Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

[Thoracic trauma: incidence, social and economic costs, educational opportunities. Experience on the last eight years of Thoracic Surgical Unit of Messina University]

The Authors, after extensive introduction on the incidence, etiology, classification, pathophysiology, possible complications, diagnosis and treatment of thoracic trauma, relate their experience on the last eight years, stressing the diagnostic and therapeutic strategy in management of trauma simple and complicated and assessing finally serious social impact of these pathologies and the educational opportunities provided.

Decision Making in the Face of Uncertainty and Resource Constraints: Examples from Trauma Imaging

The purpose of this review is to illustrate how tools and concepts from decision and cost-effectiveness analyses can be used to help make decisions in the face of uncertainty and resource constraints, select appropriate subjects for imaging, choose between competing imaging modalities, and prioritize future research. Examples from trauma imaging illustrate the use of the presented tools. The author advocates the PROACTIVE approach in deciding which imaging strategies are cost-effective (PRO for defining the problem, reframing the problem from multiple perspectives, and focusing on the objective; ACT for expanding the alternatives, considering the consequences and associated chances of each alternative, and identifying the trade-offs involved; IVE for integrating the evidence and values, optimizing the value of interest, and exploring uncertainty). Simulation models play an important role in the assessment of imaging strategies by helping to identify alternative strategies and to integrate the best-available evidence related to risks, benefits, patient values, and costs. Exploring the uncertainty in the evidence and assessing the value of obtaining more information can help prioritize future research and guide study design.

Reevaluation of diagnostic procedures for transmediastinal gunshot wounds

BACKGROUND

Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies.

METHODS

Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures.

RESULTS

Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation.

CONCLUSION

Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.

Limited utility of emergency department thoracotomy

To assess the therapeutic role and cost effectiveness of resuscitative thoracotomy in an urban trauma center, a retrospective review of thoracotomies (n = 273) performed in a trauma unit between 1986 and 1992 was undertaken. A total of 252 thoracotomies were performed for penetrating injuries (92%), and 21 (8%) were performed for blunt trauma. Ten neurologically intact survivors (3.7%) were identified. Mechanisms of injury in survivors were stab wound (n = 6) and gunshot wound (n = 4). There were no neurologically intact survivors when resuscitative thoracotomy was done for blunt trauma. All survivors sustained penetrating truncal injuries; isolated thoracic injuries existed in six patients, while four patients presented with both thoracic and abdominal wounds. All survivors had signs of life either in the field or in the trauma unit. Of the 242 non-survivors who had sustained penetrating trauma, only 49 had signs of life either in the field or upon arrival at the trauma unit. In this group, survival was 17 per cent. Revised Trauma Scores, calculated in the trauma unit, failed to differentiate between survivors and nonsurvivors. In 1992, the average hospital charge for resuscitative thoracotomy was $3413 per patient. Total charges during the study period for resuscitative thoracotomy were approximately $932,000. This represents an expenditure of $93,000 per successful thoracotomy. If thoracotomy was limited to patients sustaining penetrating trauma who demonstrated signs of life, total charges would be approximately $201,367, representing an expenditure of $20,137 per successful thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Toward a comprehensive biomechanical injury cost model

The proposed biomechanical injury cost model utilizes surrogate-based injury assessment functions to predict the probability of occurrence and the probable cost of specific injuries to the head, thorax, abdomen, and lower extremities. The resulting probability cost is a function of the number, location, and severity of injuries. As more precise injury assessment functions and more accurate cost estimates become available, the model will become an effective tool for comparing and classifying different injury patterns.

Medically related motor vehicle injury costs by body region and severity

For motor vehicle crashes, we estimated the medically related costs of nonfatal injury by body region and severity. Our primary data sources were paid charges reported in the Detailed Claims Information data base of the National Council on Compensation Insurance and injury incidence and severity reported in the National Highway Traffic Safety Administration's National Accident Sampling System (NASS). Brain and lower extremity injuries account for the largest portion of medical costs. Spinal cord and severe brain injuries cost more per case. Our average costs per case are very close to those in a report to Congress but come from completely different data sources. Thus, national data bases are providing consistent medical cost estimates.

Outcome of treatment of 686 gunshot wounds of the trunk at Los Angeles County-USC Medical Center: implications for the community

The Los Angeles County-University of Southern California (LAC-USC) Medical Center, a level I trauma center, has experienced a rapidly increasing incidence of gunshot wounds (GSWs). We sought to enumerate the annual monetary costs and medical consequences of thoracoabdominal gunshot wounds in the epicenter of urban violence. A consecutive series of patients admitted from September 1, 1989 to August 31, 1990 was studied. Their records were coded by trauma nurse reviewers and held in the Trauma Emergency Medical Information System (TEMIS) and Automated Medical Record Abstracting and Reporting System (AMRARS). Diagnoses, procedures, and complications were verified by chart review. An estimate of disability 3 months after discharge was made from the record and reported on a functional activity scale. The total number of patients with GSWs admitted to all of the level I Los Angeles County trauma centers was 2771 during the study period. The total number of patients with major gunshot injuries admitted to LAC-USC Medical Center was 1007. Thoracoabdominal wounds without any head wound component occurred in 686 gunshot patients. Three quarters of the injured patients with truncal gunshot injuries were Hispanic. Total length of stay at the LAC-USC Medical Center for those with truncal wounds was 4666 hospital bed days including 432 ICU bed days, representing a minimum estimated total medical cost of $5,441,334. Annual medical cost of all admissions including rehabilitation, however, could be as great as $12 million for the Medical Center and $53 million for the County of Los Angeles. Thirty percent of patients had MediCal insurance. Payment could not be recovered from another 57% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Reappraisal of emergency room thoracotomy in a changing environment

The efficacy of resuscitative emergency room thoracotomy (ERT), particularly in blunt injury, has been questioned. Wide application of the procedure may not be cost effective. The risk of exposure and lethal infection to medical personnel during ERT is considerable. For the past decade, the policy at this institution has been to perform ERT on all moribund patients sustaining penetrating torso injury and all patients sustaining blunt injury with any evidence of cardiac electrical activity. To evaluate whether such a liberal policy is currently justified, the charts of all patients undergoing ERT over a 4-year period were reviewed. One hundred twelve patients underwent ERT; 24 (21%) sustained penetrating injury, 88 (79%) blunt injury. The overall survival rate was 1.8%. Penetrating injury had a 4.2% survival and blunt injury 1.1%. No patients with CPR initiated at the scene and required throughout transport survived. In those patients with both blood pressure and spontaneous respirations present in the field, survival rate was 11.8%. Survival rate in patients manifesting sinus rhythm or ventricular fibrillation upon arrival at the ER was 6.4%. No survivors were noted among patients coming to the hospital with an idioventricular rhythm or asystole. The total hospital charges for patients undergoing ERT exceeded reimbursement by $59,565. Screening for HIV and hepatitis could be documented in only two patients; both were negative. Liberal performance of ERT has dismal results, incurs monetary loss, and affords a greater potential for exposure to lethal infection. Emergency room thoracotomy is justified only when vital signs or a resuscitatible cardiac rhythm are present in the field or ER and deteriorate shortly before thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)