Level-I trauma center effects on return-to-work outcomes

Does the implementation of a trauma system affect injury-related morbidity and economic outcomes? A systematic review

BACKGROUND

Trauma accounts for a huge burden of disease worldwide. Trauma systems have been implemented in multiple countries across the globe, aiming to link and optimise multiple aspects of the trauma care pathway, and while they have been shown to reduce overall mortality, much less is known about their cost-effectiveness and impact on morbidity.

METHODS

We performed a systematic review to explore the impact the implementation of a trauma system has on morbidity, quality of life and economic outcomes, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All comparator study types published since 2000 were included, both retrospective and prospective in nature, and no limits were placed on language. Data were reported as a narrative review.

RESULTS

Seven articles were identified that met the inclusion criteria, all of which reported a pre-trauma and post-trauma system implementation comparison in high-income settings. The overall study quality was poor, with all studies demonstrating a severe risk of bias. Five studies reported across multiple types of trauma patients, the majority describing a positive impact across a variety of morbidity and health economic outcomes following trauma system implementation. Two studies focused specifically on traumatic brain injury and did not demonstrate any impact on morbidity outcomes.

DISCUSSION

There is currently limited and poor quality evidence that assesses the impact that trauma systems have on morbidity, quality of life and economic outcomes. While trauma systems have a fundamental role to play in high-quality trauma care, morbidity and disability data can have large economic and cultural consequences, even if mortality rates have improved. The sociocultural and political context of the surrounding healthcare infrastructure must be better understood before implementing any trauma system, particularly in resource-poor and fragile settings.

PROSPERO REGISTRATION NUMBER

CRD42022348529 LEVEL OF EVIDENCE: Level III.

An Analysis of Injured Patients Treated at Level 1 Trauma Centers Versus Other Centers: A Scoping Review

INTRODUCTION

Trauma systems continue to evolve to create the best outcomes possible for patients who have undergone traumatic injury.

OBJECTIVE

This review aims to evaluate the existing research on outcomes based on field triage to a Level 1 trauma center (L1TC) compared to other levels of hospitals and nontrauma centers.

METHODS

A structured literature search was conducted using PubMed, CINAHL, Embase, and the Cochrane Database. Studies analyzing measures of morbidity, mortality, and cost after receiving care at L1TCs compared to lower-level trauma centers and nontrauma centers in the United States and Canada were included. Three independent reviewers reviewed abstracts, and two independent reviewers conducted full-text review and quality assessment of the included articles.

RESULTS

Twelve thousand five hundred fourteen unique articles were identified using the literature search. 61 relevant studies were included in this scoping review. 95.2% of included studies were national or regional studies, and 96.8% were registry-based studies. 72.6% of included studies adjusted their results to account for injury severity. The findings from receiving trauma care at L1TCs vary depending on severity of injury, type of injury sustained, and patient characteristics. Existing literature suffers from limitations inherent to large de-identified databases, making record linkage between hospitals impossible.

CONCLUSIONS

This scoping review shows that the survival benefit of L1TC care is largest for patients with the most severe injuries. This scoping review demonstrates that further research using high-quality data is needed to elucidate more about how to structure trauma systems to improve outcomes for patients with different severities of injuries and in different types of facilities.

A cross-sectional study of trauma certification and hospital referral region diversity: A system theory approach

BACKGROUND

There are clear racial/ethnic disparities in the trauma care service delivery. However, no study has examined the relationships between structural determinants of trauma care designations (L-I through L-IV) or verification and social factors of the surrounding health region in the U.S.

OBJECTIVE

This study examined the relationship between U.S. community segregation in a hospital referral region (HRR) and hospitals' attainment of trauma certification and trauma designation L-I/II.

METHODS

Two-year retrospective analysis of 2,348 acute hospitals that participated in the Hospital Value-Based Purchasing (HVBP) Program. Multivariate Poisson and 1:2 matching ratio using Propensity Score Matching regressions were used. Our primary variables were composite segregation scores for each county-aggregated to the HRR level (n=303)-and hospital performance on the HVBP Program.

RESULTS

Segregated HRRs are 69% and 40% less likely to have an increase in the number of hospitals with trauma care designations L-I/II and trauma certification, respectively. Our matching ratio showed that hospitals with trauma certification or hospitals with trauma care designations L-I/II were more likely to be within HRRs with lower community diversity.

CONCLUSION

Our findings highlight that system disparities exist in trauma care. Research is needed to determine if other factors, such as resource allocation and reimbursement distribution, impact the availability of trauma facilities.

Association of Practitioner Interfacility Triage Performance With Outcomes for Severely Injured Patients With Fee-for-Service Medicare Insurance

Importance

Despite evidence that treatment of severely injured patients at trauma centers is associated with reduced mortality, nearly half of all such patients are treated at nontrauma centers (undertriaged). Little is known about whether interfacility undertriage occurs because of practitioner decision-making or institutional and regional factors.

Objectives

To assess the associations between variation in triage practitioners at nontrauma centers and between practitioner-level variation and patient outcomes after injury.

Design, Setting, and Participants

This retrospective cohort study used Medicare claims data from severely injured patients presenting to nontrauma centers and the practitioners who evaluated them in the emergency department from January 1, 2010, to October 15, 2015. Data analysis was performed from January 15, 2018, to March 21, 2019.

Main Outcomes and Measures

Proportion of variation in undertriage associated with practitioners, practitioner rates of undertriage, practitioner characteristics associated with undertriage, and 30-day case-fatality rate.

Results

A total of 124 008 severely injured patients (mean [SD] age, 81 [8.4] years; 67 253 [54.2%] female) and the 25 376 practitioners (5564 [21.9%] female) who evaluated the patients in the emergency department of nontrauma centers were included in the study. Undertriage occurred among 85 403 patients (68.9%), with 40.6% of total variation associated with practitioners, 37.8% with hospitals, and 6.7% with regions. Compared with physicians with National Provider Identification (NPI) enumeration before 2007, those with an NPI enumerated between 2007 and 2010 had an undertriage risk ratio (RR) of 0.98 (95% CI, 0.97-0.99), and those with an NPI enumerated after 2010 had an undertriage RR of 0.96 (95% CI, 0.94-0.99). Hospitals with neurosurgeons had an undertriage RR of 1.51 (95% CI, 1.45-1.57) compared with those that did not; hospitals with spine surgeons had an undertriage RR of 1.10 (95% CI, 1.06-1.13); hospitals with general surgeons had an undertriage RR of 1.13 (95% CI, 1.09-1.17). Compared with practitioners who undertriaged 25% or less of patients, a statistically significant increase was found in the odds of death for patients treated by practitioners with a triage rate of less than 25% to 50% (odds ratio [OR], 1.08; 95% CI, 1.05-1.20) and less than 50% to 75% undertriage (OR, 1.12; 95% CI, 1.09-1.26) but not undertriage at greater than 75% (OR, 1.03, 95% CI, 1.00-1.18). In sensitivity analyses to adjust for unmeasured confounding, the association between triage practices and the case fatality rate became monotonic; compared with patients treated by practitioners with an undertriage rate of 25% or less, the odds of case fatality were 1.13 (95% CI, 1.05-1.21; P = .001) among patients treated by practitioners with undertriage rates less than 25% to 50%, 1.22 (95% CI, 1.13-1.32; P < .001) for patients treated by practitioners with undertriage rates less than 50% to 75%, and 1.20 (95% CI, 1.10-1.30; P < .001) for patients treated by practitioners with undertriage rates greater than 75%.

Conclusions and Relevance

The findings suggest that individual practitioner practices are an important source of variation in triage and represent a potential locus of intervention to reduce preventable deaths after injury.

Treatment Effect Estimation Using Nonlinear Two-Stage Instrumental Variable Estimators: Another Cautionary Note

OBJECTIVE

To examine the settings of simulation evidence supporting use of nonlinear two-stage residual inclusion (2SRI) instrumental variable (IV) methods for estimating average treatment effects (ATE) using observational data and investigate potential bias of 2SRI across alternative scenarios of essential heterogeneity and uniqueness of marginal patients.

STUDY DESIGN

Potential bias of linear and nonlinear IV methods for ATE and local average treatment effects (LATE) is assessed using simulation models with a binary outcome and binary endogenous treatment across settings varying by the relationship between treatment effectiveness and treatment choice.

PRINCIPAL FINDINGS

Results show that nonlinear 2SRI models produce estimates of ATE and LATE that are substantially biased when the relationships between treatment and outcome for marginal patients are unique from relationships for the full population. Bias of linear IV estimates for LATE was low across all scenarios.

CONCLUSIONS

Researchers are increasingly opting for nonlinear 2SRI to estimate treatment effects in models with binary and otherwise inherently nonlinear dependent variables, believing that it produces generally unbiased and consistent estimates. This research shows that positive properties of nonlinear 2SRI rely on assumptions about the relationships between treatment effect heterogeneity and choice.

Accelerated death rate in population-based cohort of persons with traumatic brain injury

OBJECTIVES

To determine the influence of preexisting heart, liver, kidney, cancer, stroke, and mental health problems and examine the influence of low socioeconomic status on mortality after discharge from acute care facilities for individuals with traumatic brain injury.

PARTICIPANTS

Population-based retrospective cohort study of 33695 persons discharged from acute care hospital with traumatic brain injury in South Carolina, 1999-2010.

MAIN MEASURES

Days elapsing from the dates of injury to death established the survival time (T). Data were censored at the 145th month. Multivariable Cox regression was used to examine the independent effect of the variables on death. Age-adjusted cumulative probability of death for each chronic disease of interest was plotted.

RESULTS

By the 70th month of follow-up, rate of death was accelerated from 10-fold for heart diseases to 2.5-fold for mental health problems. Adjusted hazard ratios for diseases of the heart (2.13), liver-renal (3.25), cancer (2.64), neurological diseases and stroke (2.07), diabetes (1.89), hypertension (1.43), and mental health problems (1.59) were highly significant (each with P < .001). Compared with persons with private insurance, the hazard ratio was significantly elevated with Medicaid (1.67), Medicare (1.54), and uninsured (1.27) (each with P < .001).

CONCLUSION

Specific chronic diseases strongly influenced postdischarge mortality after traumatic brain injury. Low socioeconomic status as measured by the type of insurance elevated the risk of death.

Saving lives, limbs and livelihoods: considerations in restructuring a national trauma service

STUDY HYPOTHESIS

Level 1 trauma centers reduce mortality and improve functional outcomes in major trauma. Despite this, many countries, including Ireland, do not have officially designated major trauma centers (MTC). This study aimed to examine international trauma systems, and determine how to "best fit" trauma care in a small country (Ireland) to international models.

METHODS

The literature was reviewed to examine international models of trauma systems. An estimate of Irish trauma burden and distribution was made using data from the Road Safety Authority (RSA) on serious or fatal RTAs. Models of a restructured trauma service were constructed and compared with international best practice.

RESULTS

Internationally, a major trauma center surrounded by a regional trauma network has emerged as the gold standard in trauma care. In Ireland, there are no nationally coordinated trauma networks and care is provided by 26 acute hospitals with a mean distance to hospital from RTAs of 20.6 km ± 15.6. Based on our population, Ireland needs two Level 1 MTCs (in the two areas of major population density in the east and south), with robust surrounding trauma networks including Level 2 or 3 trauma centers. With this model, the estimated mean number of cases per Level 1 MTC per year would be 628, with a mean distance to MTC of 80.5 ± 59.2 km, (maximum distance 263.5 km).

CONCLUSION

Clearly designated and adequately resourced MTCs with trauma networks are needed to improve trauma outcomes, with concomitant investment in pre-hospital infrastructure.

Level-I trauma centre treatment effects on return to work in teaching hospitals

BACKGROUND

Previous research found a positive effect of Level-I trauma centres on return to work outcomes for patients 18-64 years old who were mainly working before injury. Trauma centres were compared to hospitals that differed on average in characteristics such as size and staffing, among others. Thus, a portion of the effect found could be due to general differences in hospital variables rather than the special characteristics of Level I trauma centres. Comparing Level I trauma centres to other Teaching hospitals provides a more refined test of the effect of these centres on return-to-work outcomes.

METHODS

The National Study on the Costs and Outcomes of Trauma (NSCOT) is the main source of data for our empirical investigation. We used non-linear instrumental variables methods to control for unobserved characteristics and restrict the sample to teaching hospitals. The first method is the two-stage residual inclusion model in which we identify the effect using the proportion of resident population served by Helicopter Ambulance Services (at the state level) as an instrumental variable. The second method is a recursive bivariate probit model.

RESULTS

We found that treatment at Level-I trauma centres has a positive effect on return to work outcomes three months after injury. The estimated effect is statistically significant and positive, but lower than the estimate that did not focus on teaching hospitals.

CONCLUSIONS

A previous study found positive effects of treatment at a Level-I trauma centre on return-to-work outcomes, however, a portion of the effect found was due to general differences in hospital variables.

Management and outcomes of trauma during pregnancy

Approximately 1% to 4% of pregnant women are evaluated in emergency/delivery room because of traumatic injury, yet there are few educational strategies targeted toward prevention/management of maternal trauma. Use of illicit drugs and alcohol, domestic abuse, and depression contribute to maternal trauma; thus a high index of suspicion should be maintained when treating injured young women. Treating the mother appropriately is beneficial for both the mother and the fetus. Fetal viability should be assessed after maternal stabilization. Pregnancy-related morbidity occurs in approximately 25% of cases and may include placental abruption, uterine rupture, preterm delivery, and the need for cesarean delivery.

Delayed amputation following trauma increases residual lower limb infection

INTRODUCTION

Residual limb infection following amputation is a devastating complication, resulting in delayed rehabilitation, repeat surgery, prolonged hospitalisation and poor functional outcome. The aim of this study was to identify variables predicting residual limb infection following non-salvageable lower limb trauma.

METHODS

All cases of non-salvageable lower limb trauma presenting to a specialist centre over 5 years were evaluated from a prospective database and clinical and management variables correlated with the development of deep infection.

RESULTS

Forty patients requiring 42 amputations were identified with a mean age of 49 years (±19.9, 1SD). Amputations were performed for 21 Gustilo IIIB injuries, 12 multi-planar degloving injuries, seven IIIC injuries and one open Schatzker 6 fracture. One limb was traumatically amputated at the scene and surgically revised. Amputation level was transtibial in 32, through-knee in one and transfemoral in nine. Median time from injury to amputation was 4 days (range 0-30 days). Amputation following only one debridement and within 5 days resulted in significantly fewer stump infections (p = 0.026 and p = 0.03, respectively, Fisher's exact test). The cumulative probability of infection-free residual limb closure declined steadily from day 5. Multivariate analyses revealed that neither the nature of the injury nor pre-injury patient morbidity independently influenced residual limb infection.

CONCLUSION

Avoiding residual limb infection is critically dependent on prompt amputation of non-salvageable limbs.