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Green A, Sommer ER, Johnson MR, Gonzalez H, Sia T, Spain DA, Choi J. Career Trajectory After General Surgery Residency: Do Academic Program Graduates Pursue Academic Surgery? Ann Surg 2024:00000658-990000000-00852. [PMID: 38652655 DOI: 10.1097/sla.0000000000006307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Determine the proportion of contemporary US academic general surgery residency program graduates who pursue academic careers and identify factors associated with pursuing academic careers. SUMMARY BACKGROUND DATA Many academic residency programs aim to cultivate academic surgeons, yet the proportion of contemporary graduates who choose academic careers is unclear. The potential determinants that affect graduates' decisions to pursue academic careers remain underexplored. METHODS We collected program and individual-level data on 2015 and 2018 graduates across 96 US academic general surgery residency programs using public resources. We defined those pursuing academic careers as faculty within US allopathic medical school-affiliated surgery departments who published two or more peer-reviewed publications as the first or senior author between 2020-2021. After variable selection using sample splitting LASSO regression, multivariable regression evaluated association with pursuing academic careers among all graduates, and graduates of top-20 residency programs. Secondary analysis using multivariable ordinal regression explored factors associated with high research productivity during early faculty years. RESULTS Among 992 graduates, 166 (17%) were pursuing academic careers according to our definition. Graduating from a top-20 ranked residency program (OR[95%CI]: 2.34[1.40-3.88]), working with a longitudinal research mentor during residency (OR[95%CI]: 2.21[1.24-3.95]), holding an advanced degree (OR[95%CI]: 2.20[1.19-3.99]), and the number of peer-reviewed publications during residency as first or senior author (OR[95%CI]: 1.13[1.07-1.20]) were associated with pursuing an academic surgery career, while the number of peer-reviewed publications before residency was not (OR[95%CI]: 1.08[0.99-1.20]). Among top 20 program graduates, working with a longitudinal research mentor during residency (OR[95%CI]: 0.95[0.43-2.09]) was not associated with pursuing an academic surgery career. The number of peer-reviewed publications during residency as first or senior author was the only variable associated with higher productivity during early faculty years (OR[95%CI]: 1.12[1.07-1.18]). CONCLUSIONS Our findings suggest programs that aim to graduate academic surgeons may benefit from ensuring trainees receive infrastructural support and demonstrate sustained commitment to research throughout residency. Our results should be interpreted cautiously as the impact of unmeasured confounders is unclear.
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Affiliation(s)
- Allen Green
- School of Medicine, Stanford University, Palo Alto, California
| | - Elijah R Sommer
- School of Medicine, Stanford University, Palo Alto, California
| | - Max R Johnson
- School of Medicine, Stanford University, Palo Alto, California
| | - Hector Gonzalez
- School of Medicine, Stanford University, Palo Alto, California
| | - Twan Sia
- School of Medicine, Stanford University, Palo Alto, California
| | - David A Spain
- Department of Surgery, Stanford University, Palo Alto, California
| | - Jeff Choi
- Department of Surgery, Stanford University, Palo Alto, California
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Korah M, Tennakoon L, Knowlton LM, Tung J, Spain DA, Ko A. Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis From 2018 to 2019. J Surg Res 2024; 298:307-315. [PMID: 38640616 DOI: 10.1016/j.jss.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/08/2024] [Accepted: 03/17/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. METHODS The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. RESULTS Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). CONCLUSIONS NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.
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Affiliation(s)
- Maria Korah
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Lisa M Knowlton
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Jamie Tung
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Ara Ko
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California.
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Tennakoon L, Ko A, Knight AW, Nassar AK, Wu R, Spain DA, Knowlton LM. Firearm-Related Injuries and the US Opioid and Other Substance Use Epidemic: A Nationwide Evaluation of Emergency Department Encounters. J Surg Res 2024; 298:128-136. [PMID: 38603943 DOI: 10.1016/j.jss.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION There has been a sharp climb in the Unites States' death rate among opioid and other substance abuse patients, as well as an increased prevalence in gun violence. We aimed to investigate the association between substance abuse and gun violence in a national sample of patients presenting to US emergency departments (EDs). METHODS We queried the 2018-2019 Nationwide Emergency Department Sample for patients ≥18 years with substance abuse disorders (opioid and other) using International Classification of Diseases, 10th Revision, Clinical Modification codes. Within this sample, we analyzed characteristics and outcomes of patients with firearm-related injuries. The primary outcome was mortality; secondary outcomes were ED charges and length of stay. RESULTS Among the 25.2 million substance use disorder (SUD) patients in our analysis, 35,306 (0.14%) had a firearm-related diagnosis. Compared to other SUD patients, firearm-SUD patients were younger (33.3 versus 44.7 years, P < 0.001), primarily male (88.6% versus 54.2%, P < 0.001), of lower-income status (0-25th percentile income: 56.4% versus 40.5%, P < 0.001), and more likely to be insured by Medicaid or self-pay (71.6% versus 53.2%, P < 0.001). Firearm-SUD patients had higher mortality (1.4% versus 0.4%, P < 0.001), longer lengths of stay (6.5 versus 4.9 days, P < 0.001), and higher ED charges ($9269 versus $5,164, P < 0.001). Firearm-SUD patients had a 60.3% rate of psychiatric diagnoses. Firearm-SUD patients had 5.5 times greater odds of mortality in adjusted analyses (adjusted odds ratio: 5.5, P < 0.001). CONCLUSIONS Opioid-substance abuse patients with firearm injuries have higher mortality rates and costs among these groups, with limited discharge to postacute care resources. All these factors together point to the urgent need for improved screening and treatment for this vulnerable group of patients.
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Affiliation(s)
- Lakshika Tennakoon
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, California
| | - Ara Ko
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, California
| | - Ariel W Knight
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, California
| | - Aussama K Nassar
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, California
| | - Ruoxue Wu
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, California
| | - David A Spain
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, California
| | - Lisa M Knowlton
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, California.
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Ioannidis I, Forssten MP, Mohammad Ismail A, Cao Y, Tennakoon L, Spain DA, Mohseni S. The relationship and predictive value of dementia and frailty for mortality in patients with surgically managed hip fractures. Eur J Trauma Emerg Surg 2024; 50:339-345. [PMID: 37656179 PMCID: PMC11035458 DOI: 10.1007/s00068-023-02356-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery. METHODS All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models. RESULTS An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.80)]. CONCLUSION Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.
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Affiliation(s)
- Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Lakshika Tennakoon
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David A Spain
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Shahin Mohseni
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheik Shakhbot Medical City Mayo Clinic, Abu Dhabi, United Arab Emirates.
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Carlson EB, Palmieri PA, Barlow MR, Macia K, Bruns BR, Shieh L, Spain DA. Development and Initial Performance of the Hospital Mental Health Risk Screen. J Am Coll Surg 2024; 238:147-156. [PMID: 38038350 PMCID: PMC10786439 DOI: 10.1097/xcs.0000000000000904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/05/2023] [Accepted: 10/02/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Patients hospitalized after emergency care are at risk for later mental health problems such as depression, anxiety, and posttraumatic stress disorder symptoms. The American College of Surgeons Committee on Trauma standards for verification require Level I and II trauma centers to screen patients at high risk for mental health problems. This study aimed to develop and examine the performance of a novel mental health risk screen for hospitalized patients based on samples that reflect the diversity of the US population. STUDY DESIGN We studied patients admitted after emergency care to 3 hospitals that serve ethnically, racially, and socioeconomically diverse populations. We assessed risk factors during hospitalization and mental health symptoms at follow-up. We conducted analyses to identify the most predictive risk factors, selected items to assess each risk, and determined the fewest items needed to predict mental health symptoms at follow-up. Analyses were conducted for the entire sample and within 5 ethnic and racial subgroups. RESULTS Among 1,320 patients, 10 items accurately identified 75% of patients who later had elevated levels of mental health symptoms and 71% of those who did not. Screen performance was good to excellent within each of the ethnic and racial groups studied. CONCLUSIONS The Hospital Mental Health Risk Screen accurately predicted mental health outcomes overall and within ethnic and racial subgroups. If performance is replicated in a new sample, the screen could be used to screen patients hospitalized after emergency care for mental health risk. Routine screening could increase health and mental health equity and foster preventive care research and implementation.
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Affiliation(s)
- Eve B Carlson
- From the Dissemination and Training Division, National Center for Posttraumatic Stress Disorder (Carlson, Barlow, Macia), VA Palo Alto Health Care System, Department of Veterans Affairs, Menlo Park, CA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA (Carlson)
| | | | - M Rose Barlow
- From the Dissemination and Training Division, National Center for Posttraumatic Stress Disorder (Carlson, Barlow, Macia), VA Palo Alto Health Care System, Department of Veterans Affairs, Menlo Park, CA
| | - Kathryn Macia
- From the Dissemination and Training Division, National Center for Posttraumatic Stress Disorder (Carlson, Barlow, Macia), VA Palo Alto Health Care System, Department of Veterans Affairs, Menlo Park, CA
- Center for Innovation to Implementation (Macia), VA Palo Alto Health Care System, Department of Veterans Affairs, Menlo Park, CA
| | - Brandon R Bruns
- Department of Surgery, University of Maryland School of Medicine and R. Adams Cowley Shock Trauma Center, Baltimore, MD (Bruns)
| | - Lisa Shieh
- Department of Medicine, Division of Hospital Medicine (Shieh), Stanford University School of Medicine, Stanford, CA
| | - David A Spain
- Department of Surgery (Spain), Stanford University School of Medicine, Stanford, CA
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Brough SC, Tennakoon L, Spitzer SA, Thomas A, Forrester JD, Spain DA, Weiser TG. Impact of Medicaid Expansion and Firearm Legislation on Cost of Firearm Injuries. Am J Prev Med 2024; 66:37-45. [PMID: 37582417 DOI: 10.1016/j.amepre.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Firearm injury-related hospitalizations in the U.S. cost $900 million annually. Before the Affordable Care Act, government insurance programs covered 41% of the costs. This study describes the impact of Affordable Care Act Medicaid expansion and state-level firearm legislation on coverage and costs for firearm injuries. METHODS This cross-sectional study included 35,854,586 hospitalizations from 27 states in 2013 and 2016. Data analyses were performed in 2022. Firearm injuries were classified by mechanism: assault, unintentional, self-harm, or undetermined. The impact of the Affordable Care Act expansion was determined using difference-in-differences analysis. Differences in per capita costs between states with stronger and weak firearm legislation were compared using univariable and multivariable analyses. RESULTS The authors identified 31,451 initial firearm injury-related hospitalizations. In states with weak firearm legislation, hospitalization costs per 100,000 residents were higher from unintentional ($25,834; p=0.04) and self-inflicted ($11,550; p=0.02) injuries; there were no state-level differences in assault or total per capita firearm-related hospitalization costs. Affordable Care Act expansion increased government coverage of costs by 15 percentage points (95% CI=3, 29) and decreased costs to uninsured/self-pay by 14 percentage points (95% CI=6, 21). In 2016, states with weak firearm legislation and no Affordable Care Act expansion had the highest proportion of hospitalization costs attributed to uninsured/self-pay patients (24%, 95% CI=15, 34). CONCLUSIONS Affordable Care Act expansion increased government coverage of hospitalizations for firearm injuries. Unintentional and self-harm costs were significantly higher for states with weak firearm legislation. States with weak firearm legislation that did not expand Medicaid had the highest proportion of uninsured/self-pay patients.
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Affiliation(s)
- Siqi C Brough
- Department of General Surgery, Inova Fairfax Hospital, Fairfax, Virginia; Department of Surgery, School of Medicine, Stanford University, Stanford, California.
| | | | - Sarabeth A Spitzer
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Arielle Thomas
- American College of Surgeons, Chicago, Illinois; Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - David A Spain
- Department of Surgery, Stanford University, Stanford, California
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California
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Spain DA, Cryer HG. The acute care surgery model and elective surgery. J Trauma Acute Care Surg 2023; 95:e42-e44. [PMID: 37335180 DOI: 10.1097/ta.0000000000004089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
ABSTRACT Two senior surgeons with active elective surgery practices call on their personal experiences to encourage acute care surgery programs to explore ways to incorporate elective surgery into their practice models. Although there are obstacles, these are not insurmountable problems, potential solutions exist, and this may help protect against burnout.
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Affiliation(s)
- David A Spain
- From the David L. Gregg, MD, Professor/Chief of Acute Care Surgery, Department of Surgery, Stanford University (D.A.S.), Stanford; and Department of Surgery (H.G.C.), UCLA, Los Angeles, California
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Choi J, Vendrow EB, Moor M, Spain DA. Development and Validation of a Model to Quantify Injury Severity in Real Time. JAMA Netw Open 2023; 6:e2336196. [PMID: 37812422 PMCID: PMC10562944 DOI: 10.1001/jamanetworkopen.2023.36196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/22/2023] [Indexed: 10/10/2023] Open
Abstract
Importance Quantifying injury severity is integral to trauma care benchmarking, decision-making, and research, yet the most prevalent metric to quantify injury severity-Injury Severity Score (ISS)- is impractical to use in real time. Objective To develop and validate a practical model that uses a limited number of injury patterns to quantify injury severity in real time through 3 intuitive outcomes. Design, Setting, and Participants In this cohort study for prediction model development and validation, training, development, and internal validation cohorts comprised 223 545, 74 514, and 74 514 admission encounters, respectively, of adults (age ≥18 years) with a primary diagnosis of traumatic injury hospitalized more than 2 days (2017-2018 National Inpatient Sample). The external validation cohort comprised 3855 adults admitted to a level I trauma center who met criteria for the 2 highest of the institution's 3 trauma activation levels. Main Outcomes and Measures Three outcomes were hospital length of stay, probability of discharge disposition to a facility, and probability of inpatient mortality. The prediction performance metric for length of stay was mean absolute error. Prediction performance metrics for discharge disposition and inpatient mortality were average precision, precision, recall, specificity, F1 score, and area under the receiver operating characteristic curve (AUROC). Calibration was evaluated using calibration plots. Shapley addictive explanations analysis and bee swarm plots facilitated model explainability analysis. Results The Length of Stay, Disposition, Mortality (LDM) Injury Index (the model) comprised a multitask deep learning model trained, developed, and internally validated on a data set of 372 573 traumatic injury encounters (mean [SD] age = 68.7 [19.3] years, 56.6% female). The model used 176 potential injuries to output 3 interpretable outcomes: the predicted hospital length of stay, probability of discharge to a facility, and probability of inpatient mortality. For the external validation set, the ISS predicted length of stay with mean absolute error was 4.16 (95% CI, 4.13-4.20) days. Compared with the ISS, the model had comparable external validation set discrimination performance (facility discharge AUROC: 0.67 [95% CI, 0.67-0.68] vs 0.65 [95% CI, 0.65-0.66]; recall: 0.59 [95% CI, 0.58-0.61] vs 0.59 [95% CI, 0.58-0.60]; specificity: 0.66 [95% CI, 0.66-0.66] vs 0.62 [95%CI, 0.60-0.63]; mortality AUROC: 0.83 [95% CI, 0.81-0.84] vs 0.82 [95% CI, 0.82-0.82]; recall: 0.74 [95% CI, 0.72-0.77] vs 0.75 [95% CI, 0.75-0.76]; specificity: 0.81 [95% CI, 0.81-0.81] vs 0.76 [95% CI, 0.75-0.77]). The model had excellent calibration for predicting facility discharge disposition, but overestimated inpatient mortality. Explainability analysis found the inputs influencing model predictions matched intuition. Conclusions and Relevance In this cohort study using a limited number of injury patterns, the model quantified injury severity using 3 intuitive outcomes. Further study is required to evaluate the model at scale.
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University, Stanford, California
| | - Edward B. Vendrow
- Department of Computer Science, Stanford University, Stanford, California
| | - Michael Moor
- Department of Computer Science, Stanford University, Stanford, California
| | - David A. Spain
- Department of Surgery, Stanford University, Stanford, California
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Forssten MP, Cao Y, Mohammad Ismail A, Ioannidis I, Tennakoon L, Spain DA, Mohseni S. Validation of the orthopedic frailty score for measuring frailty in hip fracture patients: a cohort study based on the United States National inpatient sample. Eur J Trauma Emerg Surg 2023; 49:2155-2163. [PMID: 37349513 PMCID: PMC10520138 DOI: 10.1007/s00068-023-02308-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND The Orthopedic Frailty Score (OFS) has been proposed as a tool for measuring frailty in order to predict short-term postoperative mortality in hip fracture patients. This study aims to validate the OFS using a large national patient register to determine its relationship with adverse outcomes as well as length of stay and cost of hospital stay. METHODS All adult patients (18 years or older) registered in the 2019 National Inpatient Sample Database who underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. The association between the OFS and mortality, complications, and failure-to-rescue (FTR) was determined using Poisson regression models adjusted for potential confounders. The relationship between the OFS and length of stay and cost of hospital stay was instead determined using a quantile regression model. RESULTS An estimated 227,850 cases met the study inclusion criteria. There was a stepwise increase in the rate of complications, mortality, and FTR for each additional point on the OFS. After adjusting for potential confounding, OFS 4 was associated with an almost ten-fold increase in the risk of in-hospital mortality [adjusted IRR (95% CI): 10.6 (4.02-27.7), p < 0.001], a 38% increased risk of complications [adjusted IRR (95% CI): 1.38 (1.03-1.85), p = 0.032], and an almost 11-fold increase in the risk of FTR [adjusted IRR (95% CI): 11.6 (4.36-30.9), p < 0.001], compared to OFS 0. Patients with OFS 4 also required a day and a half additional care [change in median length of stay (95% CI): 1.52 (0.97-2.08), p < 0.001] as well as cost approximately $5,200 more to manage [change in median cost of stay (95% CI): 5166 (1921-8411), p = 0.002], compared to those with OFS 0. CONCLUSION Patients with an elevated OFS display a substantially increased risk of mortality, complications, and failure-to-rescue as well as a prolonged and more costly hospital stay.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, 701 82 Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Lakshika Tennakoon
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA USA
| | - David A. Spain
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheik Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
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Choi J, Chen Y, Sivura A, Vendrow EB, Wang J, Spain DA. TraumaICDBERT, A Natural Language Processing Algorithm to Extract Injury ICD-10 Diagnosis Code from Free Text. Ann Surg 2023:00000658-990000000-00646. [PMID: 37753654 DOI: 10.1097/sla.0000000000006107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To develop and validate TraumaICDBERT, a natural language processing algorithm to predict injury ICD-10 diagnosis codes from trauma tertiary survey notes. SUMMARY BACKGROUND DATA The adoption of ICD-10 diagnosis codes in clinical settings for injury prediction is hindered by the lack of real-time availability. Existing natural language processing algorithms have limitations in accurately predicting injury ICD-10 diagnosis codes. METHODS Trauma tertiary survey notes from hospital encounters of adults between January 2016 and June 2021 were used to develop and validate TraumaICDBERT, an algorithm based on BioLinkBERT. The performance of TraumaICDBERT was compared to Amazon Web Services Comprehend Medical, an existing natural language processing tool. RESULTS A dataset of 3,478 tertiary survey notes with 15,762 4-character injury ICD-10 diagnosis codes was analyzed. TraumaICDBERT outperformed Amazon Web Services Comprehend Medical across all evaluated metrics. On average, each tertiary survey note was associated with 3.8 (standard deviation: 2.9) trauma registrar-extracted 4-character injury ICD-10 diagnosis codes. CONCLUSIONS TraumaICDBERT demonstrates promising initial performance in predicting injury ICD-10 diagnosis codes from trauma tertiary survey notes, potentially facilitating the adoption of downstream prediction tools in clinical settings.
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University, Stanford, California
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Yifu Chen
- Department of Biomedical Data Science, Stanford University, Stanford, California
| | - Alexander Sivura
- Center for Professional Development, Stanford University, Stanford, California
| | - Edward B Vendrow
- Department of Computer Science, Stanford University, Stanford, California
| | - Jenny Wang
- Department of Surgery, Stanford University, Stanford, California
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California
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Carlson EB, Shieh L, Barlow MR, Palmieri PA, Yen F, Mellman TA, Williams M, Williams MY, Chandran M, Spain DA. Mental health symptoms are comparable in patients hospitalized with acute illness and patients hospitalized with injury. PLoS One 2023; 18:e0286563. [PMID: 37729187 PMCID: PMC10511104 DOI: 10.1371/journal.pone.0286563] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/18/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND High rates of mental health symptoms such as depression, anxiety, and posttraumatic stress disorder (PTSD) have been found in patients hospitalized with traumatic injuries, but little is known about these problems in patients hospitalized with acute illnesses. A similarly high prevalence of mental health problems in patients hospitalized with acute illness would have significant public health implications because acute illness and injury are both common, and mental health problems of depression, anxiety, and PTSD are highly debilitating. METHODS AND FINDINGS In patients admitted after emergency care for Acute Illness (N = 656) or Injury (N = 661) to three hospitals across the United States, symptoms of depression, anxiety, and posttraumatic stress were compared acutely (Acute Stress Disorder) and two months post-admission (PTSD). Patients were ethnically/racially diverse and 54% female. No differences were found between the Acute Illness and Injury groups in levels of any symptoms acutely or two months post-admission. At two months post-admission, at least one symptom type was elevated for 37% of the Acute Illness group and 39% of the Injury group. Within racial/ethnic groups, PTSD symptoms were higher in Black patients with injuries than for Black patients with acute illness. A disproportionate number of Black patients had been assaulted. CONCLUSIONS This study found comparable levels of mental health sequelae in patients hospitalized after emergency care for acute illness as in patients hospitalized after emergency care for injury. Findings of significantly higher symptoms and interpersonal violence injuries in Black patients with injury suggest that there may be important and actionable differences in mental health sequelae across ethnic/racial identities and/or mechanisms of injury or illness. Routine screening for mental health risk for all patients admitted after emergency care could foster preventive care and reduce ethnic/racial disparities in mental health responses to acute illness or injury.
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Affiliation(s)
- Eve B. Carlson
- Dissemination and Training Division, National Center for Posttraumatic Stress Disorder, VA Palo Alto Health Care System, Department of Veterans Affairs, Menlo Park, California, United States of America
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, United States of America
| | - Lisa Shieh
- Department of Medicine, Division of Hospital Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - M. Rose Barlow
- Dissemination and Training Division, National Center for Posttraumatic Stress Disorder, VA Palo Alto Health Care System, Department of Veterans Affairs, Menlo Park, California, United States of America
| | - Patrick A. Palmieri
- Traumatic Stress Center, Summa Health, Akron, Ohio, United States of America
| | - Felicia Yen
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Thomas A. Mellman
- Georgetown Howard Universities Center for Clinical Translational Research, Washington, DC, United States of America
- Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC, United States of America
| | - Mallory Williams
- Department of Surgery, Howard University College of Medicine, Washington, DC, United States of America
- Center of Excellence in Trauma and Violence Prevention, Howard University College of Medicine, Washington, DC, United States of America
| | - Michelle Y. Williams
- Department of Medicine, Division of Hospital Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Mayuri Chandran
- Department of Medicine, Division of Hospital Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - David A. Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America
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Handley TJ, Kang A, Alawa J, Arnow K, Spain DA, Choi J. For-Profit Status and Geographic Distribution of Trauma Centers in the US. JAMA Surg 2023; 158:979-981. [PMID: 37494053 PMCID: PMC10372751 DOI: 10.1001/jamasurg.2023.2751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/06/2023] [Indexed: 07/27/2023]
Abstract
This cohort study assesses geographic distribution of for-profit and not-for-profit trauma centers in the US designated by their states between 2014 and 2018.
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Affiliation(s)
- Thomas J. Handley
- Department of Health Policy, Stanford University School of Medicine, Stanford, California
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Palo Alto, California
| | - Augustine Kang
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jude Alawa
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Palo Alto, California
| | - David A. Spain
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Palo Alto, California
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jeff Choi
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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13
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Cruz-Gonzalez M, Alegría M, Palmieri PA, Spain DA, Barlow MR, Shieh L, Williams M, Srirangam P, Carlson EB. Racial/ethnic differences in acute and longer-term posttraumatic symptoms following traumatic injury or illness. Psychol Med 2023; 53:5099-5108. [PMID: 35903010 PMCID: PMC9884321 DOI: 10.1017/s0033291722002112] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Racial/ethnic differences in mental health outcomes after a traumatic event have been reported. Less is known about factors that explain these differences. We examined whether pre-, peri-, and post-trauma risk factors explained racial/ethnic differences in acute and longer-term posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in patients hospitalized following traumatic injury or illness. METHODS PTSD, depression, and anxiety symptoms were assessed during hospitalization and 2 and 6 months later among 1310 adult patients (6.95% Asian, 14.96% Latinx, 23.66% Black, 4.58% multiracial, and 49.85% White). Individual growth curve models examined racial/ethnic differences in PTSD, depression, and anxiety symptoms at each time point and in their rate of change over time, and whether pre-, peri-, and post-trauma risk factors explained these differences. RESULTS Latinx, Black, and multiracial patients had higher acute PTSD symptoms than White patients, which remained higher 2 and 6 months post-hospitalization for Black and multiracial patients. PTSD symptoms were also found to improve faster among Latinx than White patients. Risk factors accounted for most racial/ethnic differences, although Latinx patients showed lower 6-month PTSD symptoms and Black patients lower acute and 2-month depression and anxiety symptoms after accounting for risk factors. Everyday discrimination, financial stress, past mental health problems, and social constraints were related to these differences. CONCLUSION Racial/ethnic differences in risk factors explained most differences in acute and longer-term PTSD, depression, and anxiety symptoms. Understanding how these risk factors relate to posttraumatic symptoms could help reduce disparities by facilitating early identification of patients at risk for mental health problems.
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Affiliation(s)
- Mario Cruz-Gonzalez
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Margarita Alegría
- Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Patrick A. Palmieri
- Traumatic Stress Center, Department of Psychiatry, Summa Health, Akron, OH, USA
| | - David A. Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - M. Rose Barlow
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Menlo Park, CA, USA
| | - Lisa Shieh
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mallory Williams
- Department of Surgery, Howard University College of Medicine, Washington, DC, USA
- Center of Excellence in Trauma and Violence Prevention, Howard University College of Medicine, Washington, DC, USA
| | | | - Eve B. Carlson
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, U.S. Department of Veterans Affairs, Menlo Park, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
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14
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Edamadaka S, Brown DW, Swaroop R, Kolodner M, Spain DA, Forrester JD, Choi J. FasterRib: A deep learning algorithm to automate identification and characterization of rib fractures on chest computed tomography scans. J Trauma Acute Care Surg 2023; 95:181-185. [PMID: 36872505 DOI: 10.1097/ta.0000000000003913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Characterizing and enumerating rib fractures are critical to informing clinical decisions, yet in-depth characterization is rarely performed because of the manual burden of annotating these injuries on computed tomography (CT) scans. We hypothesized that our deep learning model, FasterRib , could predict the location and percentage displacement of rib fractures using chest CT scans. METHODS The development and internal validation cohort comprised more than 4,700 annotated rib fractures from 500 chest CT scans within the public RibFrac. We trained a convolutional neural network to predict bounding boxes around each fracture per CT slice. Adapting an existing rib segmentation model, FasterRib outputs the three-dimensional locations of each fracture (rib number and laterality). A deterministic formula analyzed cortical contact between bone segments to compute percentage displacements. We externally validated our model on our institution's data set. RESULTS FasterRib predicted precise rib fracture locations with 0.95 sensitivity, 0.90 precision, 0.92 f1 score, with an average of 1.3 false-positive fractures per scan. On external validation, FasterRib achieved 0.97 sensitivity, 0.96 precision, and 0.97 f1 score, and 2.24 false-positive fractures per scan. Our publicly available algorithm automatically outputs the location and percent displacement of each predicted rib fracture for multiple input CT scans. CONCLUSION We built a deep learning algorithm that automates rib fracture detection and characterization using chest CT scans. FasterRib achieved the highest recall and the second highest precision among known algorithms in literature. Our open source code could facilitate FasterRib's adaptation for similar computer vision tasks and further improvements via large-scale external validation. LEVEL OF EVIDENCE Diagnostic Tests/Criteria; Level III.
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Affiliation(s)
- Sathya Edamadaka
- From the Department of Electrical Engineering (S.E.), Stanford Center for Professional Development (D.J.B.), Department of Computer Science (R.S., M.K.), and Department of Surgery (D.A.S, J.D.F.,J.C.), Stanford University, Stanford, California
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15
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Choi J, Anderson T, Tennakoon L, Spain DA, Forrester JD. Explainable Machine Learning to Bring Database to the Bedside: Development and Validation of the TROUT (Trauma fRailty OUTcomes) Index, a Point-of-Care Tool to Prognosticate Outcomes After Traumatic Injury Based on Frailty. Ann Surg 2023; 278:135-139. [PMID: 35920568 DOI: 10.1097/sla.0000000000005649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Exemplify an explainable machine learning framework to bring database to the bedside; develop and validate a point-of-care frailty assessment tool to prognosticate outcomes after injury. BACKGROUND A geriatric trauma frailty index that captures only baseline conditions, is readily-implementable, and validated nationwide remains underexplored. We hypothesized Trauma fRailty OUTcomes (TROUT) Index could prognosticate major adverse outcomes with minimal implementation barriers. METHODS We developed TROUT index according to Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis guidelines. Using nationwide US admission encounters of patients aged ≥65 years (2016-2017; 10% development, 90% validation cohorts), unsupervised and supervised machine learning algorithms identified baseline conditions that contribute most to adverse outcomes. These conditions were aggregated into TROUT Index scores (0-100) that delineate 3 frailty risk strata. After associative [between frailty risk strata and outcomes, adjusted for age, sex, and injury severity (as effect modifier)] and calibration analysis, we designed a mobile application to facilitate point-of-care implementation. RESULTS Our study population comprised 1.6 million survey-weighted admission encounters. Fourteen baseline conditions and 1 mechanism of injury constituted the TROUT Index. Among the validation cohort, increasing frailty risk (low=reference group, moderate, high) was associated with stepwise increased adjusted odds of mortality {odds ratio [OR] [95% confidence interval (CI)]: 2.6 [2.4-2.8], 4.3 [4.0-4.7]}, prolonged hospitalization [OR (95% CI)]: 1.4 (1.4-1.5), 1.8 (1.8-1.9)], disposition to a facility [OR (95% CI): 1.49 (1.4-1.5), 1.8 (1.7-1.8)], and mechanical ventilation [OR (95% CI): 2.3 (1.9-2.7), 3.6 (3.0-4.5)]. Calibration analysis found positive correlations between higher TROUT Index scores and all adverse outcomes. We built a mobile application ("TROUT Index") and shared code publicly. CONCLUSION The TROUT Index is an interpretable, point-of-care tool to quantify and integrate frailty within clinical decision-making among injured patients. The TROUT Index is not a stand-alone tool to predict outcomes after injury; our tool should be considered in conjunction with injury pattern, clinical management, and within institution-specific workflows. A practical mobile application and publicly available code can facilitate future implementation and external validation studies.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
- Department of Biomedical Data Science, Stanford University, Stanford, CA
| | - Taylor Anderson
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
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16
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Montgomery KB, Sarosi GA, Spain DA, Lindeman B. Precision Medicine as a Blueprint for Surgical Education: Concepts and Competencies. Ann Surg 2023; 277:e981-e983. [PMID: 36521098 PMCID: PMC10264541 DOI: 10.1097/sla.0000000000005777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - George A. Sarosi
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - David A. Spain
- Department of Surgery, Stanford University, Palo Alto, CA, USA
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17
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Fu SJ, Arnow K, Barreto NB, Aouad M, Trickey AW, Spain DA, Morris AM, Knowlton LM. Insurance churn after adult traumatic injury: A national evaluation among a large private insurance database. J Trauma Acute Care Surg 2023; 94:692-699. [PMID: 36623273 DOI: 10.1097/ta.0000000000003861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Traumatic injury leads to significant disability, with injured patients often requiring substantial health care resources to return to work and baseline health. Temporary disability or inability to work can result in changes or loss of employer-based private insurance coverage, which may significantly impact health care access and outcomes. Among privately insured patients, we hypothesized increased instability in insurance coverage for patients with higher severity of injury. METHODS Adults 18 years and older presenting to a hospital with traumatic injury were evaluated for insurance churn using Clinformatics Data Mart private-payer claims. Insurance churn was defined as cessation of enrollment in the patient's private health insurance plan. Using Injury Severity Score (ISS), we compared insurance churn over the year following injury between patients with mild (ISS, <9), moderate (ISS, 9-15), severe (ISS, 16-24), and very severe (ISS, >24) injuries. Kaplan-Meier analysis was used to compare time with insurance churn by ISS category. Flexible parametric regression was used to estimate hazard ratios for insurance churn. RESULTS Among 750,862 privately insured patients suffering from a traumatic injury, 50% experienced insurance churn within 1 year after injury. Compared with patients who remained on their insurance plan, patients who experienced insurance churn were younger and more likely male and non-White. The median time to insurance churn was 7.7 months for those with mild traumatic injury, 7.5 months for moderately or severely injured, and 7.1 months for the very severely injured. In multivariable analysis, increasing injury severity was associated with higher rates of insurance churn compared with mild injury, up to 14% increased risk for the very severely injured. CONCLUSION Increasing severity of traumatic injury is associated with higher levels of health coverage churn among the privately insured. Lack of continuous access to health services may prolong recovery and further aggravate the medical and social impact of significant traumatic injury. LEVEL OF EVIDENCE Economic and Value Based Evaluations; Level III.
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Affiliation(s)
- Sue J Fu
- From the S-SPIRE, Department of Surgery (S.J.F., K.A., N.B.B., A.W.T., D.A.S., A.M., L.K.), Division of General Surgery, Stanford University School of Medicine, Stanford, California; Department of Economics (M.A.), School of Social Sciences, University of California-Irvine, Irvine, California
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18
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Choi J, Spain DA. Maturing as an Impactful Academic Surgeon during Residency Research Time. Ann Surg 2023; 277:e733-e736. [PMID: 36538632 DOI: 10.1097/sla.0000000000005766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University, Stanford, CA
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19
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Nassar AK, Weimer-Elder B, Yang R, Kline M, Dang BK, Spain DA, Knowlton LM, Valdez AB, Korndorffer JR, Johnson T. Developing an Inpatient Relationship Centered Communication Curriculum (I-RCCC) rounding framework for surgical teams. BMC Med Educ 2023; 23:137. [PMID: 36859253 PMCID: PMC9979403 DOI: 10.1186/s12909-023-04105-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Morning rounds by an acute care surgery (ACS) service at a level one trauma center are uniquely demanding, given the fast pace, high acuity, and increased patient volume. These demands notwithstanding, communication remains integral to the success of surgical teams. Yet there are limited published curricula that address trauma inpatient communication needs. Observations at our institution confirmed that the surgical team lacked a shared mental model for communication. We hypothesized that creating a relationship-centered rounding conceptual framework model would enhance the provider-patient experience. STUDY DESIGN A mixed-methods approach was used for this study. A multi-pronged needs assessment was conducted. Provider communion items for Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to measure patients' expressed needs. Faculty with experience in relationship-centered communication observed morning rounds and documented demonstrated behaviors. A five-hour workshop was designed based on the identified needs. A pre-and post-course Assessment and course evaluation were conducted. Provider-related patient satisfaction items were measured six months before the course and six months after the workshop. RESULTS Needs assessment revealed a lack of a shared communication framework and a lack of leadership skills for senior trauma residents. Barriers included: time constraints, patient load, and interruptions during rounds. The curriculum was very well received. The self-reflected behaviors that demonstrated the most dramatic change between the pre and post-workshop surveys were: I listened without interrupting; I spoke clearly and at a moderate pace; I repeated key points; and I checked that the patient understood. All these changed from being performed by 50% of respondents "about half of the time" to 100% of them "always". Press Ganey top box likelihood to recommend (LTR) and provider-related top box items showed a trend towards improvement after implementing the training with a percentage difference of up to 20%. CONCLUSION The Inpatient Relationship Centered Communication Curriculum (I-RCCC) targeting senior residents and Nurse Practitioners (NP) was feasible, practical, and well-received by participants. There was a trend of an increase in LTRs and provider-specific patient satisfaction items. This curriculum will be refined based on the study results and potentially scalable to other surgical specialties.
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Affiliation(s)
| | | | - Rachel Yang
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Merisa Kline
- Stanford Medicine Patient Experience, Physician Partnership Team, Stanford, CA, USA
| | - Bryan K Dang
- Stanford Medicine Patient Experience, Physician Partnership Team, Stanford, CA, USA
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Lisa M Knowlton
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Andre B Valdez
- Stanford Medicine Patient Experience, Physician Partnership Team, Stanford, CA, USA
| | | | - Tyler Johnson
- Department of Surgery, Stanford University, Stanford, CA, USA
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20
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Marwaha JS, Chen HW, Habashy K, Choi J, Spain DA, Brat GA. Appraising the Quality of Development and Reporting in Surgical Prediction Models. JAMA Surg 2023; 158:214-216. [PMID: 36449299 PMCID: PMC9713676 DOI: 10.1001/jamasurg.2022.4488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/23/2022] [Indexed: 12/03/2022]
Abstract
This cross-sectional study uses the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis reporting guideline to assess 120 published studies about surgical prediction models.
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Affiliation(s)
- Jayson S Marwaha
- Beth Israel Deaconess Medical Center, Department of Surgery, Boston, Massachusetts
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Hao Wei Chen
- Beth Israel Deaconess Medical Center, Department of Surgery, Boston, Massachusetts
| | - Karl Habashy
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Jeff Choi
- Department of Surgery, Stanford University, Palo Alto, California
- Department of Biomedical Data Science, Stanford University, Palo Alto, California
| | - David A Spain
- Department of Surgery, Stanford University, Palo Alto, California
| | - Gabriel A Brat
- Beth Israel Deaconess Medical Center, Department of Surgery, Boston, Massachusetts
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
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Abstract
BACKGROUND Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse. METHODS The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race. RESULTS Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type. CONCLUSIONS Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Modupeola Diyaolu
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Chaonan Ye
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Zhuoyi Huang
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ryan Han
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Hannah Wild
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Lakshika Tennakoon
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David A Spain
- Department of Surgery, Division of General Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie D Chao
- Department of Surgery, Division of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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22
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Knowlton LM, Tran LD, Arnow K, Trickey AW, Morris AM, Spain DA, Wagner TH. Emergency Medicaid programs may be an effective means of providing sustained insurance among trauma patients: A statewide longitudinal analysis. J Trauma Acute Care Surg 2023; 94:53-60. [PMID: 36138539 PMCID: PMC9805493 DOI: 10.1097/ta.0000000000003796] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization that offsets costs of care, increases access to postdischarge resources, and provides patients with a path to sustain coverage through Medicaid. Because HPE only lasts up to 60 days, we aimed to determine Medicaid insurance status 6 months after injury among HPE-approved trauma patients and identify factors associated with successful sustainment. METHODS Using a customized longitudinal claims data set for HPE-approved patients from the California Department of Health Care Services, we analyzed adults with a primary trauma diagnosis (International Classification of Diseases version 10) who were HPE approved in 2016 and 2017. Our primary outcome was Medicaid sustainment at 6 months. Univariate and multivariate analyses were performed. RESULTS A total of 9,749 trauma patients with HPE were analyzed; 6,795 (69.7%) sustained Medicaid at 6 months. Compared with patients who did not sustain, those who sustained had higher Injury Severity Score (ISS > 15: 73.5% vs. 68.7%, p < 0.001), more frequent surgical intervention (74.8% vs. 64.5%, p < 0.001), and were more likely to be discharged to postacute services (23.9% vs. 10.4%, p < 0.001). Medicaid sustainment was high among patients who identified as White (86.7%), Hispanic (86.7%), Black (84.3%), and Asian (83.7%). Medicaid sustainment was low among the 2,505 patients (25.7%) who declined to report race, ethnicity, or preferred language (14.8% sustainment). In adjusted analyses, major injuries (ISS > 16) (vs. ISS < 15: adjusted odds ratio [aOR], 1.51; p = 0.02) and surgery (aOR, 1.85; p < 0.001) were associated with increased likelihood of Medicaid sustainment. Declining to disclose race, ethnicity, or language (aOR, 0.05; p < 0.001) decreased the likelihood of Medicaid sustainment. CONCLUSION Hospital Presumptive Eligibility programs are a promising pathway for securing long-term insurance coverage for trauma patients, particularly among the severely injured who likely require ongoing access to health care services. Patient and provider interviews would help to elucidate barriers for patients who do not sustain. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Lisa Marie Knowlton
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Linda D. Tran
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Katherine Arnow
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
| | - David A. Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Todd H. Wagner
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE)
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Spain DA. Ensuring excellence in patient care, research, and education: thoughts on leadership and teamwork. Trauma Surg Acute Care Open 2023; 8:e001027. [PMID: 36895781 PMCID: PMC9990611 DOI: 10.1136/tsaco-2022-001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 02/06/2023] [Indexed: 03/11/2023] Open
Abstract
There are many ways to develop your leadership skills and many ways to be an effective leader. This is one perspective. The best style is the one that works for you and your environment. I would encourage you to spend some time and effort exploring your leadership style, develop new leadership skills, and look for opportunities to serve others.
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Affiliation(s)
- David A Spain
- Surgery, Stanford University, Stanford, California, USA
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Tennakoon L, Korah MM, Tung JT, Spain DA, Ko A. Management of Uncomplicated Appendicitis in Adults: A Nationwide Analysis of Healthcare Use, Cost, and Outcomes From 2018-2019. J Am Coll Surg 2022. [DOI: 10.1097/01.xcs.0000895912.96883.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
This study uses data from the American Trauma Society’s Trauma Information Exchange Program to evaluate trends in nationwide 60-minute access to American College of Surgeons Committee on Trauma–verified level I-IV trauma centers between 2013 and 2019.
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University, Stanford, California
| | - Sarah Karr
- Department of Computer Science, Stanford University, Stanford, California
| | - Arjun Jain
- Department of Computer Science, Stanford University, Stanford, California
| | | | | | - David A. Spain
- Department of Surgery, Stanford University, Stanford, California
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Choi J, Tennakoon L, Khan S, Jaramillo JD, Rajasingh CM, Hakes NA, Forrester JD, Knowlton LM, Nassar AK, Weiser TG, Spain DA. Building a Trainee-led Research Community to Propel Academic Productivity in Health Services Research. J Surg Educ 2022; 79:855-860. [PMID: 35272969 DOI: 10.1016/j.jsurg.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/02/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
Academic productivity is an increasingly important asset for trainees pursuing academic careers. Medical schools and graduate medical education programs offer structured research programs, but providing longitudinal and individualized health services research education remains challenging. Whereas in basic science research, members at multiple training levels support each other within a dedicated community (the laboratory), health services research projects frequently occur within individual faculty-trainee relationships. An optimal match of expertise, availability, and interest may be elusive for an individual mentor-mentee pair. We aimed to share our experience building Surgeons Writing about Trauma (SWAT), a trainee-led research community that propels academic productivity by facilitating peer collaboration and opportunities to transition into independent researchers. We highlight challenges of health services research for trainees, present how structured mentorship and a peer community can address this challenge, and detail SWAT's operational structure to guide replication at peer institutions.
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University, Stanford, California; Department of Biomedical Data Science, Stanford University, Stanford, California.
| | | | - Suleman Khan
- School of Medicine, Stanford University, Stanford, California
| | | | | | - Nicholas A Hakes
- Department of Surgery, Stanford University, Stanford, California
| | | | - Lisa M Knowlton
- Department of Surgery, Stanford University, Stanford, California
| | - Aussama K Nassar
- Department of Surgery, Stanford University, Stanford, California
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California
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Spitzer SA, Forrester JD, Tennakoon L, Spain DA, Weiser TG. A decade of hospital costs for firearm injuries in the United States by region, 2005-2015: government healthcare costs and firearm policies. Trauma Surg Acute Care Open 2022; 7:e000854. [PMID: 35497324 PMCID: PMC8995943 DOI: 10.1136/tsaco-2021-000854] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/07/2022] [Indexed: 11/19/2022] Open
Abstract
Background Firearm injuries are a costly, national public health emergency, and government-sponsored programs frequently pay these hospital costs. Understanding regional differences in firearm injury burden may be useful for crafting appropriate policies, especially with widely varying state gun laws. Objective To estimate the volume of, and hospital costs for, fatal and non-fatal firearm injuries from 2005 to 2015 for each region of the United States and analyze the proportionate cost by payer status. Methods We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2005 to 2015. We converted hospitalization charges to costs, which were inflation-adjusted to 2015 dollars. We used survey weights to create regional estimates. We used the Brady Gun Law to determine significance between firearm restrictiveness and firearm hospitalizations by region. Results There were a total of 317 479 firearm related admissions over the study period: 52 829 (16.66%), 66 671 (21.0%), 134 008 (42.2%), and 63 972 (20.2%) for the Northeast, Midwest, South, and West respectively, demonstrating high regional variability. In the Northeast, hospital costs were $1.98 billion (13.9% of total), of which 56.0% was covered by government payers; for the Midwest, costs were $1.53 billion (19.7% of total), 40.4% of which was covered by government payers; in the South costs were highest at $3.2 billion (41.4% of total), but government payers only covered 34.3%; and costs for the West were $1.94 billion (25.0% of total), with government programs covering 41.6% of the cost burden. Conclusions Hospital admissions and costs for firearm injuries demonstrated wide variation by region, suggesting opportunities for financial savings. As government insurance programs cover 41.5% of costs, tax dollars heavily subsidize the financial burden of firearm injuries and cost recovery options for treating residents injured by firearms should be considered. Injury control strategies have not been well applied to this national public health crisis. Level of evidence Level II, Economic and Value Based Evaluation
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Affiliation(s)
- Sarabeth A Spitzer
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | | | | | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Thomas G Weiser
- Department of Surgery, Stanford University, Stanford, California, USA
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McShane EK, Sun BJ, Maggio PM, Spain DA, Forrester JD. Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative. BMJ Open Qual 2022; 11:e001589. [PMID: 35551095 PMCID: PMC9109116 DOI: 10.1136/bmjoq-2021-001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7 days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU). LOCAL PROBLEM From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7 days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57). METHODS Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients. INTERVENTIONS In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app. RESULTS Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8 days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21 days) to 6 days (range: 1-15 days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008). CONCLUSIONS We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.
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Affiliation(s)
- Erin K McShane
- Stanford University School of Medicine, Stanford, California, USA
| | - Beatrice J Sun
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Paul M Maggio
- Department of Surgery, Stanford University, Stanford, California, USA
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
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Abstract
OBJECTIVE We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs (OOPCs). SUMMARY OF BACKGROUND DATA Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown. METHODS We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A 2-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month OOPCs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure (CHE) after injury. RESULTS Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to high deductible health plan enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12-month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however high-deductible health plan enrollees faced a 13% chance of CHE. CONCLUSIONS Privately insured trauma patients face substantial OOPCs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.
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Affiliation(s)
- Sue J Fu
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
- Health Research and Development, Veteran Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Katherine Arnow
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Amber Trickey
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - David A Spain
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Arden Morris
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
| | - Lisa Knowlton
- S-SPIRE, Department of Surgery, Division of General Surgery, Stanford University
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Richardson JD, Spain DA, Livingston DH. Trauma and acute care surgery: The evolution of a specialty. J Trauma Acute Care Surg 2022; 92:242-249. [PMID: 34739005 DOI: 10.1097/ta.0000000000003456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J David Richardson
- From the Department of Surgery, University of Louisville School of Medicine (J.D.R.), Louisville, Kentucky; Department of Surgery, Stanford University School of Medicine (D.A.S.), Palo Alto, California; and Department of Surgery, Rutgers-New Jersey Medical School (D.H.L.), Newark, New Jersey
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Affiliation(s)
- David A Spain
- From the Department of Surgery, Stanford University, Stanford, California
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Choi J, Khan S, Sheira D, Hakes NA, Aboukhater L, Spain DA. Prospective study of long-term quality-of-life after rib fractures. Surgery 2021; 172:404-409. [PMID: 34969527 DOI: 10.1016/j.surg.2021.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/11/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term quality-of-life after rib fractures remains understudied. We aimed to evaluate quality-of-life of patients who had rib fractures 1 year after discharge. We hypothesized that patients with rib fractures, even as an isolated injury, have suboptimal long-term quality-of-life. METHODS We prospectively enrolled adults admitted to our level 1 trauma center with acute rib fractures. Primary outcome was quality-of-life at 1 year after discharge, characterized using the revised trauma-specific quality-of-life questionnaire and a supplemental survey. Secondary analysis evaluated association between baseline frailty (measured using the Rib Fracture Frailty Index) and quality-of-life. Patients with low versus moderate frailty risk underwent full matching and linear mixed model analysis. RESULTS We enrolled 139 patients, among whom 72 (52%) completed 1-year surveys. Patients reported excellent emotional well-being (median [interquartile range]: 4.8 [3.7-5.0]) and functional engagement (median [interquartile range]: 5.0 [4.3-5.0]) but poor physical well-being and recovery (median [interquartile range]: 3.2 [2.8-3.6]). Nearly 40% of patients reported some degree of rib pain, and 29% had not returned to preinjury working capacity. Patients with and without isolated rib fractures reported similar median revised trauma-specific quality-of-life scores. We did not find statistically significant association between low versus moderate frailty and any quality-of-life domain, but no patients in our cohort had high frailty risk and our study was underpowered to detect this association. CONCLUSION Rib fractures are associated with suboptimal quality-of-life 1 year after discharge, even after isolated injury. Our sample size was limited, but our findings highlight persistent long-term consequences of rib fractures despite advances in inpatient management. Patients should be counseled on the potential for prolonged convalescence.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA.
| | - Suleman Khan
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA. https://twitter.com/_SulemanKhan_
| | - Dina Sheira
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Nicholas A Hakes
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - Layla Aboukhater
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA. https://twitter.com/DavidASpain
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Knudson MM, Moore EE, Kornblith LZ, Shui AM, Brakenridge S, Bruns BR, Cipolle MD, Costantini TW, Crookes BA, Haut ER, Kerwin AJ, Kiraly LN, Knowlton LM, Martin MJ, McNutt MK, Milia DJ, Mohr A, Nirula R, Rogers FB, Scalea TM, Sixta SL, Spain DA, Wade CE, Velmahos GC. Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism. JAMA Surg 2021; 157:e216356. [PMID: 34910098 DOI: 10.1001/jamasurg.2021.6356] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events. Objective To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE. Design, Setting, and Participants This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days. Exposures Investigational imaging, prophylactic measures used, and treatment of clots. Main Outcomes and Measures The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT. Results A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE. Conclusions and Relevance To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.
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Affiliation(s)
| | | | | | - Amy M Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Scott Brakenridge
- Department of Surgery, University of Florida, Gainesville.,Now with Department of Surgery, University of Washington, Seattle
| | - Brandon R Bruns
- Department of Surgery, University of Maryland, Baltimore.,Now with the Department of Surgery, University of Texas Southwestern, Dallas
| | - Mark D Cipolle
- Department of Surgery, Christiana Health Care, Newark, Delaware.,Now with the Department of Surgery Lehigh Valley Health, Allentown, Pennsylvania
| | | | - Bruce A Crookes
- Department of Surgery, Medical University of South Carolina, Charleston
| | - Elliot R Haut
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Andrew J Kerwin
- Now with Department of Surgery, University of Washington, Seattle.,Now with the Department of Surgery, University of Tennessee, Memphis
| | - Laszlo N Kiraly
- Department of Surgery, University of Oregon Health Sciences University, Portland
| | - Lisa M Knowlton
- Department of Surgery, Stanford University, Palo Alto, California
| | - Matthew J Martin
- Department of Surgery, Scripps Mercy Hospital, San Diego, California
| | | | - David J Milia
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Alicia Mohr
- Now with Department of Surgery, University of Washington, Seattle
| | - Ram Nirula
- Department of Surgery, University of Utah, Salt Lake City
| | - Fredrick B Rogers
- Department of Surgery, Lancaster General Hospital, Lancaster, Pennsylvania
| | | | - Sherry L Sixta
- Department of Surgery, Christiana Health Care, Newark, Delaware
| | - David A Spain
- Department of Surgery, Stanford University, Palo Alto, California
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Choi J, Marafino BJ, Vendrow EB, Tennakoon L, Baiocchi M, Spain DA, Forrester JD. Rib Fracture Frailty Index: A risk stratification tool for geriatric patients with multiple rib fractures. J Trauma Acute Care Surg 2021; 91:932-939. [PMID: 34446653 DOI: 10.1097/ta.0000000000003390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rib fractures are consequential injuries for geriatric patients (age, ≥65 years). Although age and injury patterns drive many rib fracture management decisions, the impact of frailty-which baseline conditions affect rib fracture-specific outcomes-remains unclear for geriatric patients. We aimed to develop and validate the Rib Fracture Frailty (RFF) Index, a practical risk stratification tool specific for geriatric patients with rib fractures. We hypothesized that a compact list of frailty markers can accurately risk stratify clinical outcomes after rib fractures. METHODS We queried nationwide US admission encounters of geriatric patients admitted with multiple rib fractures from 2016 to 2017. Partitioning around medoids clustering identified a development subcohort with previously validated frailty characteristics. Ridge regression with penalty for multicollinearity aggregated baseline conditions most prevalent in this frail subcohort into RFF scores. Regression models with adjustment for injury severity, sex, and age assessed associations between frailty risk categories (low, medium, and high) and inpatient outcomes among validation cohorts (odds ratio [95% confidence interval]). We report results according to Transparent Reporting of Multivariable Prediction Model for Individual Prognosis guidelines. RESULTS Development cohort (n = 55,540) cluster analysis delineated 13 baseline conditions constituting the RFF Index. Among external validation cohort (n = 77,710), increasing frailty risk (low [reference group], moderate, high) was associated with stepwise worsening adjusted odds of mortality (1.5 [1.2-1.7], 3.5 [3.0-4.0]), intubation (2.4 [1.5-3.9], 4.7 [3.1-7.5]), hospitalization ≥5 days (1.4 [1.3-1.5], 1.8 [1.7-2.0]), and disposition to home (0.6 [0.5-0.6], 0.4 [0.3-0.4]). Locally weighted scatterplot smoothing showed correlations between increasing RFF scores and worse outcomes. CONCLUSION The RFF Index is a practical frailty risk stratification tool for geriatric patients with multiple rib fractures. The mobile app we developed may facilitate rapid implementation and further validation of RFF Index at the bedside. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Jeff Choi
- From the Division of General Surgery, Department of Surgery (J.C., L.T., D.A.S., J.D.F.), Surgeons Writing About Trauma (J.C., E.B.V., L.T., D.A.S., J.D.F.), Department of Biomedical Data Science (J.C., B.J.M.), Department of Epidemiology and Population Health (B.J.M., M.B.), and Department of Computer Science (E.B.V.), Stanford University, Stanford, California
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Choi J, Patil A, Vendrow E, Touponse G, Aboukhater L, Forrester JD, Spain DA. Practical Computer Vision Application to Compute Total Body Surface Area Burn: Reappraising a Fundamental Burn Injury Formula in the Modern Era. JAMA Surg 2021; 157:129-135. [PMID: 34817552 DOI: 10.1001/jamasurg.2021.5848] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Critical burn management decisions rely on accurate percent total body surface area (%TBSA) burn estimation. Existing %TBSA burn estimation models (eg, Lund-Browder chart and rule of nines) were derived from a linear formula and a limited number of individuals a century ago and do not reflect the range of body habitus of the modern population. Objective To develop a practical %TBSA burn estimation tool that accounts for exact burn injury pattern, sex, and body habitus. Design, Setting, and Participants This population-based cohort study evaluated the efficacy of a computer vision algorithm application in processing an adult laser body scan data set. High-resolution surface anthropometry laser body scans of 3047 North American and European adults aged 18 to 65 years from the Civilian American and European Surface Anthropometry Resource data set (1998-2001) were included. Of these, 1517 participants (49.8%) were male. Race and ethnicity data were not available for analysis. Analyses were conducted in 2020. Main Outcomes and Measures The contributory %TBSA for 18 body regions in each individual. Mobile application for real-time %TBSA burn computation based on sex, habitus, and exact burn injury pattern. Results Of the 3047 individuals aged 18 to 65 years for whom body scans were available, 1517 (49.8%) were male. Wide individual variability was found in the extent to which major body regions contributed to %TBSA, especially in the torso and legs. Anterior torso %TBSA increased with increasing body habitus (mean [SD], 15.1 [0.9] to 19.1 [2.0] for male individuals; 15.1 [0.8] to 18.0 [1.7] for female individuals). This increase was attributable to increase in abdomen %TBSA (mean [SD], 5.3 [0.7] to 8.7 [1.8]) among male individuals and increase in abdomen (mean [SD], 4.6 [0.6] to 6.8 [1.7]) and pelvis (mean [SD], 1.5 [0.2] to 2.9 [0.9]) %TBSAs among female individuals. For most body regions, Lund-Browder chart and rule of nines estimates fell outside the population's measured interquartile ranges. The mobile application tested in this study, Burn Area, facilitated accurate %TBSA burn computation based on exact burn injury pattern for 10 sex and body habitus-specific models. Conclusions and Relevance Computer vision algorithm application to a large laser body scan data set may provide a practical tool that facilitates accurate %TBSA burn computation in the modern era.
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Affiliation(s)
- Jeff Choi
- Department of Surgery, Stanford University, Stanford, California.,Surgeons Writing About Trauma, Stanford University, Stanford, California
| | - Advait Patil
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,Department of Computer Science, Stanford University, Stanford, California.,School of Engineering, Stanford University, Stanford, California
| | - Edward Vendrow
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,Department of Computer Science, Stanford University, Stanford, California
| | - Gavin Touponse
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,School of Medicine, Stanford University, Stanford, California
| | - Layla Aboukhater
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,School of Medicine, Stanford University, Stanford, California
| | - Joseph D Forrester
- Department of Surgery, Stanford University, Stanford, California.,Surgeons Writing About Trauma, Stanford University, Stanford, California
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California.,Surgeons Writing About Trauma, Stanford University, Stanford, California
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Carlos GM, Tennakoon L, Spain DA, Poultsides GA. Contemporary Predictors of Mortality after Liver Metastasectomy. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Patil A, Tennakoon L, Choi J, Hakes N, Spain DA, Tung J. Traumatic Injury and Death Among Law Enforcement Officers. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tennakoon LD, Hakes NA, Spain DA, Knowlton LM. A National Evaluation of Ambulatory Surgery Utilization Among Emergency General Surgery and Trauma Patients. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Choi J, Tennakoon L, Spain DA, Staudenmayer KL. Outcome-specific Injury Scores (OSIS): Development and Validation of Tailored Prediction Tools for Injured Older Adults. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Purdy AC, de Virgilio C, Kaji AH, Shields Frey E, Lee-Kong S, Inaba K, Gauvin JM, Neville AL, Donahue TR, Smith BR, Salcedo ES, Calhoun KE, Poola VP, Namm JP, Spain DA, Dickinson KJ, Tanner T, Wolfe M, Amersi F. Factors Associated With General Surgery Residents' Operative Experience During the COVID-19 Pandemic. JAMA Surg 2021; 156:767-774. [PMID: 33929493 DOI: 10.1001/jamasurg.2021.1978] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Importance The suspension of elective operations in March 2020 to prepare for the COVID-19 surge posed significant challenges to resident education. To mitigate the potential negative effects of COVID-19 on surgical education, it is important to quantify how the pandemic influenced resident operative volume. Objective To examine the association of the pandemic with general surgical residents' operative experience by postgraduate year (PGY) and case type and to evaluate if certain institutional characteristics were associated with a greater decline in surgical volume. Design, Setting, and Participants This retrospective review included residents' operative logs from 3 consecutive academic years (2017-2018, 2018-2019, and 2019-2020) from 16 general surgery programs. Data collected included total major cases, case type, and PGY. Faculty completed a survey about program demographics and COVID-19 response. Data on race were not collected. Operative volumes from March to June 2020 were compared with the same period during 2018 and 2019. Data were analyzed using Kruskal-Wallis test adjusted for within-program correlations. Main Outcome and Measures Total major cases performed by each resident during the first 4 months of the pandemic. Results A total of 1368 case logs were analyzed. There was a 33.5% reduction in total major cases performed in March to June 2020 compared with 2018 and 2019 (45.0 [95% CI, 36.1-53.9] vs 67.7 [95% CI, 62.0-72.2]; P < .001), which significantly affected every PGY. All case types were significantly reduced in 2020 except liver, pancreas, small intestine, and trauma cases. There was a 10.2% reduction in operative volume during the 2019-2020 academic year compared with the 2 previous years (192.3 [95% CI, 178.5-206.1] vs 213.8 [95% CI, 203.6-223.9]; P < .001). Level 1 trauma centers (49.5 vs 68.5; 27.7%) had a significantly lower reduction in case volume than non-level 1 trauma centers (33.9 vs 63.0; 46%) (P = .03). Conclusions and Relevance In this study of operative logs of general surgery residents in 16 US programs from 2017 to 2020, the first 4 months of the COVID-19 pandemic was associated with a significant reduction in operative experience, which affected every PGY and most case types. Level 1 trauma centers were less affected than non-level 1 centers. If this trend continues, the effect on surgical training may be even more detrimental.
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Affiliation(s)
- Amanda C Purdy
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Christian de Virgilio
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance.,Statistical Editor, JAMA Surgery
| | - Edgar Shields Frey
- Department of Surgery, Brookwood Baptist Medical Center, Birmingham, Alabama
| | - Steven Lee-Kong
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Kenji Inaba
- Department of Surgery, University of Southern California/Los Angeles County Medical Center, Los Angeles
| | - Jeffrey M Gauvin
- Department of Surgery, Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Angela L Neville
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Timothy R Donahue
- Department of Surgery, University of California, Los Angeles Health, Los Angeles
| | - Brian R Smith
- Department of Surgery, University of California, Irvine, Medical Center, Orange
| | - Edgardo S Salcedo
- Department of Surgery, University of California, Davis, School of Medicine, Sacramento
| | | | - V Prasad Poola
- Department of Surgery, Southern Illinois School of Medicine, Springfield
| | - Jukes P Namm
- Department of Surgery, Loma Linda University Health, Loma Linda, California
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California
| | | | - Tiffany Tanner
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - Mary Wolfe
- Department of Surgery, University of California, San Francisco, at Fresno, Fresno
| | - Farin Amersi
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Wise CE, Bereknyei Merrell S, Sasnal M, Forrester JD, Hawn MT, Lau JN, Lin DT, Schmiederer IS, Spain DA, Nassar AK, Knowlton LM. COVID-19 Impact on Surgical Resident Education and Coping. J Surg Res 2021; 264:534-543. [PMID: 33862581 PMCID: PMC7877215 DOI: 10.1016/j.jss.2021.01.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Healthcare systems and surgical residency training programs have been significantly affected by the novel coronavirus disease 2019 (COVID-19) pandemic. A shelter-in-place and social distancing mandate went into effect in our county on March 16, 2020, considerably altering clinical and educational operations. Along with the suspension of elective procedures, resident academic curricula transitioned to an entirely virtual platform. We aimed to evaluate the impact of these modifications on surgical training and resident concerns about COVID-19. MATERIALS AND METHODS We surveyed residents and fellows from all eight surgical specialties at our institution regarding their COVID-19 experiences from March to May 2020. Residents completed the survey via a secure Qualtrics link. A total of 38 questions addressed demographic information and perspectives regarding the impact of the COVID-19 pandemic on surgical training, education, and general coping during the pandemic. RESULTS Of 256 eligible participants across surgical specialties, 146 completed the survey (57.0%). Junior residents comprised 43.6% (n = 61), compared to seniors 37.1% (n = 52) and fellows 19.3% (n = 27). Most participants, 97.9% (n = 138), anticipated being able to complete their academic year on time, and 75.2% (n = 100) perceived virtual learning to be the same as or better than in-person didactic sessions. Participants were most concerned about their ability to have sufficient knowledge and skills to care for patients with COVID-19, and the possibility of exposure to COVID-19. CONCLUSIONS Although COVID-19 impacted residents' overall teaching and clinical volume, residency programs may identify novel virtual opportunities to meet their educational and research milestones during these challenging times.
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Affiliation(s)
| | - Sylvia Bereknyei Merrell
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California
| | - Marzena Sasnal
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California
| | - Joseph D Forrester
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Mary T Hawn
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - James N Lau
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Dana T Lin
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Ingrid S Schmiederer
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - David A Spain
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Aussama K Nassar
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Lisa Marie Knowlton
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California.
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Jaramillo JD, Arnow K, Trickey AW, Dickerson K, Wagner TH, Harris AHS, Tran LD, Bereknyei S, Morris AM, Spain DA, Knowlton LM. Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage. J Trauma Acute Care Surg 2021; 91:249-259. [PMID: 33783416 DOI: 10.1097/ta.0000000000003195] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. LEVEL OF EVIDENCE Economic, level IV.
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Affiliation(s)
- Joshua D Jaramillo
- From the Division of General Surgery, Department of Surgery (J.D.J., K.D.), Stanford University School of Medicine; Department of Surgery, (K.A., A.W.T., T.H.W., A.H.S.H., L.D.T., S.B., A.M.M., L.M.K.), Stanford-Surgery Policy Improvement Research and Education Center, Stanford University School of Medicine; and Department of Surgery (D.A.S., L.M.K.), Section of Trauma, Surgical Critical Care and Acute Care Surgery (L.M.K.), Stanford University, Stanford, California
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Dismuke-Greer CE, Fakhry SM, Horner MD, Pogoda TK, Pugh MJ, Gebregziabher M, Hall CL, Taber D, Spain DA. Ethnicity/race and service-connected disability disparities in civilian traumatic brain injury mechanism of injury and VHA health services costs in military veterans: Evidence from a Level 1 Trauma Center and VA Medical Center. Trauma 2021. [DOI: 10.1177/1460408620914436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The objective of this study was to examine the association of military veteran socio-demographics and service-connected disability with civilian mechanism of traumatic brain injury and long-term Veterans Health Administration (VHA) costs. Methods We conducted a 17-year retrospective longitudinal cohort study of veterans with a civilian-related traumatic brain injury from a Level 1 Trauma Center between 1999 and 2013, with VHA follow-up through 2016. We merged trauma center VHA data, and used logit to model mechanism of injury, and generalized linear model to model VHA costs. Results African American race or Hispanic ethnicity veterans had a higher unadjusted rate of civilian assault/gun as mechanism of injury (15.38%) relative to non-Hispanic White (7.19%). African American race or Hispanic veterans who were discharged from the trauma center with traumatic brain injury and followed in VHA had more than twice the odds of assault/gun (OR 2.47; 95% CI 1.16:5.26), after adjusting for sex, age, and military service-connected disability. Veterans with service-connected disability ≥50% had more than twice the odds of assault/gun (OR 2.48; 95% CI 0.97:6.31). Assault/gun was associated with significantly higher annual VHA costs post-discharge ($16,807; 95% CI 672:32,941) among non-Hispanic White veterans. Military service-connected disability ≥50% was associated with higher VHA costs among both non-Hispanic White ($44,987; 95% CI $17,159:$72,816) and African American race or Hispanic ($37,901; 95% CI $4,543:$71,258) veterans. Conclusions We found that African American race or Hispanic veterans had higher adjusted likelihood of assault/gun mechanism of traumatic brain injury, and non-Hispanic White veterans had higher adjusted annual VHA resource costs associated with assault/gun, post trauma center discharge. Veterans with higher than 50% service-connected disability had higher likelihood of assault/gun and higher adjusted annual VHA resource costs. Assault/gun prevention efforts may be indicated within the VHA, especially in minority and service-connected disability veterans. More data from Level 1 Trauma Centers are needed to assess the generalizability of these findings.
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Affiliation(s)
- CE Dismuke-Greer
- Health Economics Resource Center (HERC), Ci2i, VA Palo Alto Health Care System, Palo Alto, USA
| | - SM Fakhry
- Center for Trauma and Acute Care Surgery Research, CSG, HCA Healthcare, Nashville, USA
| | - MD Horner
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, USA
| | - TK Pogoda
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, USA
- Boston University School of Public Health, Boston, USA
| | - MJ Pugh
- Salt Lake City VA Health Care System and University of Utah Health Sciences, Salt Lake City, USA
| | - M Gebregziabher
- Ralph H. Johnson VA Medical Center and Medical University of South Carolina, Charleston, USA
| | - CL Hall
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VAMC, Charleston, USA
| | - D Taber
- Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VAMC, Charleston, USA
| | - DA Spain
- Department of Surgery, Stanford University, Stanford Healthcare, Stanford, USA
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Affiliation(s)
- Jeff Choi
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,School of Medicine, Stanford University, Stanford, California.,Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Anshal Gupta
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,School of Medicine, Stanford University, Stanford, California
| | - Aydin Kaghazchi
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - Thinzar S Htwe
- Surgeons Writing About Trauma, Stanford University, Stanford, California
| | - Michael Baiocchi
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | - David A Spain
- Surgeons Writing About Trauma, Stanford University, Stanford, California.,Department of Surgery, Stanford University, Stanford, California
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Choi J, Villarreal J, Andersen W, Min JG, Touponse G, Wong C, Spain DA, Forrester JD. Scoping review of traumatic hemothorax: Evidence and knowledge gaps, from diagnosis to chest tube removal. Surgery 2021; 170:1260-1267. [PMID: 33888318 DOI: 10.1016/j.surg.2021.03.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/01/2021] [Accepted: 03/11/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Traumatic hemothorax is a common injury that invites diagnostic and management strategy debates. Evidence-based management has been associated with improved care efficiency. However, the literature abounds with long-debated, re-emerging, and new questions. We aimed to consolidate up-to-date evidence on traumatic hemothoraces, focusing on clinical conundra debated in literature. METHODS We conducted a scoping review of 21 clinical conundra in traumatic hemothorax diagnosis and management according to PRISMA-ScR guidelines. Experimental and observational studies evaluating patients (aged ≥18 years) with traumatic hemothoraces were identified through database searches (PubMed, EMBASE, Web of Science, Cochrane Library; database inception to Sep, 26 2020) and bibliography reviews of selected articles. Three reviewers screened and selected articles using standardized forms. RESULTS We screened 1,440 articles for eligibility, of which 71 met criteria for synthesis. The review comprises 6 sections: (1) Presumptive antibiotics before tube thoracostomy; (2) Initial diagnostic and intervention decisions; (3) Chest tubes; (4) Retained hemothoraces; (5) Delayed hemothoraces; and (6) Chest tube removal). The 21 conundra across these sections follow the format of a question, our recommendation based on interpretation of available evidence, and succinct rationale. Rationale sections detail knowledge gaps and opportunities for future research. CONCLUSION Even practices engrained into surgical dogma, such as obtaining chest x-rays after inserting or removing chest tubes and mandating operation for patients who develop chest tube output above a certain threshold, deserve re-evaluation. Some knowledge gaps require rigorous future investigation; sound clinical judgment can likely supplement others.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA.
| | - Joshua Villarreal
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - Wyatt Andersen
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Jung Gi Min
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Gavin Touponse
- Surgeons Writing About Trauma, Stanford University, Stanford, CA; School of Medicine, Stanford University, Stanford, CA
| | - Connie Wong
- Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, CA; Surgeons Writing About Trauma, Stanford University, Stanford, CA
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Choi J, Mulaney B, Laohavinij W, Trimble R, Tennakoon L, Spain DA, Salomon JA, Goldhaber-Fiebert JD, Forrester JD. Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups. J Trauma Acute Care Surg 2021; 90:451-458. [PMID: 33559982 DOI: 10.1097/ta.0000000000003021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE Economic/decision, level II.
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Affiliation(s)
- Jeff Choi
- From the Department of Surgery (J.C., L.T., D.A.S., J.D.F.), Division of General Surgery, Department of Epidemiology and Population Health (J.C.), Surgeons Writing About Trauma (J.C., B.M., R.T., L.T., D.A.S., J.D.F.), and School of Medicine (B.M., R.T.), Stanford University, Stanford, California; Department of Surgery, Chulalongkorn University (W.L.), Bangkok, Thailand; and Stanford Health Policy (J.A.S., J.D.G.-F.), Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, California
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Choi J, Kaghazchi A, Dickerson KL, Tennakoon L, Spain DA, Forrester JD. Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers. Am J Surg 2021; 222:849-854. [PMID: 33612257 DOI: 10.1016/j.amjsurg.2021.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/10/2021] [Accepted: 02/10/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND We aimed to elucidate management patterns and outcomes of high-risk patients with rib fractures (elderly or flail chest) across non-trauma and trauma centers. We hypothesized highest-capacity (level I) centers would have best outcomes for high-risk patients. METHODS We queried the 2016 National Emergency Department Sample to identify adults presenting with rib fractures. Multivariable regression assessed ED and inpatient events across non-trauma and level III/II/I trauma centers. RESULTS Among 504,085 rib fracture encounters, 46% presented to non-trauma centers. Elderly patients with multiple rib fractures had stepwise increase in inpatient admission odds and stepwise decrease in pneumonia odds at higher-capacity trauma centers compared to non-trauma centers. Among patients with flail chest, odds of undergoing surgical stabilization (SSRF) increased at trauma centers. Undergoing SSRF was associated with reduced mortality but remained underutilized. CONCLUSION Half of patients with rib fractures present to non-trauma centers. Nationwide care-optimization for high-risk patients requires further effort.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, Stanford University, USA; Department of Epidemiology and Population Health, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA.
| | - Aydin Kaghazchi
- Department of Epidemiology and Population Health, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
| | - Katherine L Dickerson
- Surgeons Writing About Trauma, Stanford University, USA; Department of Emergency Medicine, Massachusetts General Hospital, Harvard University, USA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, USA; Surgeons Writing About Trauma, Stanford University, USA
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Choi J, Mulaney B, Sun B, Trimble R, Tennakoon L, Spain DA, Forrester JD. Concomitant Sternal Fractures: Harbinger of Worse Pulmonary Complications and Mortality in Patients With Rib Fractures. Am Surg 2021; 88:1201-1206. [PMID: 33522281 DOI: 10.1177/0003134821991978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Sternal and rib fractures are common concomitant injuries. However, the impact of concurrent sternal fractures on clinical outcomes of patients with rib fractures is unclear. We aimed to unveil the pulmonary morbidity and mortality impact of concomitant sternal fractures among patients with rib fractures. METHODS We identified adult patients admitted with traumatic rib fractures with vs. without concomitant sternal fractures using the 2012-2014 National Inpatient Sample (NIS). After 2:1 propensity score matching and adjustment for residual imbalances, we compared risk of pulmonary morbidity and mortality between patients with vs. without concomitant sternal fractures. Subgroup analysis in patients with flail chest assessed whether sternal fractures modify the association between undergoing surgical stabilization of rib fractures (SSRF) and pulmonary morbidity or mortality. RESULTS Of 475 710 encounters of adults admitted with rib fractures, 24 594 (5%) had concomitant sternal fractures. After 2:1 propensity score matching, patients with concomitant sternal fractures had 70% higher risk (95% CI: 50-90% higher, P < 0.001) of undergoing tracheostomy, 40% higher risk (30-50% higher, P <.001) of undergoing intubation, and 20% higher risk of respiratory failure (10-30% higher, P <.001) and mortality (10-40% higher, P =.007). Subgroup analysis of 8600 patients with flail chest showed concomitant sternal fractures did not impact the association between undergoing SSRF and any pulmonary morbidity or mortality. CONCLUSION Concomitant sternal fractures are associated with increased risk for pulmonary morbidity and mortality among patients with rib fractures. However, our findings are limited by a binary definition of sternal fractures, which encompasses heterogeneous injury patterns with likely variable clinical relevance.
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Affiliation(s)
- Jeff Choi
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Department of Epidemiology and Population Health, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - Bianca Mulaney
- Surgeons Writing about Trauma, 6429Stanford University, CA, USA.,School of Medicine, 6429Stanford University, CA, USA
| | - Beatrice Sun
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - Richard Trimble
- Surgeons Writing about Trauma, 6429Stanford University, CA, USA.,School of Medicine, 6429Stanford University, CA, USA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - David A Spain
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, 6429Stanford University, CA, USA.,Surgeons Writing about Trauma, 6429Stanford University, CA, USA
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Spain DA. A Review of "Will Future Surgeons Be Interested in Trauma Care? Results of a Resident Survey" (1992). Am Surg 2021; 87:191-194. [PMID: 33502249 DOI: 10.1177/0003134820988821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David A Spain
- Department of Surgery, 6429Stanford University, Stanford, CA, USA
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Gupta A, Tennakoon L, Spain DA, Forrester JD. Outcomes after Surgery among Patients Diagnosed with One or More Multi-Drug-Resistant Organisms. Surg Infect (Larchmt) 2021; 22:722-729. [PMID: 33471591 DOI: 10.1089/sur.2020.400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background: Infections with multi-drug-resistant organisms (MDROs) may be difficult to treat and prolong patient hospitalization and recovery. Multiple MDRO coinfections may increase the complexity of clinical management. However, association between multiple MDROs and outcomes of patients who undergo surgery is unknown. Patients and Methods: We performed a retrospective, cross-sectional analysis of the 2016 National Inpatient Sample for identified by International Classification of Disease, 10th Revision Clinical Modification (ICD-10-CM) diagnosis codes associated with multi-drug-resistant organisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), multi-drug-resistant gram-negative bacilli, and Clostridioides difficile infection (CDI). Admitted patients with diagnosis codes for MDROs were cross-matched with codes for common general surgery procedures. Outcomes of interest included length of stay and mortality. Weighted univariable and multivariable analyses accounting for the survey methodology were performed. Results: Of 1,550,224 patients undergoing surgery in 2016, 39,065 (3%) admissions were diagnosed with an MDRO and 1,176 (0.1%) were associated with dual MDROs diagnoses. Patients diagnosed with one MDRO were hospitalized three times longer (17.3 days; 95% confidence interval [CI], 16.8-17.7) and patients diagnosed with two MDROs five times longer (31.6 days; 95% CI, 27.0-36.2; p < 0.0001) than undiagnosed patients (6.1 days; 95% CI, 6.1-6.1; all p < 0.0001). On multivariable analysis, the strongest predictor of mortality was a diagnosis of two MDRO infections (odds ratio [OR], 4.8; 95% CI, 3.16-7.21; p < 0.0001). The second strongest predictor was diagnosis of single MDRO infection (OR, 2.9; 95% CI, 2.64-3.20; p < 0.0001). Conclusion: Presence of an MDRO was associated with increased odds of mortality and length of stay in admitted surgical patients. Interventions to reduce MDRO infection among surgical patients may reduce hospital length of stay and mortality.
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Affiliation(s)
- Anshal Gupta
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - David A Spain
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Joseph D Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
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