and it is not clear whether trauma center care provides the same benefit in this population. Objective To examine whether 30- and 365-day mortality of injured older adults is associated with the treating hospital's trauma center level. Design, Setting, and Participants This prospective, population-based cohort study used Medicare claims data from January 1, 2013, to December 31, 2016, for all fee-for-service Medicare beneficiaries 66 years or older with inpatient admission for traumatic injury in 2014 to 2015. Data analysis was performed from January 1 to June 31, 2021. Preinjury health was measured using 2013 claims, and outcomes were measured through 2016. The population was stratified by anatomical injury pattern. Propensity scores for level I trauma center treatment were estimated using the Abbreviated Injury Scale, age, and residential proximity to trauma center and then used to match beneficiaries from each trauma level (I, II, III, and IV/non-trauma centers) by injury type. Exposure Admitting hospital's trauma center level. Main Outcomes and Measures Case fatality rates (CFRs) at 30 and 365 days after injury, estimated in the matched sample using multivariable, hierarchical logistic regression models. Results A total of 433 169 Medicare beneficiaries (mean [SD] age, 82.9 [8.3] years; 68.4% female; 91.5% White) were included in the analysis. A total of 206 275 (47.6%) were admitted to non-trauma centers and 161 492 (37.3%) to level I or II trauma centers. Patients with isolated extremity fracture had the fewest deaths (365-day CFR ranged from 16.1% [95% CI, 11.2%-22.4%] to 17.4% [95% CI, 11.8%-24.6%] by trauma center status). Patients with both hip fracture and traumatic brain injury had the most deaths (365-day CFRs ranged from 33.4% [95% CI, 25.8%-42.1%] to 35.8% [95% CI, 28.9%-43.5%]). Conclusions and Relevance These findings suggest that older adults do not benefit from existing trauma center care, which is designed with younger patients in mind. There is a critical need to improve trauma care practices to address common injury mechanisms and types of injury in older adults.
Collapse
Affiliation(s)
- Molly P. Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ginger Jin
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Joel S. Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Arlene S. Ash
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worchester
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worchester
| | - Ali Salim
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Medical College, The Aga Khan University, Karachi, Pakistan
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
- Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
22
|
Jenkins PC, Timsina L, Murphy P, Tignanelli C, Holena DN, Hemmila MR, Newgard C. Extending Trauma Quality Improvement Beyond Trauma Centers: Hospital Variation in Outcomes Among Nontrauma Hospitals. Ann Surg 2022; 275:406-413. [PMID: 35007228 PMCID: PMC8794234 DOI: 10.1097/sla.0000000000005258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The American College of Surgeons (ACS) conducts a robust quality improvement program for ACS-verified trauma centers, yet many injured patients receive care at non-accredited facilities. This study tested for variation in outcomes across non-trauma hospitals and characterized hospitals associated with increased mortality. SUMMARY BACKGROUND DATA The study included state trauma registry data of 37,670 patients treated between January 1, 2013, and December 31, 2015. Clinical data were supplemented with data from the American Hospital Association and US Department of Agriculture, allowing comparisons among 100 nontrauma hospitals. METHODS Using Bayesian techniques, risk-adjusted and reliability-adjusted rates of mortality and interfacility transfer, as well as Emergency Departments length-of-stay (ED-LOS) among patients transferred from EDs were calculated for each hospital. Subgroup analyses were performed for patients ages >55 years and those with decreased Glasgow coma scores (GCS). Multiple imputation was used to address missing data. RESULTS Mortality varied 3-fold (0.9%-3.1%); interfacility transfer rates varied 46-fold (2.1%-95.6%); and mean ED-LOS varied 3-fold (81-231 minutes). Hospitals that were high and low statistical outliers were identified for each outcome, and subgroup analyses demonstrated comparable hospital variation. Metropolitan hospitals were associated increased mortality [odds ratio (OR) 1.7, P = 0.004], decreased likelihood of interfacility transfer (OR 0.7, P ≤ 0.001), and increased ED-LOS (coef. 0.1, P ≤ 0.001) when compared with nonmetropolitan hospitals and risk-adjusted. CONCLUSIONS Wide variation in trauma outcomes exists across nontrauma hospitals. Efforts to improve trauma quality should include engagement of nontrauma hospitals to reduce variation in outcomes of injured patients treated at those facilities.
Collapse
Affiliation(s)
- Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lava Timsina
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick Murphy
- Department of Surgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | | | - Daniel N. Holena
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark R. Hemmila
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, OR, USA
| |
Collapse
|
23
|
Hassler J, Ceccato V. Socio-spatial disparities in access to emergency health care-A Scandinavian case study. PLoS One 2021; 16:e0261319. [PMID: 34890436 PMCID: PMC8664193 DOI: 10.1371/journal.pone.0261319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/30/2021] [Indexed: 11/17/2022] Open
Abstract
Having timely access to emergency health care (EHC) depends largely on where you live. In this Scandinavian case study, we investigate how accessibility to EHC varies spatially in order to reveal potential socio-spatial disparities in access. Distinct measures of EHC accessibility were calculated for southern Sweden in a network analysis using a Geographical Information System (GIS) based on data from 2018. An ANOVA test was carried out to investigate how accessibility vary for different measures between urban and rural areas, and negative binominal regression modelling was then carried out to assess potential disparities in accessibility between socioeconomic and demographic groups. Areas with high shares of older adults show poor access to EHC, especially those in the most remote, rural areas. However, rurality alone does not preclude poor access to EHC. Education, income and proximity to ambulance stations were also associated with EHC accessibility, but not always in expected ways. Despite indications of a well-functioning EHC, with most areas served within one hour, socio-spatial disparities in access to EHC were detected both between places and population groups.
Collapse
Affiliation(s)
- Jacob Hassler
- Department of Urban Planning and Environment, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Vania Ceccato
- Department of Urban Planning and Environment, KTH Royal Institute of Technology, Stockholm, Sweden
| |
Collapse
|
24
|
Whitley JA, Kieran K. Geographic Variations in Pharmacy Services and Availability of Commonly Prescribed Pediatric Urology Medications: An Opportunity to Improve Health Equity in Washington State. Urology 2021; 165:285-293. [PMID: 34808141 DOI: 10.1016/j.urology.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/29/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe geographic and sociodemographic variations in operating hours and availability of medications commonly prescribed by pediatric urologists at Washington State retail pharmacies. METHODS We identified all retail pharmacies in the state. We stratified counties by population density and household income (HI) and compared differences in pharmacy operating hours and availability of 10 commonly prescribed medications. RESULTS 1057/1058 pharmacies were contacted. All pharmacies had liquid formulations of oxycodone, hydrocodone, ibuprofen, acetaminophen, amoxicillin, and trimethoprim-sulfamethoxazole in stock. Liquid formulations of ciprofloxacin (10%) and oxybutynin (14.3%) were uncommonly stocked, while 92.5% of pharmacies stocked nitrofurantoin suspension, and 80.9% nitrofurantoin capsules. Statewide, 108 (10.2%) of pharmacies were closed on Saturdays and 297 (28.1%) closed on Sunday. More high (HPDC) than low population density (LPDC) (62.5% vs 0%, P < .001) and high-HI than low-HI counties (62.5% vs 0%, P = .30) had 24-hour pharmacies. A larger proportion of pharmacies were open 7-days in HPDC than LPDC (75.6% vs 56.2%, P < .0001) and in high-HI than low-HI counties (100% vs 62.5%, P = .30). The likelihood of a pharmacy being open 7 days/week was significantly higher in HPDC (vs LPDC; OR = 13.2, 95% CI: 4.39-39.7) and high-HI (vs low-HI; OR = 4.98, 95% CI: 2.58-9.60) counties. CONCLUSION Most pharmacies in Washington State carry medications commonly prescribed by pediatric urologists. However, retail pharmacy operating hours are widely variable and create geographic and temporal barriers in rural and poor areas that may limit the timely administration of prescription medication. Providers should consider a patient's practical ability to fill a prescription when starting a time-sensitive medication.
Collapse
Affiliation(s)
- Jorge A Whitley
- Division of Urology, Seattle Children's Hospital, Seattle, WA
| | - Kathleen Kieran
- Division of Urology, Seattle Children's Hospital, Seattle, WA; Department of Urology, University of Washington, Seattle, WA.
| |
Collapse
|
25
|
Magyar CTJ, Bednarski P, Jakob DA, Schnüriger B. Severe penetrating trauma in Switzerland: first analysis of the Swiss Trauma Registry (STR). Eur J Trauma Emerg Surg 2021; 48:3837-3846. [PMID: 34727193 DOI: 10.1007/s00068-021-01822-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to examine the epidemiology, demographics, injury characteristics and outcomes of patients who presented to Swiss trauma centers following severe penetrating trauma. METHODS Swiss Trauma Registry (STR)-cohort analysis including patients with severe (ISS ≥ 16 or AIS head ≥ 3) penetrating trauma between 2017 and 2019. Primary outcome was mortality. Secondary outcomes were hospital and intensive care unit (ICU) length of stay (LOS), and prehospital times. RESULTS During the 3-year study period, 134 (1.6% of entire STR) patients with severe penetrating trauma were identified [64 (48%) gunshot wounds (GSW), 70 (52%) stab wounds (SW)]. Median age was 40.5 (IQR 29.0-59.0) and 82.8% were male. Mortality rate was 50% for GSW; 9% for SW. Overall, prehospital time [incident to arrival emergency department (ED)] was 65 (IQR 45-94) minutes. The median number of patients admitted for a severe GSW/SW per center and year was 2 (range 0-14). Of 64 patients who sustained a GSW, 42 (65.6%) were self-inflicted. Mortality in self-inflicted GSW reached 66.7%, with the head being severely injured in 78.6%. The 67 patients with severe isolated torso GSW/SW had an ISS of 20 (IQR 16-26) and a mortality of 15%. Multivariable analysis identified severe chest trauma, ED Glasgow Coma Scale ≤ 8, age, self-infliction, massive blood transfusion and ISS as independent predictors for mortality. CONCLUSION Severe penetrating trauma is very rare in Switzerland. Mortality ranges from 9% in SW to 67% in self-inflicted GSW. Particularly in the setting of GSW/SW to the torso, reduction in prehospital time may further improve patient outcomes.
Collapse
Affiliation(s)
- Christian T J Magyar
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Piotr Bednarski
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Dominik A Jakob
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Beat Schnüriger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | | |
Collapse
|
26
|
Liu Z, Ayyagari RC, Martinez Monegro EY, Stansbury LG, Arbabi S, Bulger EM, Vavilala MS, Hess JR. Blood component use and injury characteristics of acute trauma patients arriving from the scene of injury or as transfers to a large, mature US Level 1 trauma center serving a large, geographically diverse region. Transfusion 2021; 61:3139-3149. [PMID: 34632587 DOI: 10.1111/trf.16679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/09/2021] [Accepted: 08/30/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Advanced trauma care demands the timely availability of hemostatic blood products, posing special challenges for regional systems in geographically diverse areas. We describe acute trauma blood use by transfer status and injury characteristics at a large regional Level 1 trauma center. STUDY DESIGN AND METHODS We reviewed Harborview Medical Center (HMC) Trauma Registry, Transfusion Service, and electronic medical records on acute trauma patients for demographics, injury patterns, blood use, and in-hospital mortality, 2011-2019. RESULTS Among 47,471 patients (mean age 45.2 ± 23.0 years; 68.3% male; Injury Severity Score 12.6 ± 11.1), 4.7% died and 8547 (18%) received at least one blood component through HMC. Firearms injuries were the most often transfused (690/2596, 26.6%) and the most urgently (39.9% ≥3 units in <1 h; 40.6% ≥5 units in <4 h), and had the highest mortality (case-fatality, 12.2%) (all p < .001). From-scene patients were younger than transfers (42.9 ± 21.0 vs. 47.2 ± 24.4), predominated among firearms injuries (68.2% from-scene vs. 31.8% transfers), were more likely to receive blood (18.5% vs. 17.6%) more urgently (≥3 units first hour, 24.4% vs. 7.7%; ≥5 units first 4 h: 25.6% vs. 8.2%), were more likely to die of hemorrhage (15.5% vs. 4.3%) and from firearms injuries (310/1360, 22.8%) (all p < .001). DISCUSSION Early blood use, firearms injuries, and mortality were all greater among from-scene patients, and firearms injuries had worse outcomes despite greater and more urgent blood use, but the role of survivor bias for transfer patients must be clarified. Future research must identify strategies for providing local hemostatic transfusion support, particularly for firearms injuries.
Collapse
Affiliation(s)
- Zhinan Liu
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Rajiv C Ayyagari
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Edison Y Martinez Monegro
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,San Juan Bautista School of Medicine, Cauguas, Puerto Rico
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - John R Hess
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA.,Harborview Medical Center Transfusion Medicine Service, Harborview Transfusion Medicine Service, Seattle, Washington, USA
| |
Collapse
|
27
|
Jarman MP, Weaver MJ, Haider AH, Salim A, Harris MB. Geographic Distribution of Orthopaedic Trauma Resources and Service Use in the United States: A Cross Sectional Analysis. J Surg Res 2021; 267:328-335. [PMID: 34186309 DOI: 10.1016/j.jss.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/15/2021] [Accepted: 05/26/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Management of orthopaedic injury is an essential component of comprehensive trauma care, and availability of orthopaedic surgeons impacts trauma system capacity and accessibility of care. We sought to estimate the geographic distribution of orthopaedic injury in the United States and identify regions needing additional orthopaedic trauma resources. METHODS In this retrospective cross-sectional study using 2014 Agency for Healthcare Research and Quality State Inpatient Datasets from 26 states and the District of Columbia, administrative data were used to determine hospital referral region (HRR)-level incidence of orthopaedic trauma and surgical care. Factors associated with HRR-level orthopaedic trauma volume were identified using negative binomial regression, and model parameters were used to estimate injury incidence and operative volume in unobserved HRRs. The primary outcomes of interest were HRR-level incidence of orthopaedic injury, polytrauma, and emergency orthopaedic surgery, as well and the number of emergency orthopaedic surgery patients per orthopaedic surgeon. RESULTS Orthopaedic injury incidence and operative patients per orthopaedic surgeon were associated with HRR-level volume of medical service use, population characteristics, geographic characteristics, and existing trauma care resources. Orthopaedic injury incidence ranged from 20 patients/HRR to 33,260 patients/HRR. Polytrauma incidence ranged from < 10 patients/HRR to 12,140 patients/HRR. Emergency orthopaedic surgery incidence ranged from < 10 patients/HRR to 18,759 patients/HRR. The volume of operative orthopaedic trauma patients per orthopaedic surgeon ranged from < 10 patients/surgeon to 224 patients and/or surgeon. DISCUSSION The incidence of orthopaedic injury and volume of injury patients per orthopaedic surgeon varies substantially across HRRs in the United States. Regions with high patient volume and moderate patient-to-provider ratios may be ideal settings for orthopaedic trauma training programs or post-fellowship professional opportunities. Future research should examine the impact of high volume orthopaedic trauma volume and high patient-to-provider ratios on health outcomes.
Collapse
Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; College of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Salim
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
28
|
Genowska A, Jamiołkowski J, Szafraniec K, Fryc J, Pająk A. Health Care Resources and 24,910 Deaths Due to Traffic Accidents: An Ecological Mortality Study in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115561. [PMID: 34067502 PMCID: PMC8197000 DOI: 10.3390/ijerph18115561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/16/2022]
Abstract
Background: Deaths due to traffic accidents are preventable and the access to health care is an important determinant of traffic accident case fatality. This study aimed to assess the relation between mortality due to traffic accidents and health care resources (HCR), at the population level, in 66 sub-regions of Poland. Methods: An area-based HCR index was delivered from the rates of physicians, nurses, and hospital beds. Associations between mortality from traffic accidents and the HCR index were tested using multivariate Poisson regression models. Results: In the sub-regions studied, the average mortality from traffic accidents was 11.7 in 2010 and 9.3/100.000 in 2015. After adjusting for sex, age and over time trends in mortality, out-of-hospital deaths were more frequently compared to hospitalized fatal cases (incidence rate ratio (IRR) = 1.68, 95% CI 1.45–1.93). Compared to sub-regions with high HCR, mortality from traffic accidents was higher in sub-regions with low and moderate HCR (IRR = 1.25, 95% CI 1.11–1.42 and IRR = 1.19, 95% CI 1.02–1.38, respectively), which reflected the differences in out-of-hospital mortality most pronounced in car accidents. Conclusions: Poor HCR is an important factor that explains the territorial differentiation of mortality due to traffic accidents in Poland. The high percentage of out-of-hospital deaths indicates the importance of preventive measures and the need for improvement in access to health care to reduce mortality due to traffic accidents.
Collapse
Affiliation(s)
- Agnieszka Genowska
- Department of Public Health, Medical University of Bialystok, 15-295 Bialystok, Poland
- Correspondence: (A.G.); (J.F.)
| | - Jacek Jamiołkowski
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, 15-269 Bialystok, Poland;
| | - Krystyna Szafraniec
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, 31-066 Krakow, Poland; (K.S.); (A.P.)
| | - Justyna Fryc
- Faculty of Medicine, Medical University of Bialystok, 15-540 Bialystok, Poland
- Correspondence: (A.G.); (J.F.)
| | - Andrzej Pająk
- Department of Epidemiology and Population Studies, Jagiellonian University Medical College, 31-066 Krakow, Poland; (K.S.); (A.P.)
| |
Collapse
|
29
|
Disparities in rural versus urban field triage: Risk and mitigating factors for undertriage. J Trauma Acute Care Surg 2020; 89:246-253. [DOI: 10.1097/ta.0000000000002690] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
30
|
McCarthy R, Gino B, Williams KL, d'Entremont P, Renouf TS. Prehospital Trauma Care: A Simulation Scenario for Rural-Based Healthcare Providers. Cureus 2020; 12:e8834. [PMID: 32742845 PMCID: PMC7384714 DOI: 10.7759/cureus.8834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/25/2020] [Indexed: 12/03/2022] Open
Abstract
Trauma is a major cause of premature death and disability worldwide, with a disproportionate number of deaths occurring in rural and remote areas. Prehospital care is a key link in the chain of trauma survival and its role may be currently underestimated. Therefore, addressing deficiencies in prehospital trauma care may help to improve outcomes. Several potential solutions have been proposed to address the disparities that exist in rural prehospital trauma care, some of which focus on educational endeavors. Simulation-based medical education (SBME) is one cost-effective strategy to train healthcare providers in high-acuity, low-opportunity (HALO) scenarios, such as those encountered during major trauma. The aim of this technical report is to present a mass casualty simulation scenario that is intended for healthcare providers in rural and remote locations to refine their skills and comfort level with such cases. It emphasizes prehospital trauma management and effective communication skills among healthcare teams, which are two key elements in improving trauma outcomes.
Collapse
Affiliation(s)
- Robert McCarthy
- Family Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, CAN
| | - Bruno Gino
- Emergency Medicine, Madrecor Hospital, Uberlândia, BRA
- Pre-Hospital, SIATE - Integrated Trauma and Emergency Assistance System, Uberlândia, BRA
| | - Kerry-Lynn Williams
- Family Medicine, Memorial University of Newfoundland, Happy Valley-Goose Bay, CAN
| | | | - Tia S Renouf
- Emergency Medicine, Memorial University of Newfoundland, St. John's, CAN
| |
Collapse
|
31
|
Sborov KD, Gallagher KC, Medvecz AJ, Brywczynski J, Gunter OL, Guillamondegui OD, Dennis BM, Smith MC. Impact of a New Helicopter Base on Transport Time and Survival in a Rural Adult Trauma Population. J Surg Res 2020; 254:135-141. [PMID: 32445928 DOI: 10.1016/j.jss.2020.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/04/2020] [Accepted: 04/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Significant disparities in access to prompt helicopter transport exist among rural trauma populations. We evaluated the impact of an additional helicopter base on transport time and mortality in a rural adult trauma population. MATERIALS AND METHODS We performed a retrospective cohort study of adult patients with trauma transported by helicopter from scene to a level one trauma center between 2014 and 2018. A new rural helicopter base added to the trauma center's catchment area in 2016 served as the transition time for an interrupted time series analysis. Patients injured in this base's county and adjoining counties were analyzed. Baseline characteristics were compared with a Student's t-test and Pearson's chi-squared test. Cox and linear regression models evaluated the new base's effect on mortality and transport time, respectively. RESULTS A total of 332 patients were analyzed: 120 (36.1%) transported before the addition of the new helicopter base and 212 (63.9%) transported after. Patients transported after the addition of the base had higher injury severity score (13.7 versus 10.1, P < 0.001) and were more likely to receive blood en route (19.3% versus 6.7%, P = 0.005). After the addition of the base, there was a decreased hazard ratio for mortality (hazard ratio 0.26, 95% confidence interval: 0.11-0.65, P = 0.004) with no significant change in transport time (-36.7 min, P = 0.071) for the area. CONCLUSIONS Local helicopter transport units may confer improved survival for the injured patient. This study demonstrates the important role of helicopter transport within a regional trauma system and the impact that expanded access to rapid air transport can have on mortality.
Collapse
Affiliation(s)
- Katherine D Sborov
- Division of Trauma and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathleen C Gallagher
- Division of Trauma and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew J Medvecz
- Division of Trauma and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeremy Brywczynski
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oliver L Gunter
- Division of Trauma and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oscar D Guillamondegui
- Division of Trauma and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley M Dennis
- Division of Trauma and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C Smith
- Division of Trauma and Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee.
| |
Collapse
|