Long-term medical and productivity costs of severe trauma: Results from a prospective cohort study

Extremity fractures, attempted suicide, blood transfusion and thromboembolic events are independent risk factors for a prolonged hospital stay in severely injured elderly

METHODS

Due to demographic change, the number of polytraumatized geriatric patients (> 64 years) is expected to further increase in the coming years. In addition to the particularities of the accident and the associated injury patterns, prolonged inpatient stays are regularly observed in this group. The aim of the evaluation is to identify further factors that cause prolonged inpatient stays. A study of the data from the TraumaRegister DGU® from 2016-2020 was performed. Inclusion criteria were an age of over 64 years, intensive care treatment in the GAS-region, and an Injury Severity Score (ISS) of at least 16 points. All patients who were above the 80th percentile for the average length of stay or average intensive care stay of the study population were defined as so-called long-stay patients. This resulted in a prolonged inpatient stay of > 25 days and an intensive care stay of > 13 days. Among other, the influence of the cause of the accident, injury patterns according to body regions, the occurrence of complications, and the influence of numerous clinical parameters were examined.

RESULTS

A total of 23,026 patients with a mean age of 76.6 years and a mean ISS of 24 points were included. Mean ICU length of stay was 11 ± 12.9 days (regular length of stay: 3.9 ± 3.1d vs. prolonged length of stay: 12.8 ± 5.7d) and mean inpatient stay was 22.5 ± 18.9 days (regular length of stay: 20.7 ± 15d vs. 35.7 ± 22.3d). A total of n = 6,447 patients met the criteria for a prolonged length of stay. Among these, patients had one more diagnosis on average (4.6 vs. 5.8 diagnoses) and had a higher ISS (21.8 ± 6 pts. vs. 26.9 ± 9.5 pts.) Independent risk factors for prolonged length of stay were intubation duration greater than 6 days (30-fold increased risk), occurrence of sepsis (4x), attempted suicide (3x), presence of extremity injury (2.3x), occurrence of a thromboembolic event (2.7x), and administration of red blood cell concentrates in the resuscitation room (1.9x).

CONCLUSIONS

The present analysis identified numerous independent risk factors for significantly prolonged hospitalization of the geriatric polytraumatized patient, which should be given increased attention during treatment. In particular, the need for a smooth transition to psychiatric follow-up treatment or patient-adapted rehabilitative care for geriatric patients with prolonged immobility after extremity injuries is emphasized by these results.

Systemic Inflammatory Changes in Spinal Cord Injured Patients after Adding Aquatic Therapy to Standard Physiotherapy Treatment

Spinal cord injury (SCI) is a severe medical condition resulting in substantial physiological and functional consequences for the individual. People with SCI are characterised by a chronic, low-grade systemic inflammatory state, which contributes to further undesirable secondary injuries. This study aimed to evaluate the effect of adding aquatic therapy to the standard physiotherapy treatment, implemented in two different schedules, on systemic inflammation in SCI patients. Additionally, the relationship between cytokine blood levels and changes in functionality (measured with the 6MWT, 10MWT, WISCI, BBS, and TUG tests) throughout the study was assessed. A quantitative multiplexed antibody assay was performed to measure the expression level of 20 pro- and anti-inflammatory cytokines in blood samples from SCI patients at three time points: baseline, week 6, and immediately post-intervention (week 12). This study identified a complex signature of five cytokines (IL-12p70, IL-8, MCP-1, IL-1α, and IP10) associated with the time course of the two physiotherapy programs. Two other cytokines (IL-4 and TNF-α) were also associated with the functional recovery of patients. These could be important indicators for SCI prognosis and provide a basis for developing novel targeted therapies.

Catecholamine concentration as a predictor of mortality in emergency surgical patients

BACKGROUND

Trauma and emergency surgery are major causes of morbidity and mortality. The objective of this study was to determine whether serum levels of epinephrine and norepinephrine are associated with aging and mortality.

METHODS

This was a prospective observational cohort study conducted in a surgical critical care unit. We included 90 patients who were admitted for postoperative care, because of major trauma, or both. We collected demographic and clinical variables, as well as serum levels of epinephrine and norepinephrine.

RESULTS

For patients in the > 60-year age group, the use of vasoactive drugs was found to be associated with an undetectable epinephrine level (OR [95% CI] = 6.36 [1.12, 36.08]), p = 0.05). For the patients with undetectable epinephrine levels, the in-hospital mortality was higher among those with a norepinephrine level ≥ 2006.5 pg/mL (OR [95% CI] = 4.00 [1.27, 12.58]), p = 0.03).

CONCLUSIONS

There is an association between age and mortality. Undetectable serum epinephrine, which is more common in older patients, could contribute to poor outcomes. The use of epinephrine might improve the clinical prognosis in older surgical patients with shock.

Costs of fracture-related infection: the impact on direct hospital costs and healthcare utilisation

PURPOSE

Fracture-Related Infection (FRI) is associated with high medical costs and prolonged healthcare utilization. However, limited data is available on the financial impact. The purpose of this study was to investigate the impact of FRI on direct hospital costs and healthcare utilization.

METHODS

This was a retrospective cohort study in a level-1 trauma centre in the Netherlands. Patients ≥ 18 years, after open reduction and internal fixation of a long bone fracture between January 1st 2016 and November 1st 2021, were included. Exclusion criteria were Injury Severity Score (ISS) ≥ 16, indefinable data on costs or incomplete follow-up. Hospital costs related to fracture treatment were individually calculated based on procedure codes raised with a fixed percentage of overhead expenses, in line with hospital billing policies.

RESULTS

In total, 246 patients were included with a median follow-up of 1 year (IQR 0.6-1.8). A total of 45 patients developed FRI, of whom 15 patients had an FRI recurrence. Compared to non-FRI patients, median hospital costs from an FRI patient without and with recurrence, were respectively three (3.1) and seven (7.6) times higher. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries, and 21 or 55 days of intravenous antibiotic treatment.

CONCLUSION

Direct healthcare costs of patients with single occurrence of FRI after long bone fracture treatment are three times higher compared to non-FRI patients. In case of FRI-recurrence, the differences in costs might even increase to sevenfold. To put this in perspective, cost of severely injured trauma patients were recently established at approximately 25.000 euros. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries and 21 or 55 days of intravenous antibiotic treatment. Not only from patient perspective but also from a financial aspect, it is important to focus on prevention of (recurrent) FRI.

Post-injury long-term sickness absence and risk of disability pension: The role of socioeconomic status

INTRODUCTION

Previous research has identified low socioeconomic status (SES) as a risk factor for long-term sickness absence (LTSA) and disability pension (DP) following trauma. However, most studies lack information on medical diagnoses, limiting our understanding of the underlying factors. To address this gap, we retrieved information about diagnostic causes for receipt of welfare benefits to explore the role of SES in the transition from post-injury LTSA to permanent DP among the working population in Norway.

MATERIALS AND METHODS

We conducted a population-based cohort study of all Norwegian residents aged 25-59 years registered with a spell of LTSA due to injury commencing in the period 2000-2003. This cohort was followed through 2014 by linking information on receipt of welfare benefits with sociodemographic data from administrative registers. SES was defined as a composite measure of educational attainment and income level. We used flexible parametric survival models to estimate hazard ratios (HR) with 95 % confidence intervals (CI) for all-cause and diagnosis-specific DP according to SES, adjusting for sex, age, marital status, immigrant status and healthcare region of residence.

RESULTS

Of 53,937 adults with post-injury LTSA, 9,665 (18 %) transferred to DP during follow-up. The crude risk of DP was highest for LTSA spells due to poisoning and head injuries. Overall, individuals in the lowest SES category had twice the risk of DP compared to those in the highest SES category (HR = 2.25, 95 % CI 2.13-2.38). The difference by SES was greatest for LTSA due to poisoning and smallest for LTSA due to head injuries. A majority (75 %) of DP recipients had a non-injury diagnosis as the primary cause of DP. The socioeconomic gradient was more pronounced for non-injury causes of DP (HR = 2.47, 95 % CI 2.31-2.63) than for injury causes (HR = 1.73, 95 % CI 1.56-1.92) and was especially steep for DP due to musculoskeletal diseases and mental and behavioural disorders.

CONCLUSIONS

The relationship between SES and DP varied by both the type of injury that caused LTSA and the diagnosis used to grant DP, highlighting the importance of taking diagnostic information into account when investigating long-term consequences of injuries.

The impact of electric scooters in Melbourne: data from a major trauma service

BACKGROUND

The proliferation of electric scooters globally has been associated with an increase in related injuries and consequent economic burden. This study aims to assess the injury patterns and the economic impact associated with electric scooter use in Melbourne, Australia.

METHODS

A retrospective cohort study was conducted using hospital and registry data from January 2022 to January 2023. Data collected included demographic details, alcohol and helmet use, injury type and severity, operative treatment provided, and direct medical costs. The economic impact (in AUD) of the patient's emergency presentation and hospital admission was calculated.

RESULTS

During the study period, 256 electric scooter related injuries were recorded, comprising 247 riders and nine pedestrians. The majority of patients were males (69%) with a median age of 29.5 (15-78). Alcohol use was reported by 34% and helmet use by 33%. Injuries most commonly affected the upper limb (53%) and head (50%), with abrasions (75%) and fractures (48%) being the most common type of injury sustained. The total hospital cost was $1 911 062, and the median cost was $1321.66 per patient (IQR: $479.37-$5096.65).

CONCLUSION

Electric scooter usage, as observed through patient presentations to the Royal Melbourne Hospital, is associated with a considerable number of injuries, primarily among young males, and an ensuing substantial economic burden. The findings underscore the urgent need for improved safety measures to minimize electric scooter-related injuries and their clinical and economic repercussions.

Frailty and Other Factors Associated With Early Outcomes in Middle-to Older Age Trauma Patients: A Prospective Cohort Study

OBJECTIVES

To prospectively investigate associations of frailty and other predictor variables with functional recovery and health outcomes in middle-aged and older patients with trauma.

DESIGN

Single-center prospective cohort study.

SETTING

Emergency department of Wan Fang Hospital in Taiwan.

PARTICIPANTS

Trauma patients aged 45 and older.

MEASUREMENTS

Frailty was assessed with the Clinical Frailty Scale (CFS). Injury mechanisms, pre-existing diseases, and fracture locations were recorded at baseline. The primary outcome was functional recovery assessed using the Barthel Index (BI). Secondary outcomes were new care needs, unscheduled return visits, and falls 3 months postinjury.

RESULTS

A total of 588 participants were included in the final analysis. For every one-point increase in the CFS, the multivariable-adjusted odds ratio (OR, 95% confidence interval [CI]) of failure to retain the preinjury BI was 1.34 (1.16-1.55); associations were consistent across levels of age and injury severities. Significant joint associations of frailty and age with poor functional recovery were observed. CFS was also associated with new care needs (OR for every one-point increase, 1.36, 95% CI, 1.17-1.58), unscheduled return visits (OR 1.26, 95% CI, 1.04-1.51), and falls (OR 1.23, 95% CI, 1.01-1.51). Other variables associated with failure to retain preinjury BI included road traffic accident and presence of hip fracture.

CONCLUSION

Frailty was significantly associated with poor functional and health outcomes regardless of injury severity in middle-aged and older patients with trauma. Injury mechanisms and fracture locations were also significant predictors of functional recovery postinjury.

Pre-Trauma Pain Is the Strongest Predictor of Persistent Enhanced Pain Patterns after Severe Trauma: Results of a Single-Centre Retrospective Study

Background and Objectives: Traumatic injuries are a significant public health issue worldwide, with persistent enhanced pain being a common complication following severe trauma. Persistent and chronic pain can have a profound impact on patients' quality of life, affecting physical, emotional, and social functioning. This study aimed to investigate the pain patterns of trauma patients before and after severe trauma, and identify the predictors of persisting pain after injury. Materials and Methods: A total of 596 patients of a level-one trauma centre with severe trauma were included in this study. The Trauma Outcome Profile Scale was used to assess pain severity before and after trauma, and a logistic regression analysis was performed to determine the most significant predictors of relevant pain after severe trauma. Results: The mean age of the included patients was 48.2 years, and 72% were males. The most frequent cause of injury was traffic accidents, and the mean Injury Severity Score was 17.6. Nearly half of the patients experienced reduced pain-related quality of life after trauma, with persisting pain predominantly occurring in the neck, spine, shoulder, pelvis, hip, knee, and feet. Even minor injuries led to increased pain scores. Preexisting pain before injury (OR: 5.43; CI: 2.60-11.34), older age (OR: 2.09, CI: 1.22-3.27), female gender (OR: 1.08, CI: 0.73-1.59), and high injury severity (OR: 1.80, CI: 1.20-2.69) were identified as significant predictors of enhanced pain. Conclusions: These findings highlight the importance of considering pre-existing pain, body area, and injury severity in assessing the risk of persistent pain in trauma patients.

Epidemiology of traumatic spinal cord injury: a large population-based study

STUDY DESIGN

A retrospective population-based study.

OBJECTIVES

Describe the incidence of traumatic spinal cord injury (TSCI) and mortality risks, based on the characteristics of the patient, anatomical level of the lesion, setting/cause of the injury, and type of healthcare support received within the regional trauma network (highly specialized trauma center or spoke hospital).

SETTING

Between 2011 and 2020, 1303 patients with incident TSCI were identified in a population of 4.9 million inhabitants.

METHODS

Hospital discharge records and mortality records were used to identify patients and outcomes. Cox regression models were fitted to estimate mortality risks across several subgroups.

RESULTS

Over the past decade, age-sex-standardized TSCI incidence rates remained stable with 26.5 cases (95% CI, 25.0-27.9) per 1,000,000 inhabitants (mean age 59.2 years) and most cases were males (68.3%). Incidence was directly associated with age while the male to female ratio was inversely related. Most TSCIs were cervical lesions (52.1%), and the most common cause of injury were traffic crashes (29.9%) followed by occupational accidents (29.8%). Sex, cause of the trauma, or inpatient hospital management were not associated with an increased risk of death. Mortality rates were greater for cervical lesions, and increased with age, remaining stably high among older individuals even 12 months after the accident. One-month mortality risk was significantly higher at ≥75 years compared to <55 years (adjusted HR 9.14 (95% CI, 4.17-20.03)).

CONCLUSION

Public health policies should aim at reducing preventable TSCIs, and special attention should be drawn to long-term management of elderly patients in the attempt to decrease mortality rates.