The Importance of Place of Residence on Hospitalized Outcomes for Severely Injured Trauma Patients: A Trauma Registry Analysis

Trauma Outcomes Based on Remoteness of Injury in Australia: A Systemic Review

INTRODUCTION

Research suggests a significant disparity between rural and urban trauma patient outcomes, causing substantial social, economic and emotional costs, impacting health-related quality of life and functionality, and straining our healthcare system. There has not been a systematic examination of contributing factors in Australia.

OBJECTIVE

This study aims to systematically describe the nature of research on trauma outcomes by geographical location and (where possible) describe factors found to increase or decrease the likelihood and severity of injury in rural Australia.

DESIGN

Five databases (EMBASE, PubMed/MEDLINE, Web of Science, Scopus, CINAHL) and reference lists were searched. Eligible studies compared injury outcomes by geographic location in Australia, using a quantitative study design. No restrictions were placed on publication year or outcomes explored. The results were synthesised narratively.

FINDINGS

We found 14 papers. Mortality, the most studied outcome (n = 11), was overall positively related to traumatic incidents in more rural locations. Other data outcomes included hospital admissions and length of stay, admission to ICU, 28-day hospital readmission, rehabilitation, and patient-reported quality of life. Study findings show different mechanisms of injury (e.g., falls) and limited accounts of pre-hospital experiences.

DISCUSSION

Geographical location of trauma may impact the likelihood of injury mortality but is potentially confounded by the different mechanisms and severity of injury. There is insufficient evidence to make conclusions on other non-mortality and longer-term outcomes, and a greater understanding of prehospital outcomes is also needed.

CONCLUSION

This relationship is considered weak due to the limited geographic representation across Australia and the general paucity of recent literature.

Increased distance or time from a major trauma centre in South Australia is not associated with worse outcomes after moderate to severe traumatic brain injury

OBJECTIVE

Considerations in traumatic brain injury (TBI) management include time to critical interventions and neurosurgical care, which can be influenced by the geographical location of injury. In Australia, these distances can be vast with varying degrees of first-responder experience. The present study aimed to evaluate the association that distance and/or time to a major trauma centre (MTC) had on patient outcomes with moderate to severe TBI.

METHODS

A retrospective cohort study was conducted using data from the Royal Adelaide Hospital's (RAH) Trauma Registry over a 3-year period (1 January 2018 to 31 December 2020). All patients with a moderate to severe TBI (Glasgow Coma Scale [GCS] ≤13 and abbreviated injury score head of ≥2) were included. The association of distance and time to the RAH and patient outcomes were compared by calculating the odds ratio utilising a logistic regression model.

RESULTS

A total of 378 patients were identified; of these, 226 met inclusion criteria and comprised our study cohort. Most patients were male (79%), injured in a major city (55%), with median age of 38 years old and median injury severity score (ISS) of 25. After controlling for age, ISS, ED GCS on arrival and pre-MTC intubation, increasing distance or time from injury site to the RAH was not shown to be associated with mortality or discharge destination in any of the models investigated.

CONCLUSION

Our analysis revealed that increasing distance or time from injury site to a MTC for patients with moderate to severe TBI was not significantly associated with adverse patient outcomes.

Disadvantaged by More Than Distance: A Systematic Literature Review of Injury in Rural Australia

Rural populations experience injury-related mortality and morbidity rates 1.5 times greater than metropolitan residents. Motivated by a call for stronger epidemiological evidence around rural injuries to inform prevention, a systematic review of peer-reviewed literature published between January 2010 and March 2021 was undertaken to explore the epidemiology of rural injury and associated risk factors in Australia. A subsequent aim was to explore definitions of rurality used in injury prevention studies. There were 151 papers included in the review, utilizing 23 unique definitions to describe rurality. People living in rural areas were more likely to be injured, for injuries to be more severe, and for injuries to have greater resulting morbidity than people in metropolitan areas. The increase in severity reflects the mechanism of rural injury, with rural injury events more likely to involve a higher energy exchange. Risk-taking behavior and alcohol consumption were significant risk factors for rural injury, along with rural cluster demographics such as age, sex, high socio-economic disadvantage, and health-related comorbidities. As injury in rural populations is multifactorial and nonhomogeneous, a wide variety of evidence-based strategies are needed. This requires funding, political leadership for policy formation and development, and implementation of evidence-based prevention interventions.

Rural and urban patterns of severe injuries and hospital mortality in Australia: An analysis of the Australia New Zealand Trauma Registry: 2015-2019

INTRODUCTION

In Australia, people living in rural areas, compared to major cities are at greater risk of poor health. There is much evidence of preventable disparities in trauma outcomes, however research quantifying geographic variations in injuries, pathways to specialised care and patient outcomes is scarce.

AIMS

(i) To analyse the Australia New Zealand Trauma Registry (ATR) data and report patterns of serious injuries according to rurality of the injury location ii) to examine the relationship between rurality and hospital mortality and iii) to compare ATR death rates with all deaths from similar causes, Australia-wide.

METHOD

A retrospective cohort study of patients in the ATR from 1^st July 2015 to 30^th June 2019 was conducted. Descriptive analyses of trauma variables according to rurality was performed. Logistic regression quantified the moderating effect of rurality on trauma variables and hospital mortality. Australian death data on similar injuries were sourced to quantify the additional mortality attributable to severe injury occurring outside Major Trauma Centres (MTCs).

RESULTS

Compared to major cities, rural patients were younger, more likely to have spinal cord injuries, and sustain traffic-related injuries that are 'off road'. Injuries occurring outside people's homes are more likely. Mortality risk was greater for patients sustaining severe traumatic brain injury (TBI) spinal cord injury (SCI) and head trauma in addition to intentional injuries. Compared to the ATR data, Australian population-wide trauma mortality rates showed diverging trends according to rurality. The ATR only captures 14.1% of all injury deaths occurring in major cities and, respectively, 6.3% and 3.2% of deaths in regional and remote areas.

CONCLUSION

Compared to major cities, injuries occurring in rural areas of Australia often involve different mechanisms and result in different types of severe injuries. Patients with neurotrauma and intentional injuries who survived to receive definitive care at a MTC were at higher risk of hospital death. To inform prevention strategies and reduce morbidity and mortality associated with rural trauma, improvements to data systems are required that involve data linkage and include information about patient care from pre-hospital providers, regional hospitals and major trauma centres.

Screening in Trauma for Opioid Misuse Prevention (STOMP): Results from a prospective cohort of victims of traumatic injury

BACKGROUND

Traumatic injury frequently requires opioid analgesia to manage pain and avoid catastrophic complications. Risk screening for opioid misuse and the development of use disorder remains uninvestigated.

METHODS

Participants were Trauma/Orthopedic Surgical Services patients at a Level I Trauma Center who were English speaking, aged 18-75, received an opioids prescription at discharge, and were under control of their own medications at discharge. Baseline measures included validated self-report instruments for psychosocial factors, such as anxiety, depression, pain coping, and social support. Health record data included diagnosis codes, procedures, Injury Severity Score, and pain severity (0-10 scale). Opioid use disorder (by Clinical International Diagnostic Interview-Substance Abuse Module) or opioid misuse (Current Opioid Misuse Measure (COMM) and survey items) were assessed at 24 weeks post-discharge.

RESULTS

295 patients enrolled with 237 completing the 24 week assessments. Stepwise regression modeling demonstrated pre-injury PTSD symptoms, Opioid Risk score, medication use behaviors, social support, and length of stay predicted opioid misuse. Pre-injury PTSD symptoms, pain coping, and length of stay predicted use disorder. The final regression models for opioid misuse by COMM, opioid misuse via survey items, and for opioid use disorder had highly favorable areas under the receiver operating curve (0.880, 0.790, and 0.943 respectively).

CONCLUSIONS

Pre-injury presence of PTSD-related symptoms, impaired pain coping, social support, and hospitalization > 6 days predicted opioid misuse and opioid addiction at 6 months after hospital discharge. Behavioral screening and management strategies appear warranted in the population of traumatic injury victims to reduce opioid-related risks.

"Making It Work": A Preliminary Mixed Methods Study of Rural Trauma Care Access and Resources in New Mexico

Introduction

Patients in the rural western United States face challenges accessing trauma and surgical services and are more likely to succumb to their injuries. New Mexico, a rural and medically underresourced state, is a salient space to study these disparities. We examine how travel distance from trauma centers impacts injured patient outcomes and describe care delivery obstacles.

Materials and Methods

We conducted an explanatory mixed methods study by creating geospatial maps of New Mexico’s trauma data, incorporating linear regression analyses on patient outcomes as a function of estimated travel distance from trauma centers. We also conducted qualitative semi-structured interviews with trauma providers to illuminate and provide context for the geospatial findings utilizing a systematic, collaborative, iterative transcript analysis process. We constructed a conceptual framework describing rural trauma care delivery obstacles.

Results

Geospatial analyses revealed that most New Mexicans face long travel times to trauma centers. Comparing regression analyses using different data sources suggests that solely hospital-derived data may undercount rural trauma deaths. Interviews with 10 providers suggest that elements that may contribute to these findings include on-the-ground resource-based challenges and those related to broader healthcare systems-based issues. Our conceptual framework denotes how these elements collectively may impact rural trauma outcomes and proposes potential solutions.

Conclusions

In addressing rural patients’ needs, healthcare policy decision-makers should ensure that their datasets are comprehensive and inclusive. They must also take into account the particular challenges of underserved rural patients and providers who care for them by eliciting their perspectives, as presented in our conceptual framework.