Preexposure Prophylaxis for Women Across the Criminal Justice System: Implications for Policy and Practice

Data that inform preexposure prophylaxis (PrEP) implementation for women involved in criminal justice (WICJ) systems are scarce. In a survey of PrEP attitudes, acceptability, and barriers across the criminal justice system, incarcerated women (n = 48) were more likely than WICJ on probation (n = 125) to be eligible for PrEP (29% vs. 15%; p = .04) and willing to take PrEP if offered (94% vs. 78%; p = .01). In multivariate models, PrEP eligibility directly correlated with being incarcerated (adjusted odds ratio [aOR] 4.81, 95% confidence interval [CI] 1.76-13.1) and inversely correlated with Hispanic/Latina ethnicity (aOR 0.31; 95% CI 0.10-0.96). Recent partner violence exposure was associated with PrEP eligibility (aOR 3.29; 95% CI 1.54-7.02) and discordant risk perception (aOR 2.36; 95% CI 1.18-4.70). Findings demonstrate high potential for PrEP for all WICJ, though implementation efforts will need to address partner violence.

Women's Decision-Making about PrEP for HIV Prevention in Drug Treatment Contexts

Despite pre-exposure prophylaxis’s (PrEP) efficacy for HIV prevention, uptake has been low among women with substance use disorders (SUDs) and attributed to women’s lack of awareness. In semistructured interviews with 20 women with SUD and 15 key stakeholders at drug treatment centers, we assessed PrEP awareness and health-related decision-making. Women often misestimated their own HIV risk and were not aware of PrEP as a personally relevant option. Although women possessed key decision-making skills, behavior was ultimately shaped by their level of motivation to engage in HIV prevention. Motivation was challenged by competing priorities, minimization of perceived risk, and anticipated stigma. Providers were familiar but lacked experience with PrEP and were concerned about women’s abilities to action plan in early recovery. HIV prevention for women with SUD should focus on immediately intervenable targets such as making PrEP meaningful to women and pursuing long-term systemic changes in policy and culture. Efforts can be facilitated by partnering with drug treatment centers to reach women and implement PrEP interventions.

Slowly progressive fatal PML-IRIS following antiretroviral initiation at CD4+ nadir of 350 cells/mm3 despite CD4+ cell count rise to 900 cells/mm3

AIDS-related progressive multifocal leukoencephalopathy (PML)-immune reconstitution inflammatory syndrome (IRIS) is a central nervous system inflammatory syndrome where immune response to John Cunningham (JC) virus antigen following antiretroviral therapy (ART) causes breakdown of the blood–brain barrier. We report a unique case of PML-IRIS, which presented with dystonic choreoathetosis after initiation of ART at a CD4+ cell count of 350 cells/mm3. This report shows continuous progression of the disease over a period of two years, despite robust immune reconstitution. The worsening of neurological symptoms, persistent positivity of JC virus in CSF, and progressive inflammatory picture on MR scans in the setting of a CD4+ cell count of 900 cells/mm3 highlight a different variant of PML-IRIS, and challenge the role of CD4+ cell count in diagnosing opportunistic infections in HIV/AIDS patients.

“Semenly” Harmless Back Pain: An Unusual Presentation of a Subcutaneous Abscess

Aims We report, with review of the literature, the case of a patient who developed a subcutaneous abscess after intravenously injecting his own semen in an attempt to treat longstanding back pain. He had devised this “cure” independent of medical advice. Methods A review of EMBASE, PubMed, google scholar and the wider internet was conducted with an emphasis on parenteral semen for the treatment of back pain and for other medical and non-medical uses. Results There were no other reported cases of intravenous semen injection found across the medical literature. A broader search of internet sites and forums found no documentation of semen injection for back pain treatment or otherwise. Conclusion While suicide attempt by intravenous injection of harmful substances is well described, this unique case demonstrates risks involved with innovative treatments prior to clinical research in the form of phased trials inclusive of safety and efficacy assessments.

Correlates of Recent HIV Testing Among Transgender Women in Greater Kuala Lumpur, Malaysia

PURPOSE

In Malaysia, an estimated 9.7%-12.4% of transgender women (TW) are HIV positive, with higher estimates among those engaged in sex work. According to the 90-90-90 Joint United Nations Programme on HIV/AIDS strategy, HIV testing is the first crucial step in curbing the HIV epidemic. This study examines correlates of recent HIV testing among TW in Greater Kuala Lumpur, Malaysia.

METHODS

TW (N = 199) in Greater Kuala Lumpur completed a survey on healthcare access and utilization, including HIV testing history. Bivariate logistic regression and penalized multivariate logistic regression were used to explore correlates of HIV testing in the last 12 months.

RESULTS

Overall, 41.7% of TW reported having ever been tested for HIV. Among participants who were HIV negative or not sure of their HIV status (n = 187), only 18.7% (n = 35) had been tested for HIV in the last 12 months. The multivariate analysis indicated that having a primary care provider (PCP), being 26-40 years of age, and having higher mental health functioning were positively associated with recent HIV testing. Active amphetamine use and previous depression diagnosis were also associated with recent HIV testing.

CONCLUSION

HIV testing is the first step in linking individuals to prevention and treatment interventions. Our findings suggest that having a PCP can improve engagement in HIV testing. Moreover, PCPs can serve as a valuable link to HIV treatment and prevention services. Current interventions that target social and behavioral risk factors for HIV, on their own, may be insufficient at engaging all HIV-vulnerable TW.

HIV Risk perception and eligibility for pre-exposure prophylaxis in women involved in the criminal justice system

Women involved in the criminal justice system (WICJ) are at high risk of acquiring HIV and would benefit from HIV pre-exposure prophylaxis (PrEP) but there are no studies in this population to inform PrEP implementation programs. We conducted a cross-sectional survey of HIV-uninfected, cis-gender women on probation, parole and/or recently released from prison/jail to assess PrEP awareness, eligibility, potential barriers to uptake, and the PrEP care continuum. The 125 WICJ surveyed reported high rates of HIV risk behaviors including recent transactional sex (22.4%) and unsafe injection practices (14.4%). Despite 33% (n = 42) meeting eligibility criteria for PrEP, only 25% were aware of PrEP and one person was currently using it. Just 16.7% of those who were PrEP eligible perceived they were at risk for HIV. Following a brief explanation of PrEP, 90% said they would try it if recommended by their physician. Compared to those not PrEP eligible (n = 83), PrEP eligible women were less likely to be stably housed or have a primary care provider, and were more likely to be violence-exposed, charged with drug possession, have lifetime substance use, or living with Hepatitis C infection. WICJ frequently engage in HIV risk behaviors that make them eligible for PrEP. Uptake may be limited by lack of PrEP awareness or underestimation of personal HIV risk. WICJ report receptiveness to PrEP and represent an important population for targeted PrEP implementation programs.

Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community

Transgender women (TGW) face compounded levels of stigma and discrimination, resulting in multiple health risks and poor health outcomes. TGW identities are erased by forcing them into binary sex categories in society or treating them as men who have sex with men (MSM). In Malaysia, where both civil and religious law criminalise them for their identities, many TGW turn to sex work with inconsistent prevention methods, which increases their health risks. This qualitative study aims to understand how the identities of TGW sex workers shapes their healthcare utilisation patterns and harm reduction behaviours. In-depth, semi-structured interviews were conducted with 21 male-to-female transgender (mak nyah) sex workers in Malaysia. Interviews were transcribed, translated into English, and analysed using thematic coding. Results suggest that TGW identity is shaped at an early age followed by incorporation into the mak nyah community where TGW were assisted in gender transition and introduced to sex work. While healthcare was accessible, it failed to address the multiple healthcare needs of TGW. Pressure for gender-affirming health procedures and fear of HIV and sexually transmitted infection screening led to potentially hazardous health behaviours. These findings have implications for developing holistic, culturally sensitive prevention and healthcare services for TGW.

A 6-year experience with 1,054 mini-gastric bypasses-first study from Indian subcontinent

BACKGROUND

We started laparoscopic mini-gastric bypass (MGB) for the first time in India in February 2007 for its reported safety, efficacy, and easy reversibility.

METHODS

A retrospective review of prospectively maintained data of all 1,054 consecutive patients (342 men and 712 women) who underwent MGB at our institute from February 2007 to January 2013 was done.

RESULTS

Mean age was 38.4 years, preoperative mean weight was 128.5 kg, mean BMI was 43.2 kg/m(2), mean operating time was 52 ± 18.5 min, and mean hospital stay was 2.5 ± 1.3 days. There were 49 (4.6%) early minor complications, 14 (1.3%) major complications, and 2 leaks (0.2%). In late complications, one patient had low albumin and one had excess weight loss; MGB was easily reversed in both (0.2%). Marginal ulcers were noted in five patients (0.6%) during follow-up for symptomatic dyspepsia, and anemia was the most frequent late complication occurring in 68 patients (7.6%). Patient satisfaction was high, and mean excess weight loss was 84, 91, 88, 86, 87, and 85% at years 1 to 6, respectively.

CONCLUSION

This study confirms previous publications showing that MGB is quite safe, with a short hospital stay and low risk of complications. It results in effective and sustained weight loss with high resolution of comorbidities and complications that are easily managed.

Analysis of the five-year outcomes of sleeve gastrectomy and mini gastric bypass: a report from the Indian sub-continent

BACKGROUND

Few reports have compared laparoscopic sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y procedure (LRNY). This study aims at comparing the 5-year follow-up results of mini gastric bypass (MGB or omega gastric bypass (OGB)) and LSG in terms of weight loss, weight regain, complications, and resolution of co-morbidities.

METHODS

A retrospective analysis of the prospectively collected database was done from the start of our bariatric practice from February 2007 to August 2008 (minimum 5-year follow-up). During this period, 118 patients underwent LSG. These patients were matched in age, gender, preoperative weight, and BMI to 104 patients who underwent MGB in the same time period. The results were compared.

RESULTS

Follow-up was achieved in 72 MGB vs 76 LSG patients up to 5 years. The mean BMI for the MGB and LSG group was 44 ± 3.1 and 42 ± 5.2 kg/m(2), respectively (P < 0.001). The average percentage of excess weight loss (%EWL) for MGB vs LSG was 63 vs 69 % at 1 year and 68 vs 51.2 % at 5 years (P = 0.166), respectively. Post-op gastro-esophageal reflux disease (GERD) was seen in 2.8 % MGB patients and marginal ulcer was diagnosed in 1 MGB patient (1.4 %). GERD was seen in 21 % post-LSG patients.

CONCLUSIONS

Both MGB and LSG are safe, short, and simple operations. Weight loss is similar in MGB and LSG in the first years, but lesser %EWL with LSG at 5 years (68 % in MGB vs 51 % in LSG). Post-op GERD is more common after LSG.

Community-based organizations are critical partners in providing complete cancer care

In Canada people affected by cancer access psychosocial care and support from two systems. In the conventional medical system, psychosocial professionals focus mainly on screening for and treating those most distressed by their diagnosis. Many patients and family members go beyond this step to find information and support provided by community-based organizations (CBOS). This article outlines the components of complete cancer care effectively provided by CBOS and why the integration of the two systems of care is critical in delivering seamless high-quality psychosocial care for all.

RAGE (Receptor for Advanced Glycation Endproducts), RAGE ligands, and their role in cancer and inflammation

The Receptor for Advanced Glycation Endproducts [RAGE] is an evolutionarily recent member of the immunoglobulin super-family, encoded in the Class III region of the major histocompatability complex. RAGE is highly expressed only in the lung at readily measurable levels but increases quickly at sites of inflammation, largely on inflammatory and epithelial cells. It is found either as a membrane-bound or soluble protein that is markedly upregulated by stress in epithelial cells, thereby regulating their metabolism and enhancing their central barrier functionality. Activation and upregulation of RAGE by its ligands leads to enhanced survival. Perpetual signaling through RAGE-induced survival pathways in the setting of limited nutrients or oxygenation results in enhanced autophagy, diminished apoptosis, and (with ATP depletion) necrosis. This results in chronic inflammation and in many instances is the setting in which epithelial malignancies arise. RAGE and its isoforms sit in a pivotal role, regulating metabolism, inflammation, and epithelial survival in the setting of stress. Understanding the molecular structure and function of it and its ligands in the setting of inflammation is critically important in understanding the role of this receptor in tumor biology.

The mini-gastric bypass: experience with the first 1,274 cases

BACKGROUND

Results of the laparoscopic Mini-Gastric Bypass (MGB) are reported.

METHODS

1,274 MGB patients are continuously monitored as part of an online computer tracking data-base system.

RESULTS

Mean preoperative weight (+/- Standard Deviation) was 132 +/- 21 kg, BMI 47 +/- 7. Mean excess weight loss was 51% at 6 months, 68% at 12 months and 77% at 2 years. The mean operating-time was 36.9 +/- 33.5 minutes. The shortest time was 19 minutes. Hospital stay was 1.5 +/- 1.6 days. The overall complication rate has been 5.2%. The overall rate of deep vein thrombosis and pulmonary embolism was 0.08% and 0.16% respectively. The leak rate was 1.6%. There was one hospital death, 0.08%. Associated medical illnesses were either completely reversed or markedly improved.

CONCLUSIONS

The MGB is safe, results in major weight loss, has a short operating-time, and has a short hospital stay. The MGB appears to meet many of the criteria of an "ideal" weight loss operation.

External laryngeal trauma analysis of 392 patients

BACKGROUND

External laryngeal trauma (ELT) is a rare but clinically important injury.

OBJECTIVE

To perform the first population-based, time series analysis of the epidemiology, management, and outcomes of ELT using an 11-state, inpatient sample database containing more than 54 million patients.

PATIENTS

Three hundred ninety-two patients with a primary or secondary diagnosis of ELT were identified. Over a 5-year period, the incidence of ELT in this series was 1/137,000. The mean (+/-SD) age was 37 (+/-7) years, and the overall mortality rate was 2.04%. Two hundred forty-eight patients required surgical intervention.

RESULTS

The average length of stay for 67 patients not requiring surgical intervention for any injury was 3 (+/-2) days, with no mortality. One hundred eighty patients underwent endoscopy, with 14 requiring tracheotomy alone and 57 requiring tracheotomy plus laryngeal repair. The average length of stay and the mortality rate were higher in these latter groups. Overall, 139 patients underwent tracheotomy, with a mortality rate of 5%, while 96 patients underwent laryngeal repair, with a mortality rate of 1%. Surgical treatment was performed in 140 patients with ELT within 24 hours after presentation, while another 60 received treatment within 48 hours. Associated injuries included skull base or intracranial injury (13%), open neck injury (9%), cervical spine injury (8%), and esophageal or pharyngeal injury (3%).

CONCLUSION

External laryngeal trauma is a rare injury, with most patients requiring surgical intervention.

Cholecystectomy in patients aged 80 and older

BACKGROUND

We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery.

METHODS

We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed.

RESULTS

In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time.

CONCLUSIONS

Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.

Penile prosthesis implantation surgery: a statewide population based analysis of 2354 patients

AIMS OF THE STUDY

Minimally invasive therapy for erectile dysfunction (ED) has changed the frequency of penile prosthesis surgery. The purpose of this study is to describe the changes in frequency, hospital stay, hospital charges and penile prosthesis type in North Carolina.

MATERIALS AND METHODS

The data source was a statewide hospital discharge database which includes data on hospitalized patients for all 151 hospitals in North Carolina.

RESULTS

From 1988-1993, 2354 patients underwent implantation of penile prostheses. The total number of penile prostheses implanted has declined over this six year period. Similarly, hospital stay has declined from an average of 4.03-2.96 d with a 46.6% decrease in total hospital days. Despite this change in hospital stay, hospital charges rose significantly from an average of $7252.48 to $12,842.18 driving total charges from $2973,516.80 to $3,826,969.60 (1993) representing a 28.7% increase.

CONCLUSIONS

Minimally invasive therapy and changes in reimbursement have had a major impact on the number of patients undergoing penile prosthesis implantation for ED. This downward trend may continue as more treatment options develop from the marked increase in research in this field. However, this may result in an increase of patients seeking treatment overall.

An analysis of 25 Milliman & Robertson guidelines for surgery: data-driven versus consensus-derived clinical practice guidelines

SUMMARY BACKGROUND DATA

Managed care guidelines such as those by Milliman & Robertson (M&R) are being implemented with increasing frequency. Many fellows of the American College of Surgeons have raised concerns that the targets set by the M&R guidelines are too aggressive. Uninformed attempts to reach these targets may harm patients. The primary hypothesis of this study was that many of the M&R guidelines are at wide variance from the actual length of stay of patients treated for these diseases.

METHODS

Data for the determination of the present practice of care for patients in 25 M&R guidelines were obtained from the hospital discharge data base for North Carolina for 1996. Twenty-five of the M&R guidelines were compared to the actual patient mean, mode, and median length of stay.

RESULTS

In 8 of the 25 patient groups, the difference between the actual mean length of stay and M&R guidelines exceeded 5 days.

CONCLUSIONS

Many of the M&R guidelines were found to be at wide variance from the actual length of stay of patients treated for these diseases in North Carolina. For many patients, the M&R guidelines are not applicable. Applying them in an uninformed way--in other words, discharging patients from the hospital too early--may hurt some patients. This study should not be interpreted as a criticism of the trend to use guidelines in general; rather, it should be considered a cautionary note that all guidelines must be reviewed scientifically to determine their soundness, applicability, and credibility.

The ICD-9-based illness severity score: a new model that outperforms both DRG and APR-DRG as predictors of survival and resource utilization

OBJECTIVE

This project is designed to develop and validate a predictive model that is a useful benchmarking and quality of care assessment tool based on International Classification of Diseases, Ninth Revision (ICD-9), diagnoses and procedures. This model, the ICD-9-Based Illness Severity Score (ICISS), was developed from the Agency for Health Care Policy Research's Health Care Utilization Project database and is used to predict hospital survival, hospital length of stay, and hospital charges of injured patients admitted to University of North Carolina Hospitals. The study also compared the outcome predictions of ICISS with those of the long-established diagnosis-related groups (DRG) and the 3M product APR-DRG systems.

METHODS

We performed a retrospective study of 9,483 trauma patients at University of North Carolina Hospitals. A model was developed to predict survival, length of stay, and hospital charges. The accuracy of the model of survival was assessed using the area under the receiver-operating characteristics curve; the adjusted R2 statistic was used to judge the proportion of variation described by the models of length of stay and hospital charges.

RESULTS

ICISS proved to be superior to both DRG and APR-DRG in predicting survival of trauma patients: the area under the receiver-operating characteristics curve for prediction of hospital survival was 0.957 for ICISS, 0.707 for DRG, and 0.808 for APR-DRG. ICISS also outperformed DRG and APR-DRG in predicting hospital length of stay and hospital charges: the adjusted R2 for the ICISS length of stay model was 0.57, compared with the DRG length of stay model with adjusted R2 of 0.31 and the APR-DRG length of stay model with adjusted R2 of 0.35. The adjusted R2 for the ICISS hospital charges model was 0.67, compared with the DRG and APR-DRG hospital charges model R2 of 0.46 and 0.51, respectively (p < 0.001 in all cases).

CONCLUSION

This study demonstrates that an ICD-9-based predictive model (ICISS) can markedly outperform both DRG and APR-DRG as a predictor of survival, hospital length of stay, and hospital charges.

Experimental infection of domestic cats with Bartonella henselae by inoculation of Ctenocephalides felis (Siphonaptera: Pulicidae) feces

Caged cat fleas, Ctenocephalides felis (Bouché), were fed on 6 cats; 3 cats were injected with 5 x 10(7) colony forming units of Bartonella henselae intradermally and 3 cats were injected with an equal volume of saline. After the fleas fed for 4 d, 5 groups of 50 B. henselae-exposed fleas were caged and allowed to feed on 5 cats for 6 d. Five cats each were injected intradermally with 1 ml of saline containing 45 mg of feces from B. henselae-exposed fleas. Five cats were fed 50 B. henselae-exposed fleas and 45 mg of fresh feces from B. henselae-exposed fleas. Five cats received all 3 treatments by using fleas and feces collected from cats inoculated with saline (controls). Cats were bled weekly and tested by culture and serology. The cats that were injected with feces from infected fleas were positive by culture for B. henselae at 1 or 2 wk after exposure and were the only cats to become bacteremic or seropositive by week 20.

Characterization of an AGAMOUS homologue from the conifer black spruce (Picea mariana) that produces floral homeotic conversions when expressed in Arabidopsis

Advances in elucidating the molecular processes controlling flower initiation and development have provided unique opportunities to investigate the developmental genetics of non-flowering plants. In addition to providing insights into the evolutionary aspects of seed plants, identification of genes regulating reproductive organ development in gymnosperms could help determine the level of homology with current models of flower induction and floral organ identity. Based upon this, we have searched for putative developmental regulators in conifers with amino acid sequence homology to MADS-box genes. PCR cloning using degenerate primers targeted to the MADS-box domain revealed the presence of over 27 MADS-box genes within black spruce (Picea mariana), including several with extensive homology to either AP1 or AGAMOUS, both known to regulate flower development in Arabidopsis. This indicates that like angiosperms, conifers contain a large and diverse MADS-box gene family that probably includes regulators of reproductive organ development. Confirmation of this was provided by the characterization of an AGAMOUS-like cDNA clone called SAG1, whose conservation of intron position and tissue-specific expression within reproductive organs indicate that it is a homologue of AGAMOUS. Functional homology with AGAMOUS was demonstrated by the ability of SAG1 to produce homeotic conversions of sepals to carpels and petals to stamens when ectopically expressed in transgenic Arabidopsis. This suggests that some of the genetic pathways controlling flower and cone development are homologous, and antedate the 300-million-year-old divergence of angiosperms and gymnosperms.

Illness severity adjustment for outcomes analysis: validation of the ICISS methodology in all 821,455 patients hospitalized in North Carolina in 1996

BACKGROUND

Previous work has demonstrated that the International Classification of Diseases 9th Revision (ICD-9) Based Illness Severity Score (ICISS) methodology developed by Rutledge and Osler can perform well in this role as a severity adjustment tool in trauma patients. The purpose of the present study was to extend this previous work to determine the ability of ICISS to predict outcomes in all types of hospitalized patients.

METHODS

The ICISS methodology was used to derive predictions of survival, length of hospital stay, and hospital charges in the entire study population.

RESULTS

A total of 821,455 hospitalized patients in North Carolina in 1996 had complete data available for analysis. The overall hospital mortality rate was 2.9%. ICISS was an accurate predictor of hospital survival in all hospitalized patients (accuracy 95.9%, sensitivity 97.2%, and specificity 52.7%.) The area of the receiver operator characteristic curve was 0.93. By adding to the model, the area under the receiver operator characteristic curve increased to 0.95. ICISS also explained a large amount of the variance in hospital stay and charges (R2 = 0.38 and 0.56, respectively, P < .0001).

CONCLUSIONS

This study extends previous work suggesting that ICISS may be an important improvement over other presently available severity adjustment models. If these findings are confirmed in comparison with other predictive tools, ICISS may find an important place in assessing illness severity.

Predicting survival, length of stay, and cost in the surgical intensive care unit: APACHE II versus ICISS

BACKGROUND

Risk stratification of patients in the intensive care unit (ICU) is an important tool because it permits comparison of patient populations for research and quality control. Unfortunately, currently available scoring systems were developed primarily in medical ICUs and have only mediocre performance in surgical ICUs. Moreover, they are very expensive to purchase and use. We conceived a simple risk-stratification tool for the surgical ICU that uses readily available International Classification of Diseases, Ninth Revision, codes to predict outcome. Called ICISS (International Classification of Disease Illness Severity Score), our score is the product of the survival risk ratios (obtained from an independent data set) for all International Classification of Diseases, Ninth Revision, diagnosis codes.

METHODS

A total of 5,322 noncardiac patients admitted to a surgical ICU during an 8-year period had their Acute Physiology and Chronic Health Evaluation (APACHE) II scores compared with their ICISS as predictors of outcome (survival/nonsurvival, length of stay, and charges).

RESULTS

ICISS proved to be a much better predictor of survival than APACHE (receiver operating characteristic (ROC) APACHE = 0.806; Hosmer-Lemeshow (HL) APACHE = 22.56; ROC ICISS = 0.892; HL ICISS = 12.06) or the APACHE survival probability (ROC = 0.836; HL = 34.47). These differences were highly statistically significant (p < 0.001). ICISS was also better correlated with ICU length of stay (APACHE R2 = 0.06; ICISS R2 = 0.32) and ICU charges (APACHE R2 = 0.07; ICISS R2 = 0.39). When combined in a logistic model with ICISS, APACHE II added slightly to the predictive power of ICISS alone (combined ROC = 0.903) but degraded the calibration of the model (combined HL = 16.29; p = 0.038).

CONCLUSION

Because ICISS is both more accurate and much less expensive to calculate than APACHE II score, ICISS should replace APACHE II score as the standard risk stratification tool in surgical ICUs.

The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores

BACKGROUND

The Glasgow Coma Scale (GCS), which is the foundation of the Trauma Score, Trauma and Injury Severity Score, and the Acute Physiology and Chronic Health Evaluation scoring systems, requires a verbal response. In some series, up to 50% of injured patients must be excluded from analysis because of lack of a verbal component for the GCS. The present study extends previous work evaluating derivation of the verbal score from the eye and motor components of the GCS.

METHODS

Data were obtained from a state trauma registry for 24,565 unintubated patients. The eye and motor scores were used in a previously published regression model to predict the verbal score: Derived Verbal Score = -0.3756 + Motor Score * (0.5713) + Eye Score * (0.4233). The correlation of the actual and derived verbal and GCS scales were assessed. In addition the ability of the actual and derived GCS to predict patient survival in a logistic regression model were analyzed using the PC SAS system for statistical analysis. The predictive power of the actual and the predicted GCS were compared using the area under the receiver operator characteristic curve and Hosmer-Lemeshow goodness-of-fit testing.

RESULTS

A total of 24,085 patients were available for analysis. The mean actual verbal score was 4.4 +/- 1.3 versus a predicted verbal score of 4.3 +/- 1.2 (r = 0.90, p = 0.0001). The actual GCS was 13.6 + 3.5 versus a predicted GCS of 13.7 +/- 3.4 (r = 0.97, p = 0.0001). The results of the comparison of the prediction of survival in patients based on the actual GCS and the derived GCS show that the mean actual GCS was 13.5 + 3.5 versus 13.7 + 3.4 in the regression predicted model. The area under the receiver operator characteristic curve for predicting survival of the two values was similar at 0.868 for the actual GCS compared with 0.850 for the predicted GCS.

CONCLUSIONS

The previously derived method of calculating the verbal score from the eye and motor scores is an excellent predictor of the actual verbal score. Furthermore, the derived GCS performed better than the actual GCS by several measures. The present study confirms previous work that a very accurate GCS can be derived in the absence of the verbal component.

The end of the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS): ICISS, an International Classification of Diseases, ninth revision-based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival, hospital charges, and hospital length of stay

INTRODUCTION

Since their inception, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS) have been suggested as measures of the quality of trauma care. In concept, they are designed to accurately assess injury severity and predict expected outcomes. ICISS, an injury severity methodology based on International Classification of Diseases, Ninth Revision, codes, has been demonstrated to be superior to ISS and TRISS. The purpose of the present study was to compare the ability of TRISS to ICISS as predictors of survival and other outcomes of injury (hospital length of stay and hospital charges). It was our hypothesis that ICISS would outperform ISS and TRISS in each of these outcome predictions.

METHODS

"Training" data for creation of ICISS predictions were obtained from a state hospital discharge data base. "Test" data were obtained from a state trauma registry. ISS, TRISS, and ICISS were compared as predictors of patient survival. They were also compared as indicators of resource utilization by assessing their ability to predict patient hospital length of stay and hospital charges. Finally, a neural network was trained on the ICISS values and applied to the test data set in an effort to further improve predictive power. The techniques were compared by comparing each patient's outcome as predicted by the model to the actual outcome.

RESULTS

Seven thousand seven hundred five patients had complete data available for analysis. The ICISS was far more likely than ISS or TRISS to accurately predict every measure of outcome of injured patients tested, and the neural network further improved predictive power.

CONCLUSION

In addition to predicting mortality, quality tools that can accurately predict resource utilization are necessary for effective trauma center quality-improvement programs. ICISS-derived predictions of survival, hospital charges, and hospital length of stay consistently outperformed those of ISS and TRISS. The neural network-augmented ICISS was even better. This and previous studies demonstrate that TRISS is a limited technique in predicting survival resource utilization. Because of the limitations of TRISS, it should be superseded by ICISS.

A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene

INTRODUCTION

Comprehensive emergency medical services and helicopter aeromedical transport systems have been developed based on the principle that early definitive care improves outcome. The purpose of this study was to compare outcomes between patients transported by helicopter and those transported by ground.

METHODS

Data were obtained from the North Carolina Trauma Registry for the period between 1987 and 1993 on all patients transported by helicopter and ground admitted to one of the eight state designated trauma centers. Study patients included only those who were transported directly from the scene of injury to the trauma center (interhospital transfers were excluded). Mortality (outcome) was compared after patient stratification by injury severity and transport time, using Cochran-Mantel-Haenszel statistics and logistic regression-derived probabilities of survival.

RESULTS

One thousand three hundred forty-six patients (7.3% of the total) were transported from scene to trauma center by helicopter and 17,144 were transported by ground. In patients transported by helicopter, the mean Trauma Score was lower (12 +/- 3.6) versus 14.3 +/- 3.6 (p < 0.001) and the mean Injury Severity Score was higher (17 +/- 11.1) versus 10.8 +/- 8.4 (p < 0.001). A trend toward increased survival was observed among patients transported by helicopter with a higher Injury Severity Score. Statistical significance was achieved only for patients with a Trauma Score between 5 and 12 and Injury Severity Score between 21 and 30.

CONCLUSION

The large majority of trauma patients transported by both helicopter and ground ambulance have low injury severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance of improved survival based on their helicopter transport. This study suggests that further effort should be expended to try to better identify patients who may benefit from this expensive and risky mode of transport.

A statewide, hospital-based analysis of frequency and outcomes in carotid endarterectomy

BACKGROUND

For more than 40 years carotid endarterectomy (CE) has been used in the treatment of extracranial carotid disease for the prevention of stroke. Recent prospective clinical trials have confirmed the benefit of CE for both symptomatic and asymptomatic patients. Our purpose was to examine statewide trends in the numbers of CE over a 6-year time period and to evaluate outcomes.

METHODS

Using data from the North Carolina Medical Database Commission (NCMDC) all CE procedures from 1988 to 1993 were identified. Numbers of CE were compared with the population and hospital admissions. Variables of length of stay, hospital charges, discharge disposition, and occurrence of stroke and death were analyzed.

RESULTS

A total of 11,973 CE were performed in 6 years. Compared by admissions, population, and the proportion of elderly, the number of CE increased yearly. The stroke rate was 1.7% and the death rate 1.2% for an overall in-hospital stroke plus mortality rate of only 2.7%.

CONCLUSIONS

From a diverse group of hospitals and a large number of surgeons and patients, this hospital-based study documents the acceptance and safety of CE in the treatment of extracranial carotid disease.

Can medical school-affiliated hospitals compete with private hospitals in the age of managed care? An 11-state, population-based analysis of 351,201 patients undergoing cholecystectomy

BACKGROUND

The purpose of this study was to use an 11-state, population-based hospital discharge database to assess the charges for care of patients undergoing cholecystectomy at both medical school affiliated hospitals (MSAHs) and private hospitals (nonMSAHs). It was our hypothesis that MSAHs could indeed provide efficient, competitively priced patient care.

STUDY DESIGN

Data were obtained from the Healthcare Cost Utilization Project of the Agency for Health Care and Policy Research. The database tracks information on all hospitalized patients from 11 states for the years 1988-1992.

RESULTS

Represented in the study were 849 nonMSAHs (82%) and 191 MSAHs (18%). During the 5 years of the study, 351,201 patients underwent cholecystectomy. The mean charges and the lengths of stay were similar in the two diagnosis related groups (DRGs) studied (197,198). The analysis demonstrated that during this same period, MSAHs led in both the adoption of laparoscopic cholecystectomy and decreased use of intraoperative cholangiography.

CONCLUSIONS

Others have reported that MSAHs cannot compete with nonMSAHs in providing competitively priced care. The present study shows that for cholecystectomy, charges and length of hospital stay are comparable in MSAHs and nonMSAHs. This study supports the hypothesis that the leadership provided at United States medical schools may also extend to the area of cost-efficient care and hints at further areas of improvement.

Trauma registry injury coding is superfluous: a comparison of outcome prediction based on trauma registry International Classification of Diseases-Ninth Revision (ICD-9) and hospital information system ICD-9 codes

BACKGROUND

Trauma registries are an essential but expensive tool for monitoring trauma system performance. The time required to catalog patients' injuries is the source of much of this expense. Typically, 15 minutes of chart review per patient are required, which in a busy trauma center may represent 25% of a full-time employee. We hypothesized that International Classification of Disease-Ninth Revision (ICD-9) codes generated by the hospital information system (HI) would be similar to those coded by a dedicated trauma registrar (TR) and would be as accurate as TR ICD-9 codes in predicting outcome.

METHODS

One thousand eight hundred twelve patients admitted to a Level I trauma center during 2 years had International Classification of Disease Injury Severity Scores (ICISS) calculated based on HI and TR ICD-9 codes. The relative predictive powers of these two ICISSs were then compared for every patient using Receiver Operator Characteristic Curve Area (ROC) and Hosmer Lemeshow Statistics.

RESULTS

Eighty-nine percent of patients (1,608 of 1,812) had identical HI and TR ICISSs. Eleven patients' ICISSs differed by >0.1, and only two patients' scores differed by >0.2. ICISS proved to be a powerful predictor of outcome whether derived from HI (ROC = 0.884; 95% confidence interval (CI) = 0.850-0.917) or TR (ROC = 0.872; 95% CI = 0.837-0.908). Although these predictive powers were not significantly different (p = 0.076), the trend was for HI to perform better than TR. ISS calculated for the same data set using the MacKenzie dictionary proved significantly less predictive of outcome than either ICISS (ROC(MacKenzie) = 0.843; 95% CI = 0.792-0.884; p = 0.034).

CONCLUSION

We conclude that in our hospital TR data on individual injuries can be replaced by HI data without loss of predictive power. ISS based on the MacKenzie dictionary should be abandoned because it is much less predictive of outcome than ICISS.

Management outcomes in splenic injury: a statewide trauma center review

OBJECTIVE

Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period.

METHODS

Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score.

SUMMARY BACKGROUND DATA

Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared.

RESULTS

One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management.

CONCLUSIONS

Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.

Outcome after severe head injury: an analysis of prediction based upon comparison of neural network versus logistic regression analysis

More reliable prediction of outcome would be helpful for clinicians who treat severely head-injured patients. To determine if neural network modeling would improve outcome prediction compared with standard logistic regression analysis and to determine if data available 24 h after severe head injury allows better prediction than data obtained within 6 h, we tested the ability of both techniques at these two times to predict outcome (dead versus alive) at 6 months. One thousand sixty-six consecutive patients with Glasgow Coma Scale scores of 8 or less during the first 24 h after injury were randomly divided into two groups. Data from the first group (n = 799) were used to develop the models; data from the second group (n = 267) were used to test the accuracy, sensitivity, and specificity of the models by comparing predicted and actual outcomes. The 6-month mortality rate was 63.5%. Our findings confirm the importance of age, Glasgow Coma Scale scores, and hypotension in predicting outcome. Using data available at 24 h improved the predictive power of both models compared with admission data; at both time points, however, the differences in the results obtained with the two models were negligible. We conclude that outcome (dead versus alive) at 6 months after severe head injury can be predicted with logistic regression or neural network models based on data available at 24 h. Critical therapeutic decisions, such as cessation of therapy, should be based on the patient's status 1 day after injury and only rarely on admission status alone.

Comparison of the Injury Severity Score and ICD-9 diagnosis codes as predictors of outcome in injury: analysis of 44,032 patients

INTRODUCTION

Appropriate stratification of injury severity is a critical tool in the assessment of the treatment and the prevention of injury. Since its inception, the Injury Severity Score (ISS) has been the generally recognized "gold standard" for anatomic injury severity assessment. However, there is considerable time and expense involved in the collection of the information required to calculate an accurate ISS. In addition, the predictive power of the ISS has been shown to be limited. Previous work has demonstrated that the anatomic information about injury contained in the International Classification of Diseases Version 9 (ICD-9) can be a significant predictor of survival in trauma patients. The goal of this study was to utilize the San Diego County Trauma Registry (SDTR), one of the nation's leading trauma registries, to compare the predictive power of the ISS with the predictive power of the information contained in the injured patients' ICD-9 diagnoses codes. It was our primary hypothesis that survival risk ratios derived from patients' ICD-9 diagnoses codes would be equal or better predictors of survival than the Injury Severity Score. The implications of such a finding would have the potential for significant cost savings in the care of injured patients.

METHODS

Data for the test population were obtained from the SDTR, which contains data from 1985 through 1993 from five participating hospitals. Four data sources were utilized to estimate the expected survival rate/mortality rate for each ICD-9 code in the SDTR. These were (1) the SDTR patients themselves, (2) the North Carolina State Hospital Discharge Database, (3) the North Carolina Trauma Registry Database, and (4) the Agency for Health Care Policy Research's Health Care Utilization Project Database. Each of these data sources was separately utilized to develop a survival risk ratio (SRR) for each ICD-9 diagnoses code. The SRR was calculated by dividing the number of survivors for patients with each ICD-9 code by the total number of all patients with the particular ICD-9 diagnoses code. The four groups of SRRs derived from our four data sources were used as predictors of survival and the ability of the SRRs to predict survival was compared with the predictive power of the ISS using measures of accuracy, sensitivity, specificity, and receiver operator characteristic curves.

RESULTS

During the years 1985 through 1993, complete data were available for analysis on 44,032 patients. Of these, 2,848 patients died during their hospitalization (6%). Survival risk ratios were calculated for each of the diagnoses in the data base. Logistic regression, using the SAS System for statistical analysis, was used to assess the relative predictive power of the ISS and the survival risk ratios derived from the ICD-9 diagnoses codes from each of the four data bases. The analyses demonstrated that the regression models using the SRRs were generally as good or better than ISS as predictors of survival. The predictive power of the SRRs derived from the SDTR data, the North Carolina Trauma Registry data and the Health Care Utilization Report data were the best. In a subsequent analysis, the SRR values and the ISS were added to the patient's age and the revised Trauma Scores to create new predictive models in the mode of TRISS methodology. The analyses again indicated that the models using SRRs had as good or better predictive power than the model using the ISS.

CONCLUSIONS

The present study confirms previous work showing that survival risk ratios derived from injured patients' ICD-9 diagnoses codes are as good as or better than ISS as predictors of survival.

A statewide, population-based, time series analysis of access to liver transplantation

While the number of patients listed for liver transplant has increased, the pool of donor organs has remained constant. Questions have arisen regarding equitable access to organs. The purpose of this study was to analyze factors associated with access to liver transplantation (LT) using a large, population-based, hospital discharge database. The primary hypothesis was that a variety of factors other than medical need could be associated with access to LT. The rate of LT was defined as the number of liver transplants per admission for liver disease. The data sources were selected to allow a population-based, time-series analysis of all patients admitted with liver disease and those receiving liver transplants in all 157 nonfederal hospitals in North Carolina from 1988 to 1993. The hypotheses of this study were that age, gender, payment source, type of liver disease, distance from the transplant center, and rural county of residence were associated with patients' likelihood of access to LT. During the six years studied, 56,803 patients were admitted with liver disease and 126 underwent liver transplantation (LT). The rate of LT increased from 0.07% to 0.27%. Age, gender, source of payment, type of liver disease, rural county of residence, and distance of residence from the transplant center were associated with rates of transplantation. In the multivariate model, source of payment appeared to have the strongest association with the likelihood of LT. These findings raise important questions associated with equitable access to health care, need for physician education, and transplant center regionalization.

Statewide, population-based, time-series analysis of the frequency and outcome of pulmonary embolus in 318,554 trauma patients

The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to analyze the frequency and outcome of PE in an entire state's trauma population using a large, population-based, hospital discharge data base. With the inclusion of an entire population, the reported incidence, high risk groups of patients, and specific risk factors regarding PE were assessed. A multivariate, logistic regression model was created from the data to determine predictive power of selected risk factors in patients at risk.

METHODS

The data source was a statewide, hospital discharge data base that includes data on all hospitalized patients for all of the hospitals in North Carolina. Data were available from 1988 to 1993. Using primary discharge diagnosis and nine additional ICD-9 coded diagnoses from the discharge abstract, patients were selected by presence of diagnostic codes for traumatic injury (800-959.9) and PE (415.1). Statistical analysis was performed using univariate and multivariate analysis to determine significant risk factors and to create a candidate model for the prediction of risk in the study population.

RESULTS

Of 318,554 patients, 952 (0.30%) had a recorded diagnosis of PE. The mortality rate for patients with PE (26%) was 10 times higher than the mortality rate in patients without PE (2.6%). In evaluating specific risk factors, age was a significant predictor of the risk of PE: 0.05% for patients under age 55 and 0.7% in those 55 years and over. The rate of PE, 0.3%, was low for the entire study population, but was highest in patients with injuries of the extremities, 0.53%. Increasing Injury Severity Score and Abbreviated Injury Scale score for determined body systems were also found to correlate with an increasing risk of PE. Over the course of the study, the incidence of PE among patients discharged from non-trauma centers showed a significant decrease. There was also a decrease in the mortality in non-trauma centers for PE. This finding cannot be due to coding changes coincident with the advent of diagnosis related groups because it would be associated with more vigorous combing of charts for diagnoses? It may well be that the use of prophylactic measures in injured patients initially used at trauma centers was adopted by the physicians at non-trauma centers over this time with the resultant decline in PE and associated mortality. From the univariate linear regression models, a logistic regression model was created that confirmed age as the most significant risk factor, followed by Injury Severity Score and Abbreviated Injury Scale score for soft tissue, extremity, and chest. The calculated area under the receiver operator characteristic curve was 0.72.

CONCLUSION

Using a large, population-based data base, we were able to determine the reported incidence of PE among trauma patients and establish specific risk factors. The reported incidence of PE in this population is low, 0.30%. The mortality among those with PE, however, is significant at 26%. In this study, age, Injury Severity Score, and injury to specific body regions (soft tissue, extremity, chest) were associated with an increased risk of PE. The investigation of prophylaxis of PE and the general management of injured patients may be influenced by the overall low reported frequency of PE and the specific high risk populations described in this study. In light of the low incidence of PE in patients without specific risk factors, prophylactic interventions cannot be routinely recommended unless their benefits clearly outweigh their risks.

Survival, quality of life, and charges in critically III surgical patients requiring prolonged ICU stays

Critical care consumes a significant portion of health care costs. Although there are currently increasing pressures to limit expenditures, data are not always available to allow physicians and patients to make informed therapeutic or triage decisions regarding prolonged intensive care unit (ICU) stays. The purpose of this study was to evaluate long-term outcome, quality of life, and charges in surgical patients requiring prolonged ICU stays (> 14 days).

METHODS

Adults requiring over 14 days of surgical ICU care from January 1991 to September 1993 were selected from our ICU data base. Survivors to hospital discharge were evaluated for outcome and quality of life by mail survey and/or telephone interview in addition to chart review.

RESULTS

Eighty-three patients spent over 14 days in the surgical ICU during the study period. Fifty-two patients (62.6%) survived to hospital discharge. Average age was 53 years, average ICU length of stay was 26 days, and average hospital length of stay was 50 days. Complete follow-up data were available for 39 patients (75%). Thirty of the 39 patients (77%) were alive at an average follow-up of 18 months. Long-term survival in patients over 65 years old was 67% compared with 83% for younger patients (p < 0.05). Seventy percent reported less than 50% functional recovery. Seventy percent wer living at home and 23% were on disability. Of 11 patients employed before discharge, five had returned to work. Eighty percent of respondents reported good to fair quality of life, and 81% stated that they would undergo critical care again. The average ICU charge was $51,512 per patient, and the average hospital charge was $164,019 per patient. The average charge to achieve one long-term survivor was $247,812.

CONCLUSIONS

In this population, prolonged ICU stays resulted in acceptable quality of life and a relatively high survival rate despite significant economic investment. This study does not support withdrawal of therapy or triage decisions based solely or primarily on age or length of ICU stay.

Management and outcome of splenic injury: the results of a five-year statewide population-based study

Although splenectomy was the preferred method of treating the injured spleen in the past, the methods of splenorrhaphy and nonoperative management have appeared to gain in popularity. The purpose of this study was to determine whether the management of splenic injuries has changed over the course of time and if there has been any differences in the morbidity and mortality associated with different methods of treatment. We retrospectively examined the discharge records from 2627 patients with splenic injuries from the North Carolina Discharge Database. There were 2258 adults and 369 pediatric patients for evaluation. The rate of nonoperative therapy increased from 33.9 per cent to 46.3 per cent over the 5 years of the study, whereas the rate of splenectomy decreased from 52.9 per cent to 43.4 per cent over the same time period. Splenorrhaphy was used in approximately 10 per cent of the injuries over the course of the entire study period. Adults treated nonoperatively required late operation 6.0 per cent (49/811) of the time. The pediatric late operation rate for nonoperative management was 0.4 per cent(1/231). Reoperation after splenorrhaphy was 2.9 per cent (7/240) for adult patients and 4.3 per cent (2/47) for pediatric patients. The majority of adults (57.2%) with an Injury Severity Score (ISS) < or = 15 were able to be cared for via nonoperative methods, whereas the majority of adults (66.4%) with an ISS > 15 required splenectomy. The majority of pediatric patients were able to be cared for in a nonoperative fashion in both the ISS < or = 15 (83.4%) and ISS > 15 (45.5%).

Patient, hospital, and surgeon factors associated with breast conservation surgery. A statewide analysis in North Carolina

OBJECTIVE

The objective of this study was to determine the trend of breast conservation surgery (BCS) in North Carolina over a 6-year period and to identify patient, hospital, and surgeon factors associated with the use of BCS.

SUMMARY BACKGROUND DATA

Despite evidence that BCS is an appropriate method of treatment for early stage breast cancer, surgeons in the United States have been slow to adopt this treatment method.

METHODS

Cases of primary breast cancer surgery in all 157 hospitals in the state from 1988 to 1993, inclusive (N = 20,760), were obtained from the State Medical Database Commission, Area Resource File, American Hospital Association and State Board of Medical Examiner's Databases. Multiple logistic regression was used to generate odds ratios (ORs) and 95% confidence intervals (CIs) to determine factors associated with BCS.

RESULTS

The rate of BCS doubled from 7.3% in 1988 to 14.3% in 1993, with an overall rate of 10.2% (2117/ 20.760). Multiple logistic regression identified the following factors associated with BCS: patient age younger than 50 years of age (OR = 1.7, 95% CI = 1.4, 2.1), patient age 50 to 69 years of age (OR = 1.2, 95% CI = 1.1, 1.4), private insurance (OR = 1.2, 95% CI = 1.0, 1.4), hospital bed size 401+(OR = 2.0, 95% CI = 1.6, 2.5), bed size 101 to 400 (OR = 1.7, 95% CI = 1.3, 2.1), and surgeon graduation from medical school since 1981 (OR = 1.6, 95% CI = 1.2, 2.0).

CONCLUSIONS

Rates of BCS in North Carolina are low. Least likely to have BCS were women older than 70 years of age, without private insurance, treated at small hospitals by older surgeons. To increase the use of BCS, widespread education of surgeons, other health care providers, policy makers, and the general public is warranted.

Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores

The Glasgow Coma Scale (GCS) has been shown to be a valuable tool in assessing the neurologic and physiologic status of critically ill patients. Unfortunately, the GCS requires assessment of the verbal response of the patient and this can be blocked by intubation. The purpose of this study was to assess the ability of a regression model based upon the eye and motor components of the GCS to accurately predict the verbal response of the GCS. The primary hypothesis was that the verbal response could be derived from the motor and eye responses of the GCS.

METHODS

Data were collected prospectively in an intensive care unit computer data base. Patients were divided into training and test data sets. Linear regression was used to derive a model of verbal score from the motor and eye scores of the GCS in the training data set. Correlation between the actual and the predicted verbal scores was calculated.

RESULTS

A total of 2,521 GCS assessments were available for analysis. The second order multiple regression model was an accurate predictor of the verbal score (Pearson's Correlation r = 0.9, R2 = 0.8, p = 0.0001) in 1,463 observations in the training data set. Second Order Multiple Regression Model: Estimated GCS Verbal = (2.3976) + [GCS Motor x (-0.9253)] + [GCS Eye x (-0.9214)] + [(GCS Motor)2 x (0.2208)] + [(GCS Eye)2 x (0.2318)] where r = 0.91, R2 = 0.83, and p = 0.0001. The accuracy of this model was confirmed by comparing the predicted verbal score to the actual verbal score in the test data set (n = 736, r = 0.92, R2 = 0.85, p = 0.0001)

CONCLUSIONS

The GCS is a useful tool in the intensive care unit and a critical part of the APACHE II assessment of patient acuity. GCS has been shown to be a useful tool in its own right as a predictor of outcome in the critically ill. Its use is limited with intubation. (See Segatore M, Way C: Heart Lung 21:548, 1992; and Lieh-Lai MW, Theodorou AA, Sarnaik AP, et al: J Pediatr 120:195, 1992.) The present study demonstrates that a relatively simple regression model can use the eye and motor components of the GCS to predict the expected verbal component of the GCS, thus allowing the calculation of the GCS sum score in intubated patients.

ICISS: an international classification of disease-9 based injury severity score

BACKGROUND

The Injury Severity Score (ISS) has served as the standard summary measure of human trauma for 20 years. Despite its stalwart service, the ISS has two weaknesses: it relies upon the consensus derived severity estimates for each Abbreviated Injury Scale (AIS) injury and considers, at most, only three of an individual patient's injuries, three injuries that often are not even the patient's most severe injuries. Additionally, the ISS requires that all patients have their injuries described in the AIS lexicon, an expensive step that is currently taken only at hospitals with a zealous commitment to trauma care. We hypothesized that a data driven alternative to ISS that used empirically derived injury severities and considered all of an individual patient's injuries would more accurately predict survival.

METHODS

Survival risk ratios were derived for every International Classification of Disease 9th Edition (ICD-9) injury category (800-959.9) using the North Carolina State Discharge Database experience with 300,000 trauma patients over 5 years. An ICD-9 Injury Severity Score (ICISS) was then defined as the product of all survival risk ratios for an individual patient's traumatic ICD-9 codes. We compared the performance of ISS and ICISS in a group of 3,142 patients accrued at the University of New Mexico Trauma Center over 4 years. These patients had both AIS and ICD-9 descriptors meticulously assigned prospectively by designated trauma data base personnel.

RESULTS

ICISS outperformed ISS at a level that was highly statistically significant (p < 0.0001) and may be clinically important: ISS misclassification rate 7.67%, ISS Receiver Operator Characteristic Curve area = 0.872; ICISS misclassification rate 5.95%, ICISS Receiver Operator Characteristic Curve area = 0.921. Moreover, these improvements are largely preserved when ICISS is used in a probability of survival model that includes age, mechanism, and revised trauma score. About half of ICISS's improvement in predictive power is because of its use of an individual patient's worst three injuries regardless of body region. The remainder is because of better modeling of individual injuries and allowing all injuries to contribute to the final score.

CONCLUSIONS

We conclude that ICISS is a much better predictor of survival than ISS in injured patients. The use of the ICD-9 lexicon may avoid the need for AIS coding, and thus may add an economic incentive to the statistical appeal of ICISS. It is possible that a similar data driven revision of ISS using the AIS vocabulary might perform as well or better than ICISS. Indeed, the actual lexicon used to divide up the injury "landscape" into individual injuries may be of little consequence so long as all injuries are considered and empirically derived SRRs are used to calculate the final injury measure.

The impact of laparoscopic cholecystectomy on the management and outcome of biliary tract disease in North Carolina: a statewide, population-based, time-series analysis

BACKGROUND

Laparoscopic cholecystectomy (LC) has had a major impact on the treatment of patients with biliary tract disease, but the magnitude and the details of its effects on biliary surgery remain incompletely described. The purpose of this study was to perform a statewide, population-based, time-series analysis of the effects of LC on biliary surgery.

STUDY DESIGN

Patient data were obtained from the statewide hospital discharge database that collects data from all 157 hospitals in the state of North Carolina. All patients with hospital admissions for biliary tract disease from 1988 through 1993 were selected for analysis.

RESULTS

The use of open cholecystectomy (OC) dropped from 100 percent of all cholecystectomies in 1988 to 32.3 percent in 1993, while LC increased from eight cases in 1988 to over 7,800 per year in 1993. The increase in the rate of LC was not associated with an increase in the overall rate of cholecystectomy. Bile duct (BD) repairs increased from 13 in 1988 to a high of 36 in 1992. There was a strong, statistically significant correlation between the rate of LCs and the rate of BD repairs (R = 0.89, p = 0.0001). Hospital charges and component charges were lower for patients having elective LC compared to those having elective OC (p = 0.001). This remained true after stratification by age and type of gallbladder disease. Hospital stays were shorter for patients having LC than for those having OC (p = 0.001 for all). Surgeons in smaller hospitals were slower at adopting LC. Younger and board certified surgeons adopted LC more rapidly than older and non-board certified surgeons.

CONCLUSIONS

In North Carolina, LCs progressed from nonexistent to the dominant approach for managing patients with cholelithiasis in a matter of a few years. Associated with this change were shorter hospitalizations and lower charges. Contrary to other published reports, North Carolina did not experience an increase in the overall rate of cholecystectomy with the adoption of LC. There was a highly correlated increase in the rate of bile duct repairs in the first years of the study.

The Injury Severity Score is unable to differentiate between poor care and severe injury

The Injury Severity Score (ISS) has been the most frequently used tool for stratifying injured patients. The primary hypothesis of this study was that ISS fails to differentiate between severe injury and mismanagement.

METHODS

Data models were generated for mismanaged and ideally managed patients for isolated injuries for each body system. Flow charts of care, outcomes, and Abbreviated Injury Scale (AIS) and ISS scores were generated for each model.

RESULTS

Multiple models demonstrated that minor injuries that were mismanaged would result in AIS and ISS scores that were the same as ideally managed severe injuries. Three examples are summarized as follows: A comparison of two patients with splenic injuries demonstrates that ISS is unable to differentiate between mismanagement of a minor splenic laceration as compared to a severely lacerated spleen. In the case of the minor injury to the spleen (initial AIS = 2) that was missed by the treating physicians and allowed to bleed into shock and near arrest because of massive hemorrhage that could have been prevented by early recognition and treatment, the final AIS is coded as 4 in this mismanaged patient, the same AIS and ISS as a severely lacerated spleen (AIS = 4) managed well. Both result in a discharge ISS of 16. Similarly, the ISS at discharge is the same for a well-managed severe head injury (AIS = 4) and a mismanaged minor head injury that is unrecognized, progresses and leads to coma (AIS = 4). Finally AIS, ISS does not differentiate between a well-managed cervical fracture with complete cord injury and a mismanaged cervical spine fracture that initially does not involve a cord injury, but because of mismanagement and lack of immobilization, progresses to complete cord injury because of poor care. Both result in the same injury severity assessment (AIS = 5, ISS = 25 in both).

CONCLUSIONS

This study demonstrates a fact that should be recognized by all who rely upon the ISS for comparing quality of care: ISS fails to differentiate severe injury from mismanagement of injury. Because the ISS mixes outcome data with injury severity, ISS incorrectly assigns increased severity to the lesser injuries of mismanaged patients. These findings have important implications for use of the ISS in quality of care assessments.

Trauma care reimbursement in rural hospitals: implications for triage and trauma system design

American College of Surgeons triage guidelines recommend rapid identification and transfer of seriously injured patients to regional trauma centers, bypassing local hospitals if necessary. This approach raises concerns about the potential negative financial impact of implementing such triage strategies on already strained rural hospitals.

OBJECTIVE

The purpose of this study was to determine the association between injury severity and reimbursement for trauma care in rural hospitals. It was our hypothesis that the seriously injured would be high cost and relatively low reimbursement patients, and thus be a significant financial liability to the rural hospital. This would imply that concerns by the rural hospital about triage of such patients to trauma centers would be unfounded.

METHODS

Data on every injured patient seen in the emergency department during two 3-month periods were obtained from three rural hospitals in the state using the American College of Surgeons Trauma Registry data base.

RESULTS

One thousand six hundred thirty patients had complete data available for analysis. The analyses demonstrated that as the injury severity increased, there was an increase in hospital charges, length of stay, and risk of dying. In contrast, the reimbursement changed little as the charges and severity increased. Thus, hospital losses increased in an exponential fashion as injury severity increased above 15.

CONCLUSION

The study demonstrates that as injury severity increases, costs and charges increase, but reimbursement does not keep pace with these increased charges. The rural hospital was projected to lose an average of $25,000 for each patient with an Injury Severity Score over 15. This study supports the rapid triage and transport of the seriously injured patient from the rural hospital to the regional trauma center both for improved patient outcome and for the hospital's best interest. The potential impact of such a system on the trauma center also needs to be addressed.

A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm

OBJECTIVES

The purpose of this study was to perform the first statewide, population-based, time-series analysis of the frequency of ruptured abdominal aortic aneurysm (RAAA), to determine the outcomes of RAAA, and to assess the association of patient, physician, and hospital factors with survival after RAAA. The hypotheses of the study were as follows: 1) the rate of RAAA would increase over time and 2) patient, surgeon, and hospital factors would be associated with survival.

BACKGROUND

Ruptured abdominal aortic aneurysm is a life-threatening emergency that presents the surgeon with a technically demanding challenge that must be met and surmounted in a short time if the patient is to survive.

METHODS

Data were obtained from the following four separate data sources: 1) the North Carolina Hospital Discharge database, 2) the North Carolina American Hospital Association database, 3) the North Carolina State Medical Examiner's database, and 4) the Area Resource File. All patients with the diagnosis of an abdominal aortic aneurysm (AAA) were selected for initial assessment. Patients were grouped into those with and those without rupture of the abdominal aneurysm.

RESULTS

During the 6 years of the study, 14,138 patients were admitted with a diagnosis of AAA. Of these, 1480 (10%) had an RAAA. The yearly number of patients with elective AAAs increased 33% from 1889 in 1988 to 2518 in 1993. The yearly number of RAAAs increased 27% from 203 to 258. The mortality rate for AAA was 5%, as compared with 54% in RAAA patients. The patient's age was found to be the most powerful predictor of survival. Univariate logistic regression analyses demonstrated an association of the surgeon's experience with RAAA and patient survival after RAAA. Analysis of the survival rates of board-certified and nonboard-certified surgeons demonstrated that patients with RAAAs who were treated by board-certified surgeons had significantly better survival. When the survival was compared in small (less than 100 beds) and large (more than 100 beds) hospitals, survival was significantly better in the larger hospitals.

CONCLUSIONS

Ruptured abdominal aortic aneurysm remains a highly lethal lesion, even in the best of hands. Despite the many improvements in the care of seriously ill patients, there was no significant improvement in the survival of RAAA during this study. This suggests that early diagnosis is the best hope of survival in these patients. The study demonstrated that survival after RAAA was related most strongly to patient age at the time of the RAAA. The physician's and the hospital's experience with RAAA, the physician's background as measured by board certification, and the type of hospital at which the operation was performed (small vs. large) also may be associated with survival. These findings may have important implications for the regionalization of care and the education and credentialling of physicians. Given the lack of recent progress of improving the outcome of RAAA, aggressive efforts to treat patients before rupture are appropriate.