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Gore A, Truche P, Iskerskiy A, Ortega G, Peck G. Inaccurate Ethnicity and Race Classification of Hispanics Following Trauma Admission. J Surg Res 2021; 268:687-695. [PMID: 34482009 DOI: 10.1016/j.jss.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 06/25/2021] [Accepted: 08/04/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Race and ethnicity are associated with disparate trauma outcomes. This study seeks to characterize accuracy of trauma registry classification of patient race and ethnicity and to identify factors associated with misclassification. METHODS A prospective observational study of patients admitted to an urban Level 1 trauma center was conducted over a 6-mo period. Race and ethnicity data recorded in the trauma registry were compared to patients' self-identifying data obtained through in-person interviews. Logistic regression determined rates of discordant race and ethnicity between trauma registry and patient self-identification processes, and identified factors independently associated with misclassification. RESULTS A total of 444 patients were recruited. 98 (22%) self-identified as Hispanic/Latino. 45 patients self-identifying as Hispanic (45.9%) had inaccurately recorded ethnicity in the trauma registry. There was an increased odds of ethnicity misclassification in younger patients (OR 0.97, P < 0.01) and Spanish-only speakers (OR 11.80, P < 0.001). A decreased odds was found in males (OR 0.43, P < 0.05). No factors increased odds of racial misclassification, while dual English/Spanish speakers (OR 0.05, P < 0.01) wereas found to have decreased odds. Neither ethnicity nor race misclassification was associated with clinical variables. New racial self-identification was observed with 75% of patients who self-identified ethnically as Hispanic also self-identifying racially as Hispanic. CONCLUSIONS Hispanic trauma patients have racial and ethnic misclassifications regardless of clinical status. Racial and ethnic identification is not sufficiently captured by current standardized questionnaires. Accuracy of hospital level racial data is important for local and national policies to address trauma disparities.
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Affiliation(s)
- Ankita Gore
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Paul Truche
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Anton Iskerskiy
- Rutgers School of Graduate Studies, New Brunswick, New Jersey
| | - Gezzer Ortega
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Peck
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, New Jersey.
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Kulaylat AN, Hollenbeak CS, Armen SB, Cilley RE, Engbrecht BW. The Association of Race, Sex, and Insurance With Transfer From Adult to Pediatric Trauma Centers. Pediatr Emerg Care 2021; 37:e1623-e1630. [PMID: 32569252 DOI: 10.1097/pec.0000000000002137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Our objective was to investigate whether racial/ethnic-based or payer-based disparities existed in the transfer practices of pediatric trauma patients from adult trauma center (ATC) to pediatric trauma center (PTC) in Pennsylvania. METHODS Data on trauma patients aged 14 years or less initially evaluated at level I and II ATC were obtained from the Pennsylvania Trauma Outcome Study (2008-2012) (n = 3446). Generalized estimating equations regression analyses were used to evaluate predictors of subsequent transfer controlling for confounders and clustering. Recent literature has described racial and socioeconomic disparities in outcomes such as mortality after trauma; it is unknown whether these factors also influence the likelihood of subsequent interfacility transfer between ATC and PTC. RESULTS Patients identified as nonwhite comprised 36.1% of the study population. Those without insurance comprised 9.9% of the population. There were 2790 patients (77.4%) who were subsequently transferred. Nonwhite race (odds ratio [OR], 4.3), female sex (OR, 1.3), and lack of insurance (OR, 2.3) were associated with interfacility transfer. Additional factors were identified influencing likelihood of transfer (increased odds: younger age, intubated status, cranial, orthopedic, and solid organ injury; decreased odds: operative intervention at the initial trauma center) (P < 0.05 for all). CONCLUSIONS Although we assume that a desire for specialized care is the primary reason for transfer of injured children to PTCs, our analysis demonstrates that race, female sex, and lack of insurance are also associated with transfers from ATCs to PTCs for children younger than 15 years in Pennsylvania. Further research is needed to understand the basis of these health care disparities and their impact.
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Affiliation(s)
| | | | | | | | - Brett W Engbrecht
- Division of Pediatric Surgery, Peyton Manning Children's Hospital, Indianapolis, IN
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3
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Jones RC, Creutzfeldt CJ, Cox CE, Haines KL, Hough CL, Vavilala MS, Williamson T, Hernandez A, Raghunathan K, Bartz R, Fuller M, Krishnamoorthy V. Racial and Ethnic Differences in Health Care Utilization Following Severe Acute Brain Injury in the United States. J Intensive Care Med 2020; 36:1258-1263. [PMID: 32912070 DOI: 10.1177/0885066620945911] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine racial and ethnic differences in the utilization of 3 interventions (tracheostomy placement, gastrostomy tube placement, and hospice utilization) among patients with severe acute brain injury (SABI). DESIGN Retrospective cohort study. SETTING Data from the National Inpatient Sample, from 2002 to 2012. PATIENTS Adult patients with SABI defined as a primary diagnosis of stroke, traumatic brain injury, or post-cardiac arrest who received greater than 96 hours of mechanical ventilation. EXPOSURE Race/ethnicity, stratified into 5 categories (white, black, Hispanic, Asian, and other). MEASUREMENTS AND MAIN RESULTS Data from 86 246 patients were included in the cohort, with a mean (standard deviation) age of 60 (18) years. In multivariable analysis, compared to white patients, black patients had an 20% increased risk of tracheostomy utilization (relative risk [RR]: 1.20, 95% CI: 1.16-1.24, P < .001), Hispanic patients had a 10% increased risk (RR: 1.10, 95% CI: 1.06-1.14, P < .001), Asian patients had an 8% increased risk (RR: 1.08, 95% CI: 1.01-1.16, P = .02), and other race patients had an 10% increased risk (RR: 1.10, 95% CI: 1.04-1.16, P < .001). A similar relationship was observed for gastrostomy utilization. In multivariable analysis, compared to white patients, black patients had a 25% decreased risk of hospice discharge (RR: 0.75, 95% CI: 0.67-0.85, P < .001), Hispanic patients had a 20% decreased risk (RR: 0.80, 95% CI: 0.69-0.94, P < .01), and Asian patients had a 47% decreased risk (RR: 0.53, 95% CI: 0.39-0.73, P < .001). There was no observed relationship between race/ethnicity and in-hospital mortality. CONCLUSIONS Minority race was associated with increased utilization of tracheostomy and gastrostomy, as well as decreased hospice utilization among patients with SABI. Further research is needed to better understand the mechanisms underlying these race-based differences in critical care.
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Affiliation(s)
- Rayleen C Jones
- School of Nursing, Duke University, NC, USA.,Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA
| | | | | | - Krista L Haines
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Surgery, Duke University, NC, USA
| | | | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, WA, USA
| | | | | | - Karthik Raghunathan
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Raquel Bartz
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Matt Fuller
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Epidemiologic Research (CAPER) Unit, Department of Anesthesiology, Duke University, NC, USA.,Department of Anesthesiology, Duke University, NC, USA
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4
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Disparities in Adult and Pediatric Trauma Outcomes: a Systematic Review and Meta-Analysis. World J Surg 2020; 44:3010-3021. [DOI: 10.1007/s00268-020-05591-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jarman MP, Pollack Porter K, Curriero FC, Castillo RC. Factors mediating demographic determinants of injury mortality. Ann Epidemiol 2019; 34:58-64.e2. [PMID: 31053454 DOI: 10.1016/j.annepidem.2019.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 02/20/2019] [Accepted: 03/24/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Elevated injury mortality rates persist for men and people of color despite attempts to standardize trauma care in the United States. This study investigates the role of injury characteristics and access to trauma care as mediators of the relationships between race, ethnicity, sex, and injury mortality. METHODS Data on prehospital and trauma center care were examined for adult injured patients in Maryland who were transported by emergency medical services to designated trauma centers (n = 15,355) or who died while under emergency medical services care (n = 727). Potential mediators of the relationship between demographic characteristics and injury mortality were identified through exploratory analyses. Total, direct, and indirect effects of race, ethnicity, and sex were estimated using multivariable mediation models. RESULTS Prehospital time, hospital distance, injury mechanism, and insurance status mediated the effect of African American race, resulting in a 5.7% total increase (95% CI: 1.6%, 9.9%) and 5.6% direct decrease (95% CI: 1.1%, 9.9%) in odds of death. Mechanism, insurance, and distance mediated the effect of Hispanic ethnicity, resulting in an 11.4% total decrease (95% CI: 6.4%, 16.2%) and 13.4% direct decrease (95% CI: 8.1%, 18.3%) in odds of death. Injury severity, mechanism, insurance, and time mediated the effect of male sex, resulting in a 27.3% total increase (95% CI: 21.6%, 10.9%) and a 6.2% direct increase (95% CI: 1.8%, 10.9%) in odds of death. CONCLUSIONS Distance, injury characteristics, and insurance mediate the effects of demographic characteristics on injury mortality and appear to contribute to disparities in injury mortality.
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Affiliation(s)
- Molly P Jarman
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
| | - Keshia Pollack Porter
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
| | - Frank C Curriero
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD
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7
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Weygandt PL, Dresden SM, Powell ES, Feinglass J. Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois. West J Emerg Med 2018; 19:301-310. [PMID: 29560058 PMCID: PMC5851503 DOI: 10.5811/westjem.2017.10.34949] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/15/2017] [Accepted: 10/13/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois. Methods We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression. Results There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval [CI] [0.93–1.17]). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI [1.14–1.88]). Conclusion While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma.
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Affiliation(s)
- Paul L Weygandt
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Scott M Dresden
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Emilie S Powell
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Joe Feinglass
- Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, Illinois
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Madiraju SK, Catino J, Kokaram C, Genuit T, Bukur M. In by helicopter out by cab: the financial cost of aeromedical overtriage of trauma patients. J Surg Res 2017; 218:261-270. [PMID: 28985859 DOI: 10.1016/j.jss.2017.05.102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/12/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Helicopter transport of injured patients is controversial and costly. This study aims to show that a complex trauma algorithm leads to significant aeromedical overtriage at substantial cost. Our secondary outcomes were to compare adjusted mortality and outcomes between air and ground transport and determine predictors of overtriage. MATERIALS AND METHODS A 6-y retrospective analysis was conducted of all trauma activations at a Level I center. Patients were dichotomized by transportation method as well as trauma activation criteria. Overtriage was defined as those who were discharged from the emergency department, medically admitted without injuries, or admitted to observation status only. Overtriage and associated charges were calculated for each patient cohort, and multivariate regression models were created to derive adjusted mortality rates and predictors of overtriage. RESULTS A total of 4218 patients were treated with 28% arriving by helicopter. Overtriage increased significantly from 51% to 77% with lower tier activation criteria (P < 0.001). Median charges for air-evacuated patients was $10,478 (versus $1008 ground). Eliminating overtriage of air patients would result in a cost savings of $1,316,036 annually. Adjusted mortality between air and ground transport was not significantly different (8.5% versus 10.9%, P = 0.548). Predictors of overtriage included decreasing age, Injury Severity Score, Head Abbreviated Injury Score, nonoperative treatment, and lower tier activation criteria. CONCLUSIONS Significant overtriage (52%) and unnecessary air evacuation of minimally injured patients occurs at great financial cost. Revision of trauma activation protocols may result in more judicious air transport use and significant reductions in health care costs.
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Affiliation(s)
| | - Joseph Catino
- Trauma/Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Candace Kokaram
- Trauma/Critical Care, Delray Medical Center, Delray Beach, Florida
| | - Thomas Genuit
- FAU Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Marko Bukur
- Trauma/Critical Care, Bellevue Hospital Center, New York, New York
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Jarman MP, Castillo RC, Carlini AR, Kodadek LM, Haider AH. Rural risk: Geographic disparities in trauma mortality. Surgery 2016; 160:1551-1559. [PMID: 27506860 PMCID: PMC5118091 DOI: 10.1016/j.surg.2016.06.020] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and nonrural residents with traumatic injuries. METHODS Using data from the 2009-2010 Nationwide Emergency Department Sample, multiple logistic regression analyses were conducted to estimate odds of death after traumatic injury for rural residents compared with nonrural residents, while controlling for age, sex, injury type and severity, comorbidities, trauma designation, and Census region. RESULTS Rural residents were 14% more likely to die after traumatic injury compared with nonrural residents (P < .001). Increased odds of death for rural residents were observed at level I (odds ratio = 1.20, P < .001), level II (odds ratio = 1.34, P < .001), and level IV/nontrauma centers (odds ratio = 1.23, P < .001). The disparity was greatest for injuries occurring in the South and Midwest (odds ratio = 1.54, P < .001 and odds ratio = 2.06, P < .001, respectively) and for cases with an injury severity score <9 or unknown severity (odds ratio = 2.09, P < .001 and odds ratio = 1.31, P < .001, respectively). CONCLUSION Rural residents are significantly more likely than nonrural residents to die after traumatic injury. This disparity varies by trauma center designation, injury severity, and US Census region. Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization.
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Affiliation(s)
- Molly P Jarman
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Renan C Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Anthony R Carlini
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Lisa M Kodadek
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adil H Haider
- Division of Trauma, Burn and Surgical Critical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard T.H. Chan School of Public Health, Center for Surgery and Public Health, Boston, MA
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Leopold SS. Editor's Spotlight/Take 5: Does a Patient-centered Educational Intervention Affect African-American Access to Knee Replacement? A Randomized Trial. Clin Orthop Relat Res 2016; 474:1749-54. [PMID: 27160745 PMCID: PMC4925419 DOI: 10.1007/s11999-016-4873-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 04/28/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Seth S. Leopold
- Clinical Orthopaedics and Related Research, 1600 Spruce Street, Philadelphia, PA 19013 USA
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Uninsured status may be more predictive of outcomes among the severely injured than minority race. Injury 2016; 47:197-202. [PMID: 26396045 PMCID: PMC4698055 DOI: 10.1016/j.injury.2015.09.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 08/04/2015] [Accepted: 09/06/2015] [Indexed: 02/02/2023]
Abstract
AIM Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers. METHODS We performed a retrospective analysis of the 2010-2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18-64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care. RESULTS There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29-1.98, p<0.001) and black race (OR 1.24, 1.04-1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36-0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29-2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32-0.63, p<0.001). CONCLUSION Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.
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The Hispanic paradox: does it exist in the injured? Am J Surg 2015; 210:827-32. [DOI: 10.1016/j.amjsurg.2015.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 05/27/2015] [Accepted: 05/27/2015] [Indexed: 11/21/2022]
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Abstract
STUDY DESIGN A retrospective study of surgically treated patients with cervical spinal cord injury (SCI) from the National Trauma Data Bank Research Data Set. OBJECTIVE To determine how time to surgery differs between SCI subtypes, where delays before surgery occur, and what factors are associated with delays. SUMMARY OF BACKGROUND DATA Studies have shown that patients with cervical SCI undergoing surgery within 24 hours after injury have superior neurological outcomes to patients undergoing later surgery, with most evidence coming from the incomplete SCI subpopulation. METHODS Surgically treated patients with cervical SCI from 2011 and 2012 were identified in National Trauma Data Bank Research Data Set and divided into subpopulations of complete, central, and other incomplete SCIs. Relationships between surgical timing and patient and injury characteristics were analyzed using multivariate regression. RESULTS A total of 2636 patients with cervical SCI were identified: 803 with complete SCI, 950 with incomplete SCI, and 883 with central SCI. The average time to surgery was 51.1 hours for patients with complete SCI, 55.3 hours for patients with incomplete SCI, and 83.1 hours for patients with central SCI. Only 44% of patients with SCI underwent surgery within the first 24 hours after injury, including only 49% of patients with incomplete SCI.The vast majority of time between injury and surgery was after admission, rather than in the emergency department or in the field. Upper cervical SCIs and greater Charlson Comorbidity Index were associated with later surgery in all 3 SCI subpopulations. CONCLUSION The majority of patients with SCI do not undergo surgery within the first 24 hours after injury, and the majority of delays occur after inpatient admission. Factors associated with these delays highlight areas of focus for expediting care in these patient populations. LEVEL OF EVIDENCE 4.
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