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Haddad DN, Kaufman EJ. Invited Commentary: Implications of Social Policy for Injury. J Am Coll Surg 2024; 238:888-889. [PMID: 38329111 DOI: 10.1097/xcs.0000000000000946] [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: 02/09/2024]
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Michos L, Whitehorn GL, Seamon M, Cannon JW, Yelon J, Kim P, Hatchimonji JS, Song J, Kaufman EJ. Hemodynamic Deterioration of Trauma Patients Undergoing Interhospital Transfer. J Surg Res 2024; 298:119-127. [PMID: 38603942 DOI: 10.1016/j.jss.2024.03.007] [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: 07/17/2023] [Revised: 01/30/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Organized trauma systems reduce morbidity and mortality after serious injury. Rapid transport to high-level trauma centers is ideal, but not always feasible. Thus, interhospital transfers are an important component of trauma systems. However, transferring a seriously injured patient carries the risk of worsening condition before reaching definitive care. In this study, we evaluated characteristics and outcomes of patients whose hemodynamic status worsened during the transfer process. METHODS We conducted a retrospective cohort study using data from the Pennsylvania Trauma Outcomes Study database from 2011 to 2018. Patients were included if they had a heart rate ≤ 100 and systolic blood pressure ≥ 100 at presentation to the referring hospital and were transferred within 24 h. We defined hemodynamic deterioration (HDD) as admitting heart rate > 100 or systolic blood pressure < 100 at the receiving center. We compared demographics, mechanism of injury, injury severity, management, and outcomes between patients with and without HDD using descriptive statistics and multivariable regression analysis. RESULTS Of 52,919 included patients, 5331 (10.1%) had HDD. HDD patients were more often moderately-severely injured (injury severity score 9-15; 40.4% versus 39.4%, P < 0.001) and injured via motor vehicle collision (23.2% versus 16.6%, P < 0.001) or gunshot wound (2.1% versus 1.3%, P < 0.001). HDD patients more often had extremity or torso injuries and after transfer were more likely to be transferred to the intensive care unit (35% versus 28.5%, P < 0.001), go directly to surgery (8.4% versus 5.9%, P < 0.001), or interventional radiology (0.8% versus 0.3%, P < 0.001). Overall mortality in the HDD group was 4.9% versus 2.1% in the group who remained stable. These results were confirmed using multivariable analysis. CONCLUSIONS Interhospital transfers are essential in trauma, but one in 10 transferred patients deteriorated hemodynamically in that process. This high-risk component of the trauma system requires close attention to the important aspects of transfer such as patient selection, pretransfer management/stabilization, and communication between facilities.
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Affiliation(s)
- Lia Michos
- Department of Surgery, Lankenau Medical Center, Wynnewood, Pennsylvania.
| | - Gregory L Whitehorn
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jay Yelon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Patrick Kim
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Jamie Song
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
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Ratnasekera AM, Seng SS, Kim D, Ji W, Jacovides CL, Kaufman EJ, Sadek HM, Perea LL, Poloni CM, Shnaydman I, Lee AJ, Sharp V, Miciura A, Trevizo E, Rosenthal MG, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed AT, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Moncrief M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster KM, Ferrada P. Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study. Injury 2024:111523. [PMID: 38614835 DOI: 10.1016/j.injury.2024.111523] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/09/2024] [Accepted: 04/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE Level III, Therapeutic Care Management.
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Affiliation(s)
- Asanthi M Ratnasekera
- Department of Surgery, Division of Trauma and Surgical Critical Care, Associate Professor of Surgery, Drexel College of Medicine, Philadelphia, PA, United States; Crozer Health Upland PA, Currently at Christianacare Health, Newark, DE, United States.
| | - Sirivan S Seng
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Daniel Kim
- Department of Surgery, Crozer Health, Upland, PA, United States
| | - Wenyan Ji
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Polytechnic Institute and State University, Roanoke, VA, United States
| | - Christina L Jacovides
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States; Currently at Temple University, Philadelphia, PA, United States
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Hannah M Sadek
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Lindsey L Perea
- Department of Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, United States
| | - Christina Monaco Poloni
- Department of Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, United States
| | - Ilya Shnaydman
- Department of Surgery, Medical Director, Surgical Intensive Care Unit, New York Medical College, West Chester Medical Center, Valhalla, NY, United States
| | | | - Victoria Sharp
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Angela Miciura
- Department of Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, United States
| | - Eric Trevizo
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Martin G Rosenthal
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lawrence Lottenberg
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - William Zhao
- Department of Surgery, St. Mary's Medical Center, West Palm Beach, FL, United States; Florida Atlantic University, Boca Raton, FL, United States
| | - Alicia Keininger
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - Michele Hunt
- Department of Surgery, Trinity Health Oakland, Pontiac, MI, United States
| | - John Cull
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Chassidy Balentine
- Department of Surgery, Prisma Health Upstate, Greenville, SC, United States
| | - Tanya Egodage
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Aleem T Mohamed
- Department of Surgery, Cooper University Hospital, Camden, NJ, United States
| | - Michelle Kincaid
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Stephanie Doris
- Department of Surgery, Ohio Health Grant Medical Center, Columbus, OH, United States
| | - Robert Cotterman
- Department of Surgery, Promedica Toledo Hospital, Toledo, OH, United States
| | - Sara Seegert
- Department of Research, Promedica Toledo Hospital, Toledo, OH, United States
| | - Lewis E Jacobson
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Jamie Williams
- Department of Surgery, Ascension St. Vincent Hospital, Indianapolis, IN, United States
| | - Melissa Moncrief
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Brandi Palmer
- Department of Trauma & Acute Care Surgery, Kettering Health Main Campus, Kettering, OH, United States
| | - Caleb Mentzer
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Nichole Tackett
- Department of Surgery, Spartanburg Medical Center, Spartanburg, SC, United States
| | - Tjasa Hranjec
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Thomas Dougherty
- Department of Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Shawna Morrissey
- Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, United States
| | - Lauren Donatelli-Seyler
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Amy Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Leah C Tatebe
- Department of Surgery, Cook County Hospital, Chicago, IL, United States; Currently at Northwestern Memorial Hospital, Chicago, IL, United States
| | - Tiffany J Nevill
- Department of Surgery, Cook County Hospital, Chicago, IL, United States
| | - Michel B Aboutanos
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - David Hamilton
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Diane Redmond
- Department of Surgery, Penrose Hospital, Colorado Springs, CO, United States
| | - Daniel C Cullinane
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, Portland, ME, United States
| | - Mark McMellen
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Chris Duran
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, United States
| | - Jennifer Daniels
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Shana Ballow
- Department of Surgery, University of California San Francisco, Fresno, CA, United States
| | - Kevin M Schuster
- Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Paula Ferrada
- Department of Surgery, INOVA Fairfax Health System, Fairfax, VA, United States
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Kaufman EJ, Wirtalla CJ, Keele LJ, Neuman MD, Rosen CB, Syvyk S, Hatchimonji J, Ginzberg S, Friedman A, Roberts SE, Kelz RR. Costs of Care for Operative and Nonoperative Management of Emergency General Surgery Conditions. Ann Surg 2024; 279:684-691. [PMID: 37855681 PMCID: PMC10939968 DOI: 10.1097/sla.0000000000006134] [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] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Many emergency general surgery (EGS) conditions can be managed operatively or nonoperatively, with outcomes that vary by diagnosis. We hypothesized that operative management would lead to higher in-hospital costs but to cost savings over time. BACKGROUND EGS conditions account for $28 billion in health care costs in the United States annually. Compared with scheduled surgery, patients who undergo emergency surgery are at increased risk of complications, readmissions, and death, with accompanying costs of care that are up to 50% higher than elective surgery. Our prior work demonstrated that operative management had variable impacts on clinical outcomes depending on the EGS condition. METHODS This was a nationwide, retrospective study using fee-for-service Medicare claims data. We included patients 65.5 years of age or older with a principal diagnosis for an EGS condition 7/1/2015-6/30/2018. EGS conditions were categorized as: colorectal, general abdominal, hepatopancreaticobiliary (HPB), intestinal obstruction, and upper gastrointestinal. We used near-far matching with a preference-based instrumental variable to adjust for confounding and selection bias. Outcomes included Medicare payments for the index hospitalization and at 30, 90, and 180 days. RESULTS Of 507,677 patients, 30.6% received an operation. For HPB conditions, costs for operative management were initially higher but became equivalent at 90 and 180 days. For all others, operative management was associated with higher inpatient costs, which persisted, though narrowed, over time. Out-of-pocket costs were nearly equivalent for operative and nonoperative management. CONCLUSIONS Compared with nonoperative management, costs were higher or equivalent for operative management of EGS conditions through 180 days, which could impact decision-making for clinicians, patients, and health systems in situations where clinical outcomes are similar.
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
| | - Christopher J Wirtalla
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Luke J Keele
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark D Neuman
- Department of Anesthesia and critical Care Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Claire B Rosen
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Solomiya Syvyk
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Justin Hatchimonji
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sara Ginzberg
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ari Friedman
- Department of Emergency Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia, PA
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Eisinger EC, Chen AT, Ramadan OI, Morgan AU, Delgado MK, Kaufman EJ. Health Care Use Among Patients Retroactively Insured via a Hospital-Based Insurance Linkage Program. J Gen Intern Med 2024:10.1007/s11606-024-08712-y. [PMID: 38483779 DOI: 10.1007/s11606-024-08712-y] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE Over 25% of the 27 million uninsured individuals in the United States are eligible for Medicaid. Many hospitals have insurance linkage programs that assist eligible patients with enrollment, but little is known about the impact of these programs on care utilization. This research assessed health care utilization and health outcomes among patients enrolled in Medicaid via a hospital-based insurance linkage program. METHODS This retrospective cohort study included adults aged 18-64 admitted to the hospital from 2016 to 2021. Those who obtained insurance retroactively via insurance linkage (RI) were compared with those who presented with Medicaid (MI) or remained uninsured (UI). The primary outcome was the presence of at least one visit with a primary care provider (PCP) in the 12 months following index admission. Secondary outcomes included having an assigned PCP, ED revisits, and hospital readmissions. For patients with diabetes and hypertension, 12-month hemoglobin A1c (HbA1c) and blood pressure (BP) readings were tracked. RESULTS Of 3882 patients admitted with no insurance, 2905 (74.8%) were enrolled in insurance (RI). In multivariable analysis, RI patients were 14% more likely (OR 1.14, p = 0.020) to have completed at least one PCP visit by 12 months after index admission compared to those with preexisting Medicaid (MI), and uninsured patients were 29% less likely (OR 0.71, p = 0.003). MI and RI patients also had more ED revisits (p < 0.001) and greater 12-month reductions in blood pressure (p < 0.001) compared with uninsured patients. CONCLUSION Hospital-based insurance linkage reached three-quarters of uninsured patients and was associated with increased utilization of acute and outpatient health care services. An acute care encounter represents an opportunity to connect patients to insurance, a key step toward improving their health outcomes.
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Affiliation(s)
- Ella C Eisinger
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela T Chen
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Omar I Ramadan
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna U Morgan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Kit Delgado
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Trauma, Surgical Critical Care & Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
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Hatchimonji JS, Meredyth NA, Gummadi S, Kaufman EJ, Yelon JA, Cannon JW, Martin ND, Seamon MJ. The Role of Emergency Department Thoracotomy in Patients with Cranial Gunshot Wounds. J Trauma Acute Care Surg 2024:01586154-990000000-00641. [PMID: 38374530 DOI: 10.1097/ta.0000000000004282] [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: 02/21/2024]
Abstract
BACKGROUND Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. METHODS We used Pennsylvania Trauma Outcomes Study (PTOS) data, 2002-2021, and included EDTs for GSWs. We defined EDT by ICD codes for thoracotomy or procedures requiring one, with a location flagged as ED. We defined head injuries as any head abbreviated injury scale (AIS) ≥1 and severe head injuries as head AIS ≥ 4. Head injuries were "isolated" if all other body regions AIS < 2. Descriptive statistics were performed. Discharge functional status was measured in 5 domains. RESULTS Over 20 years in Pennsylvania, 3,546 EDTs were performed, 2,771 (78.1%) for penetrating injuries. Most penetrating EDTs (2,003, 72.3%) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head-injured (n = 94/1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound - 0% (0/81) with a severe head injury (p = 0.035 vs no severe head injury), and 4.5% (5/110) with a non-severe head injury. Of the 5 head-injured survivors, 2 were fully dependent for transfer mobility, and 3 were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. CONCLUSIONS Though there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head-injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. LEVEL OF EVIDENCE Level II, retrospective observational cohort study.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nicole A Meredyth
- Division of Trauma and Critical Care, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sriharsha Gummadi
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Jeremy W Cannon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Niels D Martin
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark J Seamon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Hatchimonji JS, Bakillah E, Kaufman EJ, Dowzicky PM, Braslow BM, Kalapatapu VR, Reilly PM, Sharoky CE. The open abdomen in mesenteric ischemia: A tool for patients undergoing revascularization. World J Surg 2024; 48:331-340. [PMID: 38686782 DOI: 10.1002/wjs.12056] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/09/2023] [Accepted: 12/13/2023] [Indexed: 05/02/2024]
Abstract
BACKGROUND We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality. METHODS We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes. RESULTS Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p < 0.001). Among revascularizations, there was no such association (p = 0.528). OA was associated with ventilator support >48 h (OR 4.04, 95% CI [3.55, 4.62], and p < 0.001). CONCLUSION OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI. LEVEL OF EVIDENCE Retrospective cohort, Level III.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emna Bakillah
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Phillip M Dowzicky
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin M Braslow
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Venkat R Kalapatapu
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine E Sharoky
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Alur R, Hall E, Smith MJ, Zakrison T, Loughran C, Cosey-Gay F, Kaufman EJ. What medical-legal partnerships can do for trauma patients and trauma care. J Trauma Acute Care Surg 2024; 96:340-345. [PMID: 38147579 DOI: 10.1097/ta.0000000000004167] [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: 12/28/2023]
Abstract
ABSTRACT Trauma patients are particularly vulnerable to the impact of preexisting social and legal determinants of health postinjury. Trauma patients have a wide range of legal needs, including housing, employment, debt, insurance coverage, and access to federal and state benefits. Legal support could provide vital assistance to address the social determinants of health for injured patients. Medical legal partnerships (MLPs) embed legal professionals within health care teams to improve health by addressing legal needs that affect health. Medical legal partnerships have a successful track record in oncology, human immunodeficiency virus/acquired immune deficiency syndrome, and pediatrics, but have been little used in trauma. We conducted a scoping review to describe the role of MLPs and their potential to improve health outcomes for patients with traumatic injuries. We found that MLPs use legal remedies to address a variety of social and structural conditions that could affect patient health across several patient populations, such as children with asthma and patients with cancer. Legal intervention can assist patients in obtaining stable and healthy housing, employment opportunities, debt relief, access to public benefits, and immigration assistance. Medical legal partnership structure varies across institutions. In some, MLP lawyers are employed directly by a health care institution. In others, MLPs function as partnerships between a health system and an external legal organization. Medical legal partnerships have been found to reduce hospital readmissions, increase treatment utilization by patients, decrease patient stress levels, and benefit health systems financially. This scoping review outlines the potential of MLPs to improve outcomes for injured patients. Establishing trauma-focused MLPs could be a feasible intervention for trauma centers around the country seeking to improve health outcomes and reduce disparities for injured patients.
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Affiliation(s)
- Rucha Alur
- From the Perelman School of Medicine (R.A.); Carey School of Law (R.A.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (E.H.), Medstar Washington Hospital Center, Community Violence Intervention Program (M.J.S.), Washington, District of Columbia; Critical Trauma Research (T.Z.), University of Chicago Medicine; Legal Aid Chicago (C.L.); Violence Recovery Program (F.C.-G.), University of Chicago Medicine, Chicago, Illinois; and Traumatology, Surgical Critical Care, and Emergency Surgery (E.J.K.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Eisinger EC, Forsythe L, Joergensen S, Murali S, Cannon JW, Reilly PM, Kim PK, Kaufman EJ. Thromboembolic Complications Following Perioperative Tranexamic Acid Administration. J Surg Res 2024; 293:676-684. [PMID: 37839099 DOI: 10.1016/j.jss.2023.08.048] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION The antifibrinolytic tranexamic acid (TXA) may reduce death in trauma; however, outcomes associated with TXA use in patients without proven hyperfibrinolysis remain unclear. We analyzed the associations of empirically administered TXA, hypothesizing that TXA use would correlate to lower transfusion totals but increased thromboembolic complications. METHODS This retrospective cohort study compared trauma patients started on massive transfusion protocol at a Level I trauma center from 2016 to 2021 who either did or did not receive TXA. Our primary outcome was in-hospital mortality. Venous thromboembolism (VTE; pulmonary embolism or deep vein thrombosis), transfusion volumes, and coagulation measures were considered secondarily. Descriptive statistics, univariate analyses, and multivariable logistic regression were used to evaluate differences in outcomes. RESULTS TXA patients presented with lower systolic blood pressure (100 versus 119.5 mmHg, P = 0.009), trended toward higher injury severity (ISS of 25 versus 20, P = 0.057), and were likelier to have undergone thoracotomy or laparotomy (89 versus 71%, P = 0.002). After adjusting for age, mechanism, presenting vitals, and operation, TXA was not significantly associated with mortality or VTE. TXA patients had larger volumes of packed red blood cells, platelets, and plasma transfused within 4- and 24-h (P ≤ 0.002). No differences in clot stability, captured via thromboelastography, were noted. CONCLUSIONS Despite no differences in mortality or VTE between patients who did and did not receive TXA, there were significant differences in transfusion totals. TXA patients had worse presenting physiology and likely had more severe bleeding. This absence of adverse outcomes supports TXA's safety. Nevertheless, further inquiry into the precise mechanism of TXA may help guide its empiric use, allowing for more targeted application.
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Affiliation(s)
- Ella C Eisinger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Liam Forsythe
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Shyam Murali
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy W Cannon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick K Kim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Ginzberg SP, Wirtalla CJ, Keele LJ, Wachtel H, Kaufman EJ, Kelz RR. An acute care surgeon's dilemma: Operative vs. non-operative management of emergency general surgery conditions in patients with recent colorectal cancer treatment. Am J Surg 2024; 227:15-21. [PMID: 37741802 PMCID: PMC10841180 DOI: 10.1016/j.amjsurg.2023.09.010] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/03/2023] [Accepted: 09/10/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND This comparative effectiveness study examined outcomes of operative vs. non-operative management for emergency general surgery (EGS) conditions in patients with recent cancer treatment (RT). METHODS Medicare beneficiaries with a history of colorectal cancer hospitalized for an EGS condition (2016-2018) were identified. RT was defined as chemotherapy/radiation within 3 months prior to admission. Instrumental variable analysis assessed the impact of management on mortality and readmissions among survivors (30d, 60d, and 90d), for patients in whom there was clinical equipoise regarding optimal management strategy. RESULTS Of 26,097 patients, 13% had undergone RT. In both the RT and non-RT groups, the optimal management strategy was uncertain in 14%. Operative management conferred increased risk of mortality but not readmission in patients with RT compared to those without (90d mortality:+43%, p = 0.03; 90d readmission:+7.1%, p = 0.776). CONCLUSIONS In patients with RT for whom there is clinical equipoise regarding EGS management, operative intervention increases risk of mortality.
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Affiliation(s)
- Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Abramson Cancer Center, University of Pennsylvania Health System, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Luke J Keele
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Abramson Cancer Center, University of Pennsylvania Health System, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA; Abramson Cancer Center, University of Pennsylvania Health System, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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11
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Prentice CM, Song J, Degli Esposti M, Jay J, Wiebe DJ, Jacovides CL, Seamon MJ, Kaufman EJ. Colleges and Crime-Comparing Homicide and Suicide Rates Among College Towns and Their Counterparts. J Surg Res 2024; 293:490-496. [PMID: 37827026 PMCID: PMC10896267 DOI: 10.1016/j.jss.2023.09.020] [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: 03/27/2023] [Revised: 08/11/2023] [Accepted: 09/03/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION To investigate differences in homicide and suicide rates across college town status and determine whether college towns were predisposed to changes in rates over time. METHODS We analyzed county-level homicide and suicide rates (total and by firearm) across college town status using 2015-2019 CDC death certificate data and data from the American Communities Project. RESULTS Population-level homicide rates were similar across college town status, but younger age groups were at increased risk for firearm homicide and total homicide in college towns. College town status was associated with lower population-level firearm suicide rates, but individuals aged less than 18 y were at increased risk for total and firearm suicide. Finally, college towns were not classified as outliers for changes in either firearm homicide or suicide rates over time. CONCLUSIONS College towns had similar homicide rates and significantly lower firearm suicide rates than other counties; however, individuals aged less than 18 y were at increased risk for both outcomes. The distinctive demographic, social, economic, and cultural features of college towns may contribute to differing risk profiles among certain age groups, thus may also be amenable to focused prevention efforts.
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Affiliation(s)
- Carter M Prentice
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of General Surgery, University of California, Los Angeles, Los Angeles, California.
| | - Jamie Song
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michelle Degli Esposti
- Department of Social Policy & Intervention, University of Oxford, Oxford, United Kingdom; Federal University of Pelotas, Human Development and Violence Research Centre, Pelotas, Brazil
| | - Jonathan Jay
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christina L Jacovides
- Division Trauma, Acute Care Surgery, and Surgical Critical Care, Temple University Hospital, Philadelphia, Pennsylvania
| | - Mark J Seamon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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12
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Kern JA, Kaufman EJ. Invited Commentary: Measuring the Structural Roots of Firearm Violence in the US. J Am Coll Surg 2023; 237:854-855. [PMID: 37702394 DOI: 10.1097/xcs.0000000000000817] [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: 09/14/2023]
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13
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Garcia Whitlock AE, Gill BP, Richardson JB, Patton DU, Strong B, Nwakanma CC, Kaufman EJ. Analysis of Social Media Involvement in Violent Injury. JAMA Surg 2023; 158:1347-1349. [PMID: 37819673 PMCID: PMC10568437 DOI: 10.1001/jamasurg.2023.4995] [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: 03/16/2023] [Accepted: 06/16/2023] [Indexed: 10/13/2023]
Abstract
This cross-sectional study uses police agency–collected information to quantify the association among social media involvement, crime, and violence.
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Affiliation(s)
- Anna E. Garcia Whitlock
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Brendan P. Gill
- Prince George’s County Police Department, Upper Marlboro, Maryland
| | - Joseph B. Richardson
- Departments of African-American Studies and Medical Anthropology, University of Maryland, Baltimore, Maryland
| | - Desmond U. Patton
- University of Pennsylvania School of Social Policy and Practice, Philadelphia, Pennsylvania
| | - Bethany Strong
- Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Chidinma C. Nwakanma
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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14
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Seng SS, Kaufman EJ, Song J, Moran B, Stawicki SP, Koenig G, Timinski M, Martin ND, Ratnasekera A. A Statewide Analysis of Self-Inflicted Injuries During COVID-19 Pandemic: Is There Adequate Access to Mental Health? J Surg Res 2023; 291:620-626. [PMID: 37542776 DOI: 10.1016/j.jss.2023.06.032] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 06/07/2023] [Accepted: 06/25/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Many social and behavioral changes occurred during the COVID-19 pandemic. Our objective was to identify changes in incidence of self-inflicted injuries during COVID-19 compared to prepandemic years. Further, we aimed to identify risk factors associated with self-inflicted injuries before and during the pandemic. METHODS A retrospective cohort study of patients aged ≥18 y with self-inflicted injuries from 2018 to 2021 was performed using the Pennsylvania Trauma Outcome Study registry. Patients were grouped into pre-COVID Era (pre-CE, 2018-2019) and COVID Era (CE, 2020-2021). Statistical comparisons were accomplished using Wilcoxon rank-sum tests and chi-square or Fisher's exact tests. RESULTS There were a total of 1075 self-inflicted injuries in the pre-CE cohort and 482 during the CE. There were no differences in age, gender, race or ethnicity between the two cohorts. Among preexisting conditions, those within the pre-CE cohort had a higher incidence of mental/personality disorder (59.2% versus 52.3%, P = 0.01). There were no significant differences in the mechanism of self-inflicted injuries or place of injury between the two periods. Additionally, there were no differences in discharge destinations or mortality between the two cohorts. CONCLUSIONS During the height of social isolation in Pennsylvania, there were no associated increases in self-inflicted injuries. However, there were increased incidences of self-inflicted injuries among those with a prior diagnosis of mental or personality disorder in the pre-CE group. Further investigations are required to study the access to mental health services in future pandemics or public health disasters.
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Affiliation(s)
- Sirivan S Seng
- Department of Surgery, Crozer Chester Medical Center, Upland, Pennsylvania.
| | - Elinore J Kaufman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jamie Song
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Moran
- Department of Surgery, Einstein Medical Center, Philadelphia, Pennsylvania
| | - Stanislaw P Stawicki
- Department of Research & Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania
| | - George Koenig
- Department of Surgery, Thomas Jefferson University, Philadelphia Pennsylvania
| | - Marie Timinski
- Department of Surgery, Geisinger Wyoming Valley, Wilkes Barre, Pennsylvania
| | - Niels D Martin
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Asanthi Ratnasekera
- Department of Surgery, Crozer Chester Medical Center, Upland, Pennsylvania; Department of Surgery, Christiana Care, Newark, Delaware
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15
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Beyer CA, Hatchimonji JS, Candido K, Chreiman K, Martin N, Cannon JW, Reilly PM, Kaufman EJ, Seamon MJ. Effects of prior injury on long term patient reported outcomes after trauma. J Trauma Acute Care Surg 2023; 95:691-698. [PMID: 37418688 DOI: 10.1097/ta.0000000000004027] [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: 07/09/2023]
Abstract
BACKGROUND Trauma is an episodic, chronic disease with substantial, long-term physical, psychological, emotional, and social impacts. However, the effect of recurrent trauma on these long-term outcomes remains unknown. We hypothesized that trauma patients with a history of prior traumatic injury (PTI) would have poorer outcomes 6 months (6mo) after injury compared with patients without PTI. METHODS Adult trauma patients admitted at an urban, academic, Level I trauma center were screened for inclusion (October 2020 to November 2021). Enrolled patients were administered the PROMIS-29 instrument, the primary care post-traumatic stress disorder screen, and standardized questions about prior trauma hospitalization, substance use, employment, and living situation at baseline and 6mo after injury. Assessment data was merged with clinical registry data, and outcomes were compared with respect to PTI. RESULTS Of 3,794 eligible patients, 456 completed baseline assessments and 92 completed 6mo surveys. Between those with or without PTI, there were no differences at 6mo after injury in the proportion of patients reporting poor function in social participation, anxiety, depression, fatigue, pain interference, or sleep disturbance. Prior traumatic injury patients reported poor physical function less often than patients without PTI (10 [27.0%] vs. 33 [60.0%], p = 0.002). After controlling for age, gender, race, injury mechanism, and Injury Severity Score, PTI correlated with a fourfold decrease in poor physical function risk (adjusted odds ratio, 0.243; 95% confidence interval, 0.081-0.733; p = 0.012) in the multivariable logistic regression model. CONCLUSION Compared with patients suffering their first injury, trauma patients with PTI have better self-reported physical function after a subsequent injury and otherwise equivalent outcomes across a range of HRQoL domains at 6mo. There remains substantial room for improvement to mitigate the long-term challenges faced by trauma patients and to facilitate their societal reintegration, regardless of the number of times they are injured. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Carl A Beyer
- From the Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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16
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Kaufman EJ, Whitehorn G, Orji W, Chreiman K, Jackson S, Holena D, Lane-Fall M, Jacoby SF. Patient Experiences of Acute and Postacute Care After Trauma. J Surg Res 2023; 291:303-312. [PMID: 37506429 DOI: 10.1016/j.jss.2023.06.020] [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: 01/11/2023] [Revised: 04/13/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Traumatic injury can transform a healthy, independent individual into a patient with complex health needs. Little is known about how injured patients understand their health and healthcare needs during postacute recovery, limiting our ability to optimize care. This multiple-methods study explored injured patients' experiences of care up to 30 days after discharge. METHODS Injured adults admitted to an urban, Level I trauma center August 1, 2019-November 30, 2020 were sampled purposively to balance blunt and penetrating injuries. Patient experience and health status were assessed at baseline and 30 days postdischarge using the Quality of Trauma Care Patient-Reported Experience Measure. Fifteen qualitative interviews were conducted with a purposive subset and analyzed using qualitative content analysis. RESULTS Of 67 participants (76% male, 73% Black, 51% penetrating, median age 34 years), 37 completed follow-up surveys. Quality of acute care was rated 9-10/10 by 81% of the sample for acute and 65% for postacute care (P = 0.09). Thirty percent described fair or poor mental health, but only mental health concerns were addressed for only 2/3. Pain control was inadequate in 31% at baseline and for 46% at follow-up (P = 0.09). Qualitative analysis revealed general satisfaction with acute care but challenges in recovery with unmet needs for communication and care coordination. CONCLUSIONS Trauma patients appreciated the quality of their acute care experiences but identified opportunities for improvement in prognostic communication, pain management, and mental health support. Unmet mental and physical care needs persist at least 1 month after hospital discharge and reinforce the need for interventions that optimize postacute trauma care.
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Gregory Whitehorn
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Whitney Orji
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kristen Chreiman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sunny Jackson
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Daniel Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sara F Jacoby
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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17
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Rosen CB, Roberts SE, Wirtalla CJ, Keele LJ, Kaufman EJ, Halpern S, Kelz RR. Emergency Surgery, Multimorbidity and Hospital-Free Days: A Retrospective Observational Study. J Surg Res 2023; 291:660-669. [PMID: 37556878 PMCID: PMC10530175 DOI: 10.1016/j.jss.2023.06.049] [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: 12/01/2022] [Revised: 05/17/2023] [Accepted: 06/12/2023] [Indexed: 08/11/2023]
Abstract
INTRODUCTION Analyzing hospital-free days (HFDs) offers a patient-centered approach to health services research. We hypothesized that, within emergency general surgery (EGS), multimorbidity would be associated with fewer HFDs, whether patients were managed operatively or nonoperatively. METHODS EGS patients were identified using national Medicare claims data (2015-2018). Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set and stratified by treatment: operative (received surgery within 48 h of index admission) and nonoperative. HFDs were calculated through 180 d, beginning on the day of index admission, as days alive and spent outside of a hospital, an Emergency Department, or a long-term acute care facility. Univariate comparisons were performed using Kruskal-Wallis tests and risk-adjusted HFDs were compared between multimorbid and nonmultimorbid patients using multivariable zero-inflated negative binomial regression models. RESULTS Among 174,891 operative patients, 45.5% were multimorbid. Among 398,756 nonoperative patients, 59.2% were multimorbid. Multimorbid patients had fewer median HFDs than nonmultimorbid patients among operative and nonoperative cohorts (P < 0.001). At 6 mo, among operative patients, multimorbid patients had 6.5 fewer HFDs (P < 0.001), and among nonoperative patients, multimorbid patients had 7.9 fewer HFDs (P < 0.001). When length of stay was included as a covariate, nonoperative multimorbid patients still had 7.9 fewer HFDs than nonoperative, nonmultimorbid patients (P < 0.001). CONCLUSIONS HFDs offer a patient-centered, composite outcome for claims-based analyses. For EGS patients, multimorbidity was associated with less time alive and out of the hospital, especially when patients were managed nonoperatively.
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Affiliation(s)
- Claire B Rosen
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgery and Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania.
| | - Sanford E Roberts
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgery and Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chris J Wirtalla
- Center for Surgery and Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute, Philadelphia, Pennsylvania
| | - Luke J Keele
- Center for Surgery and Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgery and Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute, Philadelphia, Pennsylvania
| | - Scott Halpern
- Leonard Davis Institute, Philadelphia, Pennsylvania; Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Surgery and Health Economics, Perelman School of Medicine, Philadelphia, Pennsylvania; Leonard Davis Institute, Philadelphia, Pennsylvania
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18
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Rosen CB, Roberts SE, Wirtalla CJ, Keele LJ, Kaufman EJ, Halpern SD, Reilly PM, Neuman MD, Kelz RR. The Conditional Effects of Multimorbidity on Operative Versus Nonoperative Management of Emergency General Surgery Conditions: A Retrospective Observational Study Using an Instrumental Variable Analysis. Ann Surg 2023; 278:e855-e862. [PMID: 37212397 PMCID: PMC10524950 DOI: 10.1097/sla.0000000000005901] [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] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To understand how multimorbidity impacts operative versus nonoperative management of emergency general surgery (EGS) conditions. BACKGROUND EGS is a heterogenous field, encompassing operative and nonoperative treatment options. Decision-making is particularly complex for older patients with multimorbidity. METHODS Using an instrumental variable approach with near-far matching, this national, retrospective observational cohort study of Medicare beneficiaries examines the conditional effects of multimorbidity, defined using qualifying comorbidity sets, on operative versus nonoperative management of EGS conditions. RESULTS Of 507,667 patients with EGS conditions, 155,493 (30.6%) received an operation. Overall, 278,836 (54.9%) were multimorbid. After adjustment, multimorbidity significantly increased the risk of in-hospital mortality associated with operative management for general abdominal patients (+9.8%; P = 0.002) and upper gastrointestinal patients (+19.9%, P < 0.001) and the risk of 30-day mortality (+27.7%, P < 0.001) and nonroutine discharge (+21.8%, P = 0.007) associated with operative management for upper gastrointestinal patients. Regardless of multimorbidity status, operative management was associated with a higher risk of in-hospital mortality among colorectal patients (multimorbid: + 12%, P < 0.001; nonmultimorbid: +4%, P = 0.003), higher risk of nonroutine discharge among colorectal (multimorbid: +42.3%, P < 0.001; nonmultimorbid: +55.1%, P < 0.001) and intestinal obstruction patients (multimorbid: +14.6%, P = 0.001; nonmultimorbid: +14.8%, P = 0.001), and lower risk of nonroutine discharge (multimorbid: -11.5%, P < 0.001; nonmultimorbid: -11.9%, P < 0.001) and 30-day readmissions (multimorbid: -8.2%, P = 0.002; nonmultimorbid: -9.7%, P < 0.001) among hepatobiliary patients. CONCLUSIONS The effects of multimorbidity on operative versus nonoperative management varied by EGS condition category. Physicians and patients should have honest conversations about the expected risks and benefits of treatment options, and future investigations should aim to understand the optimal management of multimorbid EGS patients.
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Affiliation(s)
- Claire B Rosen
- Department of Surgery, Hospital of the University of Pennsylvania
| | | | - Chris J Wirtalla
- Department of Medicine, Hospital of the University of Pennsylvania
| | - Luke J Keele
- Department of Surgery, Hospital of the University of Pennsylvania
| | | | - Scott D Halpern
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Patrick M Reilly
- Department of Surgery, Hospital of the University of Pennsylvania
| | - Mark D Neuman
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania
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19
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Roberts SE, Rosen CB, Keele LJ, Kaufman EJ, Wirtalla CJ, Finn CB, Moneme AN, Bewtra M, Kelz RR. Association of Established Primary Care Use With Postoperative Mortality Following Emergency General Surgery Procedures. JAMA Surg 2023; 158:1023-1030. [PMID: 37466980 PMCID: PMC10357361 DOI: 10.1001/jamasurg.2023.2742] [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: 02/02/2023] [Accepted: 04/06/2023] [Indexed: 07/20/2023]
Abstract
Importance Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown. Objective To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults. Design, Setting, and Participants This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race. Exposure Primary care utilization in the year prior to presentation for an EGS operation. Main Outcome and Measures In-hospital, 30-day, 60-day, 90-day, and 180-day mortality. Results A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different. Conclusions and Relevance In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.
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Affiliation(s)
- Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Claire B. Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Luke J. Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Elinore J. Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Christopher J. Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Caitlin B. Finn
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Adora N. Moneme
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Meenakshi Bewtra
- Division of Gastroenterology, University of Pennsylvania, Philadelphia
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
| | - Rachel R. Kelz
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
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Hatchimonji JS, Mavroudis CL, Friedman A, Kaufman EJ, Syvyk S, Wirtalla CJ, Keele L, Reilly PM, Kelz RR. National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions. J Surg Res 2023; 290:310-318. [PMID: 37329626 PMCID: PMC10330654 DOI: 10.1016/j.jss.2023.05.010] [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: 11/16/2022] [Revised: 03/22/2023] [Accepted: 05/13/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Catherine L Mavroudis
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ari Friedman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Solomiya Syvyk
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Wirtalla
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Keele
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Division of Endocrine and Oncologic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Roberts SE, Rosen CB, Keele LJ, Kaufman EJ, Wirtalla CJ, Syvyk S, Reilly PM, Neuman MD, McHugh MD, Kelz RR. Conditional Effects of Race on Operative and Nonoperative Outcomes of Emergency General Surgery Conditions. Med Care 2023; 61:587-594. [PMID: 37476848 PMCID: PMC10527290 DOI: 10.1097/mlr.0000000000001883] [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] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Many emergency general surgery (EGS) conditions can be managed both operatively or nonoperatively; however, it is unknown whether the decision to operate affects Black and White patients differentially. METHODS We identified a nationwide cohort of Black and White Medicare beneficiaries, hospitalized for common EGS conditions from July 2015 to June 2018. Using near-far matching to adjust for measurable confounding and an instrumental variable analysis to control for selection bias associated with treatment assignment, we compare outcomes of operative and nonoperative management in a stratified population of Black and White patients. Outcomes included in-hospital mortality, 30-day mortality, nonroutine discharge, and 30-day readmissions. An interaction test based on a t test was used to determine the conditional effects of operative versus nonoperative management between Black and White patients. RESULTS A total of 556,087 patients met inclusion criteria, of which 59,519 (10.7%) were Black and 496,568 (89.3%) were White. Overall, 165,932 (29.8%) patients had an operation and 390,155 (70.2%) were managed nonoperatively. Significant outcome differences were seen between operative and nonoperative management for some conditions; however, no significant differences were seen for the conditional effect of race on outcomes. CONCLUSIONS The decision to manage an EGS patient operatively versus nonoperatively has varying effects on surgical outcomes. These effects vary by EGS condition. There were no significant conditional effects of race on the outcomes of operative versus nonoperative management among universally insured older adults hospitalized with EGS conditions.
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Affiliation(s)
- Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Claire B. Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Luke J. Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Elinore J. Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christopher J. Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Patrick M. Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA USA
| | - Matthew D. McHugh
- Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, University of Pennsylvania
| | - Rachel R. Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
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Brown DE, Finn CB, Roberts SE, Rosen CB, Kaufman EJ, Wirtalla C, Kelz R. Effect of Serious Mental Illness on Surgical Consultation and Operative Management of Older Adults with Acute Biliary Disease: A Nationwide Study. J Am Coll Surg 2023; 237:301-308. [PMID: 37052311 PMCID: PMC10525026 DOI: 10.1097/xcs.0000000000000710] [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] [Indexed: 04/14/2023]
Abstract
BACKGROUND Mental illness is associated with worse outcomes after emergency general surgery. To understand how preoperative processes of care may influence disparate outcomes, we examined rates of surgical consultation, treatment, and operative approach between older adults with and without serious mental illness (SMI). STUDY DESIGN We performed a nationwide, retrospective cohort study of Medicare beneficiaries aged 65.5 years or more hospitalized via the emergency department for acute cholecystitis or biliary colic. SMI was defined as schizophrenia spectrum, mood, and/or anxiety disorders. The primary outcome was surgical consultation. Secondary outcomes included operative treatment and surgical approach (laparoscopic vs open). Multivariable logistic regression was used to examine outcomes with adjustment for potential confounders related to patient demographics, comorbidities, and rates of imaging. RESULTS Of 85,943 included older adults, 19,549 (22.7%) had SMI. Before adjustment, patients with SMI had lower rates of surgical consultation (78.6% vs 80.2%, p < 0.001) and operative treatment (68.2% vs 71.7%, p < 0.001), but no significant difference regarding laparoscopic approach (92.0% vs 92.1%, p = 0.805). In multivariable regression models with adjustment for confounders, there was no difference in odds of receiving a surgical consultation (odds ratio 0.98 [95% CI 0.93 to 1.03]) or undergoing operative treatment (odds ratio 0.98 [95% CI 0.93 to 1.03]) for patients with SMI compared with those without SMI. CONCLUSIONS Older adults with SMI had similar odds of receiving surgical consultation and operative treatment as those without SMI. As such, differences in processes of care that result in SMI-related disparities likely occur before or after the point of surgical consultation in this universally insured patient population.
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Affiliation(s)
- Danielle E Brown
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Brown, Kaufman, Kelz)
| | - Caitlin B Finn
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA (Finn, Roberts, Rosen, Kaufman, Wirtalla, Kelz)
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Finn, Kelz)
| | - Sanford E Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA (Finn, Roberts, Rosen, Kaufman, Wirtalla, Kelz)
| | - Claire B Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA (Finn, Roberts, Rosen, Kaufman, Wirtalla, Kelz)
| | - Elinore J Kaufman
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Brown, Kaufman, Kelz)
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA (Finn, Roberts, Rosen, Kaufman, Wirtalla, Kelz)
| | - Chris Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA (Finn, Roberts, Rosen, Kaufman, Wirtalla, Kelz)
| | - Rachel Kelz
- From the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (Brown, Kaufman, Kelz)
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, PA (Finn, Roberts, Rosen, Kaufman, Wirtalla, Kelz)
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (Finn, Kelz)
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Kaufman EJ, Keele LJ, Wirtalla CJ, Rosen CB, Roberts SE, Mavroudis CL, Reilly PM, Holena DN, McHugh MD, Small D, Kelz RR. Operative and Nonoperative Outcomes of Emergency General Surgery Conditions: An Observational Study Using a Novel Instrumental Variable. Ann Surg 2023; 278:72-78. [PMID: 35786573 PMCID: PMC9810765 DOI: 10.1097/sla.0000000000005519] [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: 01/07/2023]
Abstract
OBJECTIVE To determine the effect of operative versus nonoperative management of emergency general surgery conditions on short-term and long-term outcomes. BACKGROUND Many emergency general surgery conditions can be managed either operatively or nonoperatively, but high-quality evidence to guide management decisions is scarce. METHODS We included 507,677 Medicare patients treated for an emergency general surgery condition between July 1, 2015, and June 30, 2018. Operative management was compared with nonoperative management using a preference-based instrumental variable analysis and near-far matching to minimize selection bias and unmeasured confounding. Outcomes were mortality, complications, and readmissions. RESULTS For hepatopancreaticobiliary conditions, operative management was associated with lower risk of mortality at 30 days [-2.6% (95% confidence interval: -4.0, -1.3)], 90 days [-4.7% (-6.50, -2.8)], and 180 days [-6.4% (-8.5, -4.2)]. Among 56,582 intestinal obstruction patients, operative management was associated with a higher risk of inpatient mortality [2.8% (0.7, 4.9)] but no significant difference thereafter. For upper gastrointestinal conditions, operative management was associated with a 9.7% higher risk of in-hospital mortality (6.4, 13.1), which increased over time. There was a 6.9% higher risk of inpatient mortality (3.6, 10.2) with operative management for colorectal conditions, which increased over time. For general abdominal conditions, operative management was associated with 12.2% increased risk of inpatient mortality (8.7, 15.8). This effect was attenuated at 30 days [8.5% (3.8, 13.2)] and nonsignificant thereafter. CONCLUSIONS The effect of operative emergency general surgery management varied across conditions and over time. For colorectal and upper gastrointestinal conditions, outcomes are superior with nonoperative management, whereas surgery is favored for patients with hepatopancreaticobiliary conditions. For obstructions and general abdominal conditions, results were equivalent overall. These findings may support patients, clinicians, and families making these challenging decisions.
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Affiliation(s)
- Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania
| | - Luke J. Keele
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Christopher J. Wirtalla
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Claire B. Rosen
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Sanford E. Roberts
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Catherine L. Mavroudis
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
| | - Patrick M. Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania
| | - Daniel N. Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Center for Surgery and Health Economics, University of Pennsylvania Perelman School of Medicine, The Leonard Davis Institute of Health Economics, The University of Pennsylvania
| | - Matthew D. McHugh
- Department of Biobehavioral Health Sciences and Center for Health Outcomes and Policy Research, The University of Pennsylvania School of Nursing
| | - Dylan Small
- Department of Statistics and Data Science, The Wharton School, The University of Pennsylvania
| | - Rachel R. Kelz
- Department of Surgery, Center for Surgery and Health Economics, The University of Pennsylvania Perelman School of Medicine
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Degli Esposti M, Goldstick J, Gravel J, Kaufman EJ, Delgado MK, Richmond TS, Wiebe DJ. How have firearm laws changed in states with unexpected decreases or increases in firearm homicide, 1990-2019? SSM Popul Health 2023; 22:101364. [PMID: 36941896 PMCID: PMC10024039 DOI: 10.1016/j.ssmph.2023.101364] [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: 12/25/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
Background Firearm violence is one of the leading preventable causes of death and injury in the United States and is on the rise. While policies regulating access to firearms offer opportunities to prevent firearm-related deaths, an understanding of the holistic impact of changing state firearm policies on firearm homicide rates over the last 30 years is limited. Objectives To identify US states that showed unexpected decreases and increases in firearm homicide rates and summarise their firearm policy changes in the last three decades. Methods We analysed changes in firearm homicide rates by US state and county from 1990 to 2019. We triangulated across three estimation approaches to derive state rankings and identify the top and bottom three states which consistently showed unexpected decreases (low outliers) and increases (high outliers) in firearm homicide rates. We summarised firearm policy changes in state outliers using the RAND State Firearm Law Database. Results We identified New York, District of Columbia, and Hawaii as low state outliers and Delaware, New Jersey, and Missouri as high state outliers. Low state outliers made more restrictive firearm policy changes than high state outliers, which covered a wider range of policy types. Restrictive changes in high state outliers primarily targeted high-risk populations (e.g., prohibited possessors, safe storage). Specific legislative details, such as the age threshold (18 vs 21 years old) for firearm minimum age requirements, also emerged as important for differentiating low from high state outliers. Conclusions While no firearm law change emerged as necessary or sufficient, an accumulation of diverse restrictive firearm policies may be key to alleviating the death toll from firearm homicide.
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Affiliation(s)
- Michelle Degli Esposti
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, USA
- University of Michigan Institute for Firearm Injury Prevention, University of Michigan, Ann Arbor, USA
- Corresponding author.
| | - Jason Goldstick
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, USA
- University of Michigan Institute for Firearm Injury Prevention, University of Michigan, Ann Arbor, USA
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, USA
| | - Jason Gravel
- Department of Criminal Justice, Temple University, Philadelphia, PA, USA
| | - Elinore J. Kaufman
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, USA
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - M. Kit Delgado
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, USA
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Therese S. Richmond
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, USA
- Biobehavioral Health Sciences Department, University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Douglas J. Wiebe
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, USA
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, USA
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
- University of Michigan Institute for Firearm Injury Prevention, University of Michigan, Ann Arbor, USA
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Finn CB, Sharpe JE, Tong JK, Kaufman EJ, Wachtel H, Aarons CB, Weissman GE, Kelz RR. Development of a Machine Learning Model to Identify Colorectal Cancer Stage in Medicare Claims. JCO Clin Cancer Inform 2023; 7:e2300003. [PMID: 37257142 PMCID: PMC10530805 DOI: 10.1200/cci.23.00003] [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: 01/13/2023] [Revised: 03/21/2023] [Accepted: 04/04/2023] [Indexed: 06/02/2023] Open
Abstract
PURPOSE Staging information is essential for colorectal cancer research. Medicare claims are an important source of population-level data but currently lack oncologic stage. We aimed to develop a claims-based model to identify stage at diagnosis in patients with colorectal cancer. METHODS We included patients age 66 years or older with colorectal cancer in the SEER-Medicare registry. Using patients diagnosed from 2014 to 2016, we developed models (multinomial logistic regression, elastic net regression, and random forest) to classify patients into stage I-II, III, or IV on the basis of demographics, diagnoses, and treatment utilization identified in Medicare claims. Models developed in a training cohort (2014-2016) were applied to a testing cohort (2017), and performance was evaluated using cancer stage listed in the SEER registry as the reference standard. RESULTS The cohort of patients with 30,543 colorectal cancer included 14,935 (48.9%) patients with stage I-II, 9,203 (30.1%) with stage III, and 6,405 (21%) with stage IV disease. A claims-based model using elastic net regression had a scaled Brier score (SBS) of 0.45 (95% CI, 0.43 to 0.46). Performance was strongest for classifying stage IV (SBS, 0.62; 95% CI, 0.59 to 0.64; sensitivity, 93%; 95% CI, 91 to 94) followed by stage I-II (SBS, 0.45; 95% CI, 0.44 to 0.47; sensitivity, 86%; 95% CI, 85 to 76) and stage III (SBS, 0.32; 95% CI, 0.30 to 0.33; sensitivity, 62%; 95% CI, 61 to 64). CONCLUSION Machine learning models effectively classified colorectal cancer stage using Medicare claims. These models extend the ability of claims-based research to risk-adjust and stratify by stage.
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Affiliation(s)
- Caitlin B. Finn
- Department of Surgery, Weill Cornell Medicine, New York, NY
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - James E. Sharpe
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Jason K. Tong
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Elinore J. Kaufman
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Heather Wachtel
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Cary B. Aarons
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Gary E. Weissman
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Rachel R. Kelz
- Department of Surgery, Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
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Ratnasekera AM, Kim D, Seng SS, Jacovides C, Kaufman EJ, Sadek HM, Perea LL, Monaco C, Shnaydman I, Jeongyoon Lee A, Sharp V, Miciura A, Trevizo E, Rosenthal M, Lottenberg L, Zhao W, Keininger A, Hunt M, Cull J, Balentine C, Egodage T, Mohamed A, Kincaid M, Doris S, Cotterman R, Seegert S, Jacobson LE, Williams J, Whitmill M, Palmer B, Mentzer C, Tackett N, Hranjec T, Dougherty T, Morrissey S, Donatelli-Seyler L, Rushing A, Tatebe LC, Nevill TJ, Aboutanos MB, Hamilton D, Redmond D, Cullinane DC, Falank C, McMellen M, Duran C, Daniels J, Ballow S, Schuster K, Ferrada P. Early VTE Prophylaxis in Severe Traumatic Brain Injury: A Propensity Score Weighted EAST Multi-Center Study. J Trauma Acute Care Surg 2023:01586154-990000000-00329. [PMID: 37017458 DOI: 10.1097/ta.0000000000003985] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Patients with TBI are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS A retrospective review of adult patients ≥18 years of age with isolated severe TBI (AIS ≥ 3) who were admitted to 24 level 1 and level 2 trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic & clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE & ICHE with patient group as predictor of interest. RESULTS Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared to those in VTEP≤24 ( [OR] = 1.51; [95%CI] = 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared to VTEP≤24 (OR = 0.75; 95%CI = 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSIONS In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE level III, Therapeutic Care Management.
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Kaufman EJ, Richmond TS, Hoskins K. Youth Firearm Injury: A Review for Pediatric Critical Care Clinicians. Crit Care Clin 2023; 39:357-371. [PMID: 36898779 PMCID: PMC9662754 DOI: 10.1016/j.ccc.2022.09.010] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Firearms are now the leading cause of death among youth in the United States, with rates of homicide and suicide rising even more steeply during the SARS-CoV-2 pandemic. These injuries and deaths have wide-ranging consequences for the physical and emotional health of youth and families. While pediatric critical care clinicians must treat the injured survivors, they can also play a role in prevention by understanding the risks and consequences of firearm injuries; taking a trauma-informed approach to the care of injured youth; counseling patients and families on firearm access; and advocating for youth safety policy and programming.
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, MOB Suite 120, 51 North 39th Street, Philadelphia, PA 19104, USA
| | - Therese S Richmond
- University of Pennsylvania School of Nursing, Fagin Hall 330, 418 Curie Boulevard, Philadelphia, PA 19104, USA.
| | - Katelin Hoskins
- University of Pennsylvania School of Nursing, Fagin Hall 312, 418 Curie Boulevard, Philadelphia, PA 19104, USA
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Hornor MA, Blank JJ, Hatchimonji JS, Bailey JA, Jacovides CL, Reilly PM, Cannon JW, Holena DN, Seamon MJ, Kaufman EJ. Higher center volume is significantly associated with lower mortality in trauma patients with shock. Injury 2023; 54:1400-1405. [PMID: 37005134 DOI: 10.1016/j.injury.2023.03.013] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/16/2023] [Accepted: 03/06/2023] [Indexed: 04/04/2023]
Abstract
INTRODUCTION Injured patients presenting in shock are at high risk of mortality despite numerous efforts to improve resuscitation. Identifying differences in outcomes among centers for this population could yield insights to improve performance. We hypothesized that trauma centers treating higher volumes of patients in shock would have lower risk-adjusted mortality. METHODS We queried the Pennsylvania Trauma Outcomes Study from 2016 to 2018 for injured patients ≥16 years of age at Level I&II trauma centers who had an initial systolic blood pressure (SBP) of <90 mmHg. We excluded patients with critical head injury (abbreviated injury score [AIS] head ≥5) and patients coming from centers with a shock patient volume of ≤10 for the study period. The primary exposure was tertile of center-level shock patient volume (low, medium, or high volume). We compared risk-adjusted mortality by tertile of volume using multivariable Cox proportional hazards model incorporating age, injury severity, mechanism, and physiology. RESULTS Of 1,805 included patients at 29 centers, 915 (50.7%) died. The median annual shock trauma patient volume was 9 patients for low volume centers, medium 19.5, and high 37. Median ISS was higher at high volume compared to low volume centers (22 vs 18, p <0.001). Raw mortality was 54.9% at high volume centers, 46.7% for medium, and 42.9% for low. Time elapsed from arrival to emergency department (ED) to the operating room (OR) was lower at high volume than low volume centers (median 47 vs 78 min) p = 0.003. In adjusted analysis, hazard ratio for high volume centers (referenced to low volume) was 0.76 (95% CI 0.59-0.97, p = 0.030). CONCLUSION After adjusting for patient physiology and injury characteristics, center-level volume is significantly associated with mortality. Future studies should seek to identify key practices associated with improved outcomes in high-volume centers. Furthermore, shock patient volume should be considered when new trauma centers are opened.
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Affiliation(s)
- Melissa A Hornor
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jacqueline J Blank
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Joanelle A Bailey
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christina L Jacovides
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jeremy W Cannon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Daniel N Holena
- Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Mark J Seamon
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Kaufman EJ, Khatri U, Hall EC, Alur R, Song J, Beard JH, Jacoby SF. Law enforcement in the trauma bay: a survey of members of the American Academy for the Surgery of Trauma. Trauma Surg Acute Care Open 2023; 8:e001022. [PMID: 36937171 PMCID: PMC10016311 DOI: 10.1136/tsaco-2022-001022] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Abstract
Background Trauma patients frequently come into contact with law enforcement officers (LEOs) during the course of their medical care, but little is known about how LEO presence affects processes of care. We surveyed members of the American Association for the Surgery of Trauma (AAST) to assess their perspectives on frequency, circumstances, and implications of LEO presence in trauma bays nationwide. Methods Survey items addressed respondents' experience with the frequency and context of LEO presence and their perspectives on the impact of LEO presence for patients, clinical care, and public safety. Respondent demographics, professional characteristics, and practice setting were collected. The survey was distributed electronically to AAST members in September and October of 2020. Responses were compared by participant age, gender, race, ethnicity, urban versus rural location using χ2 tests. Results Of 234 respondents, 189 (80.7%) were attending surgeons, 169 (72.2%) identified as white, and 144 (61.5%) as male. 187 respondents (79.9%) observed LEO presence at least weekly. Respondents found LEO presence was most helpful for public safety, followed by clinical care, and then for patients. Older respondents rated LEO presence as helpful more often than younger respondents regarding the impact on patients, clinical care, and public safety (p<0.001 across all domains). When determining LEO access, respondents assessed severity of the patient's condition, the safety of emergency department staff, the safety of LEOs, and a patient's potential role as a threat to public safety. Conclusions Respondents described a wide range of perspectives on the impact and consequence of LEO in the trauma bay, with little policy to guide interactions. The overlap of law enforcement and healthcare in the trauma bay deserves attention from institutional and professional policymakers to preserve patient safety and autonomy and patient-centered care. Level of evidence IV, survey study.
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Affiliation(s)
- Elinore J Kaufman
- Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Utsha Khatri
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York, USA
| | - Erin C Hall
- Department of Surgery, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Rucha Alur
- Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jamie Song
- Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jessica H Beard
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara F Jacoby
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Esposti MD, Kaufman EJ. Can suicide risk be predicted to plan for prevention? Lancet Public Health 2023; 8:e162-e163. [PMID: 36702143 DOI: 10.1016/s2468-2667(22)00339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/05/2022] [Indexed: 01/25/2023]
Affiliation(s)
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Kaufman EJ, Delgado MK. Tracking All Injuries From Firearms in the US-Reply. JAMA 2023; 329:514-515. [PMID: 36786792 DOI: 10.1001/jama.2022.22000] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Affiliation(s)
- Elinore J Kaufman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - M Kit Delgado
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Haddad DN, Kaufman EJ. Rising Rates of Homicide of Children and Adolescents: Preventable and Unacceptable. JAMA Pediatr 2023; 177:117-119. [PMID: 36534406 DOI: 10.1001/jamapediatrics.2022.4946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Diane N Haddad
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Kester L, Holena DN, Hynes AM, Kaufman EJ, Brahmbhatt T, Sanchez S, Byrne JP, Dechert T, Seamon M, Scantling DR. Preventing the most common firearm deaths: Modifiable factors related to firearm suicide. Surgery 2023; 173:544-552. [PMID: 36396492 DOI: 10.1016/j.surg.2022.10.012] [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: 07/10/2022] [Revised: 09/21/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND More than 20,000 firearm suicides occur every year in America. Firearm restrictive legislation, firearm access, demographics, behavior, access to care, and socioeconomic metrics have been correlated to firearm suicide rates. Research to date has largely evaluated these contributors singularly. We aimed to evaluate them together as they exist in society. We hypothesized that state firearm laws would be associated with reduced firearm suicide rates. METHODS We acquired the 2013 to 2016 data for firearm suicide rates from The Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research. Firearm laws were obtained from the State Firearms Law Database. Depression rates and access to care were obtained from the Behavioral Risk Factor Surveillance System and Occupational Employment and Wage Statistics program. Population demographics, poverty, and access to social support were obtained from the American Community Survey. Firearm access estimates were retrieved from the National Instant Criminal Background Check System. We used a univariate panel linear regression with fixed effect for state and firearm suicide rates as the outcome. We created a final multivariable model to determine the adjusted associations of these factors with firearm suicide rates. RESULTS In univariate analysis, firearm access, heavy drinking behavior, demographics, and access to care correlated to increased firearm suicide rates. The state proportion identifying as white and the proportion of those in poverty receiving food benefits correlated to decreased firearm suicide rates. In multivariable regression, only heavy drinking (β, 0.290; 95% confidence interval, 0.092-0.481; P = .004) correlated to firearm suicides rates increases. CONCLUSIONS During our study, few firearm laws changed. Heavy drinking behavior association with firearm suicide rates suggests an opportunity for interventions exists in the health care setting.
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Affiliation(s)
- Louis Kester
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/lou_was
| | - Daniel N Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin Department of Surgery, Milwaukee, WI. https://twitter.com/daniel_holena
| | - Allyson M Hynes
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, NM. https://twitter.com/elinorejkaufman
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania Department of Surgery, Philadelphia, PA
| | - Tejal Brahmbhatt
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/tejalsb
| | - Sabrina Sanchez
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/sesanchezmd
| | - James P Byrne
- Division of Traumatology, Johns Hopkins Hospital, Surgical Critical Care and Emergency Surgery, Baltimore, MD. https://twitter.com/dctrjbyrne
| | - Tracey Dechert
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA. https://twitter.com/traceydechert
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, The University of Pennsylvania Department of Surgery, Philadelphia, PA. https://twitter.com/markseamonmd
| | - Dane R Scantling
- Division of Trauma and Acute Care Surgery, The Boston University School of Medicine/Boston Medical Center, MA.
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Karnick AT, Bond AE, Kaufman EJ, Anestis MD, Capron DW. Injury characteristics and circumstances of firearm trauma: Assessing suicide survivors and decedents. Suicide Life Threat Behav 2022; 52:1217-1225. [PMID: 36056539 DOI: 10.1111/sltb.12916] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/25/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Despite representing fewer than 5% of suicide attempts, firearms account for over half of deaths. Yet there is little clinical information regarding firearm attempts, particularly survivors. We assessed clinical factors differentiating firearm suicide survivors from decedents, firearm attempters from other methods, and firearm attempters from similarly injured trauma patients. METHODS We used clinical data from the National Trauma Data Bank (2017) to assess firearm suicide attempts using cross-sectional and case-control designs. We used logistic and multinomial regression to compare groups and assess firearm type and discharge destination. RESULTS Older age, being uninsured, and injury location were associated with increased mortality among firearm attempters. Older age, White race, male sex, and being uninsured were associated with firearm attempts. Major psychiatric disorders were associated with firearm attempts and using a rifle or shotgun. Major psychiatric disorders, female sex, and smoking were associated with psychiatric discharge. Black and other race were associated with law enforcement discharge, and Black race was associated with lower odds of psychiatric discharge. Uninsured patients had lower odds of discharge to long-term care, psychiatric, or rehabilitation facilities. CONCLUSIONS This study identifies factors associated with firearm suicide and includes indicators of disparities in health services for patients at high risk of suicide death.
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Affiliation(s)
- Aleksandr T Karnick
- Department of Psychology, University of Southern Mississippi, Hattiesburg, Mississippi, USA
| | - Allison E Bond
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA.,New Jersey Gun Violence Research Center, Piscataway, New Jersey, USA
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael D Anestis
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA.,New Jersey Gun Violence Research Center, Piscataway, New Jersey, USA
| | - Daniel W Capron
- Department of Psychology, University of Southern Mississippi, Hattiesburg, Mississippi, USA
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Hatchimonji JS, Holena DN, Xiong R, Scantling DR, Hornor MA, Dowzicky PM, Reilly PM, Kaufman EJ. The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania. Surgery 2022; 173:1289-1295. [PMID: 36517291 DOI: 10.1016/j.surg.2022.11.014] [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: 07/19/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Daniel N Holena
- Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, WI. https://twitter.com/Daniel_Holena
| | - Ruiying Xiong
- Department of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/AriaXiong
| | - Dane R Scantling
- Section of Acute Care and Trauma Surgery, Boston University School of Medicine, MA. https://twitter.com/Dane_Scantling
| | - Melissa A Hornor
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/HornorMD
| | - Phillip M Dowzicky
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/PDowzicky
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/reillyp648
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/ElinoreJKaufman
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Roberts SE, Rosen CB, Keele LJ, Wirtalla CJ, Syvyk S, Kaufman EJ, Reilly PM, Neuman MD, McHugh MD, Kelz RR. Rates of Surgical Consultations After Emergency Department Admission in Black and White Medicare Patients. JAMA Surg 2022; 157:1097-1104. [PMID: 36223108 PMCID: PMC9558057 DOI: 10.1001/jamasurg.2022.4959] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/16/2022] [Indexed: 01/11/2023]
Abstract
Importance A surgical consultation is a critical first step in the care of patients with emergency general surgery conditions. It is unknown if Black Medicare patients and White Medicare patients receive surgical consultations at similar rates when they are admitted from the emergency department. Objective To determine whether Black Medicare patients have similar rates of surgical consultations when compared with White Medicare patients after being admitted from the emergency department with an emergency general surgery condition. Design, Setting, and Participants This was a retrospective cohort study that took place at US hospitals with an emergency department and used a computational generalization of inverse propensity score weight to create patient populations with similar covariate distributions. Participants were Medicare patients age 65.5 years or older admitted from the emergency department for an emergency general surgery condition between July 1, 2015, and June 30, 2018. The analysis was performed during February 2022. Patients were classified into 1 of 5 emergency general surgery condition categories based on principal diagnosis codes: colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, and upper gastrointestinal. Exposures Black vs White race. Main Outcomes and Measures Receipt of a surgical consultation after admission from the emergency department with an emergency general surgery condition. Results A total of 1 686 940 patients were included in the study. Of those included, 214 788 patients were Black (12.7%) and 1 472 152 patients were White (87.3%). After standardizing for medical and diagnostic imaging covariates, Black patients had 14% lower odds of receiving a surgical consultation (odds ratio [OR], 0.86; 95% CI, 0.85-0.87) with a risk difference of -3.17 (95% CI, -3.41 to -2.92). After standardizing for socioeconomic covariates, Black patients remained at an 11% lower odds of receiving a surgical consultation compared with similar White patients (OR, 0.89; 95% CI, 0.88-0.90) with a risk difference of -2.49 (95% CI, -2.75 to -2.23). Additionally, when restricting the analysis to Black patients and White patients who were treated in the same hospitals, Black patients had 8% lower odds of receiving a surgical consultation when compared with White patients (OR, 0.92; 95% CI, 0.90-0.93) with a risk difference of -1.82 (95% CI, -2.18 to -1.46). Conclusions and Relevance In this study, Black Medicare patients had lower odds of receiving a surgical consultation after being admitted from the emergency department with an emergency general surgery condition when compared with similar White Medicare patients. These disparities in consultation rates cannot be fully attributed to medical comorbidities, insurance status, socioeconomic factors, or individual hospital-level effects.
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Affiliation(s)
- Sanford E. Roberts
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Claire B. Rosen
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Luke J. Keele
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Christopher J. Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Solomiya Syvyk
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Elinore J. Kaufman
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Patrick M. Reilly
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia
| | - Mark D. Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia
| | - Matthew D. McHugh
- Center for Health Outcomes & Policy Research, School of Nursing, University of Pennsylvania, Philadelphia
| | - Rachel R. Kelz
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia
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Roberts SE, Rosen CB, Wirtalla CJ, Finn CB, Kaufman EJ, Reilly PM, Syvyk S, McHugh MD, Kelz RR. Examining disparities among older multimorbid emergency general surgery patients: An observational study of Medicare beneficiaries. Am J Surg 2022; 225:1074-1080. [DOI: 10.1016/j.amjsurg.2022.11.026] [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] [Received: 08/01/2022] [Revised: 10/26/2022] [Accepted: 11/19/2022] [Indexed: 11/22/2022]
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Rosen CB, Roberts SE, Wirtalla CJ, Ramadan OI, Keele LJ, Kaufman EJ, Halpern SD, Kelz RR. Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study. J Am Coll Surg 2022; 235:724-735. [PMID: 36250697 PMCID: PMC9583235 DOI: 10.1097/xcs.0000000000000303] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. STUDY DESIGN Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. RESULTS Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001). CONCLUSIONS Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.
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Affiliation(s)
- Claire B Rosen
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Chris J Wirtalla
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
| | - Luke J Keele
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Elinore J Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | - Scott D Halpern
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
- Department of Medicine, Hospital of the University of Pennsylvania; Philadelphia, PA
| | - Rachel R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania; Philadelphia, PA
- The Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
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Abstract
This Viewpoint summarizes current data on firearm injuries in the US, discusses the limitations of available data sources, and proposes measures for a comprehensive system to track firearm injury and death
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Affiliation(s)
- Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, Penn Injury Science Center, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - M Kit Delgado
- Departments of Emergency Medicine and Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, Penn Injury Science Center, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Rosen CB, Wirtalla C, Keele LJ, Roberts SE, Kaufman EJ, Holena DN, Halpern SD, Kelz RR. Multimorbidity Confers Greater Risk for Older Patients in Emergency General Surgery Than the Presence of Multiple Comorbidities: A Retrospective Observational Study. Med Care 2022; 60:616-622. [PMID: 35640050 PMCID: PMC9262850 DOI: 10.1097/mlr.0000000000001733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/13/2023]
Abstract
BACKGROUND Little is known about the impact of multimorbidity on outcomes for older emergency general surgery patients. OBJECTIVE The aim was to understand whether having multiple comorbidities confers the same amount of risk as specific combinations of comorbidities (multimorbidity) for a patient undergoing emergency general surgery. RESEARCH DESIGN Retrospective observational study using state discharge data. SUBJECTS Medicare beneficiaries who underwent an operation for an emergency general surgery condition in New York, Florida, or Pennsylvania (2012-2013). MEASURES Patients were classified as multimorbid using Qualifying Comorbidity Sets (QCSs). Outcomes included in-hospital mortality, hospital length of stay and discharge status. RESULTS Of 312,160 patients, a large minority (37.4%) were multimorbid. Non-QCS patients did not have a specific combination of comorbidities to satisfy a QCS, but 64.1% of these patients had 3+ comorbid conditions. Multimorbidity was associated with increased in-hospital mortality (10.5% vs. 3.9%, P <0.001), decreased rates of discharge to home (16.2% vs. 37.1%, P <0.001), and longer length of stay (10.4 d±13.5 vs. 6.7 d±9.3, P <0.001) when compared with non-QCS patients. Risks varied between individual QCSs. CONCLUSIONS Multimorbidity, defined by satisfying a specific QCS, is strongly associated with poor outcomes for older patients requiring emergency general surgery in the United States. Variation in risk of in-hospital mortality, discharge status, and length of stay between individual QCSs suggests that multimorbidity does not carry the same prognostic weight as having multiple comorbidities-the specifics of which are important in setting expectations for individual, complex patients.
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Affiliation(s)
- Claire B. Rosen
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Chris Wirtalla
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Luke J. Keele
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Sanford E. Roberts
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Elinore J. Kaufman
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Daniel N. Holena
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
| | - Scott D. Halpern
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Department of Medicine, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
| | - Rachel R. Kelz
- Department of Surgery, Hospital of the University of Pennsylvania; 3400 Spruce Street, Philadelphia, PA 19104
- Perelman School of Medicine; 3400 Civic Center Blvd, Philadelphia, PA 19104
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Alur R, Hall E, Khatri U, Jacoby S, South E, Kaufman EJ. Law Enforcement in the Emergency Department. JAMA Surg 2022; 157:852-854. [PMID: 35857315 DOI: 10.1001/jamasurg.2022.2595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Rucha Alur
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erin Hall
- Surgical Intensive Care Unit, MedStar Washington Hospital Center, Washington, DC
| | - Utsha Khatri
- Emergency Medicine, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
| | - Sara Jacoby
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia
| | - Eugenia South
- Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadephia
| | - Elinore J Kaufman
- Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Fouché TW, Zakrison TL, Schneider JA, Kaufman EJ, Plackett TP, Velopulos C, Slidell MB, Voisin D, Hampton DA, Carmichael HE, Valdés DM, Parker C, Ross B, Chaudhary M, Cirone J. Demographic and Regional Factors Associated With Reporting Homicides of Transgender People in the United States. J Surg Res 2022; 279:72-76. [PMID: 35724545 DOI: 10.1016/j.jss.2022.05.029] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/17/2022] [Accepted: 05/21/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The American Medical Association recently declared homicides of transgender individuals an epidemic. However, transgender homicide victims are often classified as nontransgender. Our objective was to describe existing data and coding of trans (i.e., transgender) victims and to examine the risk factors for homicides of trans people relative to nontrans people across the United States. METHODS A retrospective review of the Centers for Disease Control and Prevention's National Violent Death Reporting System for the years 2003-2018 identified victims defined as transgender either through the "transgender" variable or narrative reports. Fisher's exact tests and logistic regression models were run to compare the demographics of trans victims to those not identified as trans. RESULTS Of the 147 transgender victims identified, 14.4% were incorrectly coded as nontrans despite clear indication of trans status in the narrative description, and 6% were coded as hate crimes. Relative to nontrans victims, trans victims were more frequently Black (54.4% versus 40.7%, P = 0.001), had a mental health condition (26.5% versus 11.3%, P < 0.001), or reported being a sex worker (9.5% versus 0.2%, P < 0.001). There were disproportionately few homicides of transgender people in the South (13.6% of trans victims versus 29.1% of nontrans victims, P < 0.001). Conversely, the West and Midwest accounted for a higher-than-expected proportion of trans victims relative to nontrans victims (23.1% of trans victims versus 16.2% of nontrans victims, P = 0.03; 24.5% of trans victims versus 16.8% of nontrans victims, P = 0.02, respectively). CONCLUSIONS Though the murder of transgender individuals is a known public health crisis, inconsistencies still exist in the assessment and reporting of transgender status. Further, these individuals were more likely to have multiple distinct vulnerabilities. These findings provide important information for injury and violence prevention researchers to improve reporting of transgender status in the medical record and local trauma registries.
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Affiliation(s)
- Tom W Fouché
- University of Chicago Pritzker School of Medicine, Chicago, Illinois.
| | | | - John A Schneider
- University of Chicago Center for HIV Elimination, Chicago, Illinois
| | - Elinore J Kaufman
- University of Pennsylvania, Traumatology, Surgical Critical Care, & Emergency Surgery, Chicago, Illinois
| | | | | | - Mark B Slidell
- University of Chicago, Pediatric Surgery, Chicago, Illinois
| | - Dexter Voisin
- Case Western Reserve University Mandel School of Applied Social Sciences, Cleveland, Ohio
| | | | | | - Davel M Valdés
- University Hospital General Calixto Garcia, La Habana, Cuba
| | | | | | - Mihir Chaudhary
- University of California San Francisco, Department of Surgery, San Francisco, California
| | - Justin Cirone
- Dartmouth-Hitchcock Medical Center, New Hampshire, Lebanon
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Degli Esposti M, Gravel J, Kaufman EJ, Delgado MK, Richmond TS, Wiebe DJ. County-Level Variation in Changes in Firearm Mortality Rates Across the US, 1989 to 1993 vs 2015 to 2019. JAMA Netw Open 2022; 5:e2215557. [PMID: 35666501 PMCID: PMC9171565 DOI: 10.1001/jamanetworkopen.2022.15557] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Firearm violence remains a critical public health challenge, disproportionately impacting some US regions. County-level variation may hold key insights into how firearm mortality rates vary across the US. OBJECTIVE To model county-level changes in firearm mortality rates (total, homicide, and suicide) from 1989 to 1993 vs 2015 to 2019 and identify and characterize hot spots showing unexpected changes over time. DESIGN, SETTING, AND PARTICIPANTS This is a cross-sectional study with 2 time points using a novel small area estimation method to analyze restricted access mortality microdata by cause of death and US county. The analysis included 3111 US counties from 49 states and the District of Columbia from January 1, 1989, to December 31, 2019. Bayesian spatial models were fitted to map geographical variation in changes in age-standardized firearm mortality rates (per 100 000 person-years) from 1989 to 1993 vs 2015 to 2019. County outliers (or hot spots) were defined as having observed rates that fell outside the 95% credible intervals of their expected posterior predictive distribution. These counties were characterized using visualization and descriptive statistics of their characteristics. Data were analyzed from June to December 2021. EXPOSURES County of residence. MAIN OUTCOMES AND MEASURES Five-year age-standardized mortality rates by US county, age, and cause of death for 1989 to 1993 and 2015 to 2019. RESULTS Between 1989 and 2019, 1 036 518 firearm deaths were recorded in counties across the US. Suicide was the most common cause of firearm mortality (589 285 deaths) followed by homicide (412 231 deaths). Age-standardized rates (deaths per 100 000 individuals) for firearm deaths and suicides increased from 1989 to 1993 vs 2015 to 2019 (mean [SD] change, 0.16 [8.78] for firearm deaths and 1.21 [6.91] for suicides), while firearm homicides decreased (mean [SD] change, -0.39 [3.96]). However, these national trends were not homogeneous across counties and often varied by geographical region. The West and Midwest showed the most pronounced increases in firearm suicide rates, whereas the Southeast showed localized increases in firearm homicide rates, despite the national decreasing trend. Critical hot spots were identified in urban counties of Alabama, and firearm homicide rates (per 100 000) in Baltimore City, Maryland, almost doubled from 29.71 to 47.43, and by 2015 to 2019 it accounted for 66.7% of all firearm homicide in Maryland. By contrast, District of Columbia showed promising improvements over time, decreasing from 56.5 firearm homicides per 100 000 in 1989 to 1993 to 14.45 in 2015 to 2019. CONCLUSIONS AND RELEVANCE There was substantial variation in rates and changes in firearm deaths among US counties. Geographical hot spots may be useful to inform targeted prevention efforts and local policy responses.
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Affiliation(s)
- Michelle Degli Esposti
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
- Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
| | - Jason Gravel
- Department of Criminal Justice, Temple University, Philadelphia, Pennsylvania
| | - Elinore J. Kaufman
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - M. Kit Delgado
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Therese S. Richmond
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
- Biobehavioral Health Sciences Department, University of Pennsylvania School of Nursing, Philadelphia
| | - Douglas J. Wiebe
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Chaiyachati KH, Beidas RS, Lane-Fall MB, Rendle KA, Shelton RC, Kaufman EJ. Weaving Equity into the Fabric of Medical Research. J Gen Intern Med 2022; 37:2067-2069. [PMID: 35233707 PMCID: PMC8887658 DOI: 10.1007/s11606-022-07450-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/01/2022] [Indexed: 11/25/2022]
Affiliation(s)
| | - Rinad S Beidas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Meghan B Lane-Fall
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Katharine A Rendle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Elinore J Kaufman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Bailey JA, Jacoby SF, Hall EC, Khatri U, Whitehorn G, Kaufman EJ. Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury. Curr Trauma Rep 2022; 8:105-112. [PMID: 35578594 PMCID: PMC9096065 DOI: 10.1007/s40719-022-00231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/24/2022]
Abstract
Purpose of Review
Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care. Recent Findings Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential. Summary A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.
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Affiliation(s)
- Joanelle A. Bailey
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Sara F. Jacoby
- University of Pennsylvania School of Nursing, Philadelphia, PA USA
| | - Erin C. Hall
- Trauma Surgery and Critical Care Medicine, MedStar Health, Washington, DC USA
| | - Utsha Khatri
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Gregory Whitehorn
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
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Afif IN, Gobaud AN, Morrison CN, Jacoby SF, Maher Z, Dauer ED, Kaufman EJ, Santora TA, Anderson JH, Pathak A, Sjoholm LO, Goldberg AJ, Beard JH. The changing epidemiology of interpersonal firearm violence during the COVID-19 pandemic in Philadelphia, PA. Prev Med 2022; 158:107020. [PMID: 35301043 PMCID: PMC8920109 DOI: 10.1016/j.ypmed.2022.107020] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/26/2022] [Accepted: 03/08/2022] [Indexed: 11/29/2022]
Abstract
Recent increases in firearm violence in U.S. cities are well-documented, however dynamic changes in the people, places and intensity of this public health threat during the COVID-19 pandemic are relatively unexplored. This descriptive epidemiologic study spanning from January 1, 2015 - March 31, 2021 utilizes the Philadelphia Police Department's registry of shooting victims, a database which includes all individuals shot and/or killed due to interpersonal firearm violence in the city of Philadelphia. We compared victim and event characteristics prior to the pandemic with those following implementation of pandemic containment measures. In this study, containment began on March 16, 2020, when non-essential businesses were ordered to close in Philadelphia. There were 331 (SE = 13.9) individuals shot/quarter pre-containment vs. 545 (SE = 66.4) individuals shot/quarter post-containment (p = 0.031). Post-containment, the proportion of women shot increased by 39% (95% CI: 1.21, 1.59), and the proportion of children shot increased by 17% (95% CI: 1.00, 1.35). Black women and children were more likely to be shot post-containment (RR 1.11, 95% CI: 1.02, 1.20 and RR 1.08, 95% CI: 1.03, 1.14, respectively). The proportion of mass shootings (≥4 individuals shot within 100 m within 1 h) increased by 53% post-containment (95% CI: 1.25, 1.88). Geographic analysis revealed relative increases in all shootings and mass shootings in specific city locations post-containment. The observed changes in firearm injury epidemiology following COVID-19 containment in Philadelphia demonstrate an intensification in firearm violence, which is increasingly impacting people who are likely made more vulnerable by existing social and structural disadvantage. These findings support existing knowledge about structural causes of interpersonal firearm violence and suggest structural solutions are required to address this public health threat.
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Affiliation(s)
- Iman N Afif
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Ariana N Gobaud
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Christopher N Morrison
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Sara F Jacoby
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Zoë Maher
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Elizabeth D Dauer
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Thomas A Santora
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Jeffrey H Anderson
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Abhijit Pathak
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Lars Ola Sjoholm
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Amy J Goldberg
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Jessica H Beard
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA.
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de Angelis P, Kaufman EJ, Barie PS, Leahy NE, Winchell RJ, Narayan M. Disparities in Insurance Status are Associated With Outcomes But Not Timing of Trauma Care. J Surg Res 2022; 273:233-246. [PMID: 35144053 DOI: 10.1016/j.jss.2021.12.034] [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: 03/31/2021] [Revised: 10/19/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Patient factors influence outcomes after injury. Delays in care have a crucial impact. We investigated the associations between patient characteristics and timing of transfer from the emergency department to definitive care. METHODS This was a review of adult trauma patients treated between January 1, 2016, and December 31, 2018. Bivariate analyses were used to build Cox proportional hazards models. We built separate logistic and negative binomial regression models for secondary outcomes using mixed-step selection to minimize the Akaike information criterion c. RESULTS A total of 1219 patients were included; 68.5% were male, 56.8% White, 11.2% Black, and 7.8% Asian/Pacific Islander. The average age was 51 ± 21 y. Overall, 13.7% of patients were uninsured. The average length of stay was 5 d and mortality was 5.9%. Shorter transfer time out of the emergency department was associated with higher tier of activation (relative risk [RR] 1.39, 95% confidence interval [CI] 1.09-1.77; P = 0.0074), Injury Severity Score between 16 and 24 points (RR 1.57, 95% CI 1.04-2.32; P = 0.0307) or ≥25 (RR 3.85, 95% CI 2.45-5.94; P = 0.0001), and penetrating injury. Longer time to event was associated with Glasgow coma scale score ≥14 points (RR 0.47, 95% CI 0.27-0.85; P = 0.0141). Uninsured patients were less likely to be admitted (odds ratio 0.29, 95% CI 0.17-0.48; P = 0.0001) and more likely to experience shorter length of stay (incidence rate ratio 0.34, 95% CI 0.24-0.51; P = 0.0001). CONCLUSIONS Injury characteristics and insurance status were associated with patient outcomes in this retrospective, single-center study. We found no disparity in timing of intrafacility transfer, perhaps indicating that initial management protocols preserve equity.
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Affiliation(s)
- Paolo de Angelis
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York.
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Department of Surgery, Penn Medicine, Philadelphia, Pennsylvania
| | - Philip S Barie
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Nicole E Leahy
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
| | - Robert J Winchell
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York; Division of Medical Ethics, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mayur Narayan
- Division of Trauma, Burns, Acute and Critical Care, Department of Surgery, Weill Cornell Medicine, New York, New York
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Garcia Whitlock AE, Hatchimonji JS, Babalola D, Candido K, Seamon MJ, Kaufman EJ. Patient Reported Outcomes in Trauma and the Impact of the COVID-19 Pandemic. J Am Coll Surg 2021. [PMCID: PMC8531682 DOI: 10.1016/j.jamcollsurg.2021.07.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Kaufman EJ, Holena D, Koenig G, Martin ND, Maish GO, Moran BJ, Ratnasekera A, Stawicki SP, Timinski M, Brown J. Increase in Motor Vehicle Crash Severity: An Unforeseen Consequence of COVID-19. Am Surg 2021:31348211047466. [PMID: 34645324 PMCID: PMC8524247 DOI: 10.1177/00031348211047466] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The 2019 coronavirus (COVID-19) pandemic led to stay-at-home (SAH) orders in Pennsylvania targeted at reducing viral transmission. Limitations in population mobility under SAH have been associated with decreased motor vehicle collisions (MVC) and related injuries, but the impact of these measures on severity of injury remains unknown. The goal of this study is to measure the incidence, severity, and outcomes of MVC-related injuries associated with SAH in Pennsylvania. MATERIALS & METHODS We conducted a retrospective geospatial analysis of MVCs during the early COVID-19 pandemic using a state-wide trauma registry. We compared characteristics of patients with MVC-related injuries admitted to Pennsylvania trauma centers during SAH measures (March 21-July 31, 2020) with those from the corresponding periods in 2018 and 2019. We also compared incidence of MVCs for each zip code tabulation area (ZCTA) in Pennsylvania for the same time periods using geospatial mapping. RESULTS Of 15,550 trauma patients treated during the SAH measures, 3486 (22.4%) resulted from MVCs. Compared to preceding years, MVC incidence decreased 10% under SAH measures with no change in mortality rate. However, in ZCTA where MVC incidence decreased, there was a 16% increase in MVC injury severity. CONCLUSIONS Stay-at-home orders issued in response to the COVID-19 pandemic in Pennsylvania were associated with significant changes in MVC incidence and severity. Identifying such changes may inform resource allocation decisions during future pandemics or SAH events.
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Affiliation(s)
- Elinore J Kaufman
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Holena
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - George Koenig
- 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Niels D Martin
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, 6572University of Pennsylvania, Philadelphia, PA, USA
| | - George O Maish
- Division of Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA, USA
| | | | | | - Stanislaw P Stawicki
- Department of Research & Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | | | - Joshua Brown
- Division of Trauma and General Surgery, Department of Surgery, 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Kaufman EJ, Ong AW, Cipolle MD, Whitehorn G, Ratnasekera A, Stawicki SP, Martin ND. The impact of COVID-19 infection on outcomes after injury in a state trauma system. J Trauma Acute Care Surg 2021; 91:559-565. [PMID: 34074996 DOI: 10.1097/ta.0000000000003310] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 02/06/2023]
Abstract
BACKGROUND The COVID-19 pandemic reshaped the health care system in 2020. COVID-19 infection has been associated with poor outcomes after orthopedic surgery and elective, general surgery, but the impact of COVID-19 on outcomes after trauma is unknown. METHODS We conducted a retrospective cohort study of patients admitted to Pennsylvania trauma centers from March 21 to July 31, 2020. The exposure of interest was COVID-19 (COV+) and the primary outcome was inpatient mortality. Secondary outcomes were length of stay and complications. We compared demographic and injury characteristics between positive, negative, and not-tested patients. We used multivariable regression with coarsened exact matching to estimate the impact of COV+ on outcomes. RESULTS Of 15,550 included patients, 8,170 (52.5%) were tested for COVID-19 and 219 (2.7%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in terms of age and sex, but were less often white (53.5% vs. 74.7%, p < 0.0001), and more often uninsured (10.1 vs. 5.6%, p = 0.002). Injury severity was similar, but firearm injuries accounted for 11.9% of COV+ patients versus 5.1% of COV- patients (p < 0.001). Unadjusted mortality for COV+ was double that of COV- patients (9.1% vs. 4.7%, p < 0.0001) and length of stay was longer (median, 5 vs. 4 days; p < 0.001). Using coarsened exact matching, COV+ patients had an increased risk of death (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.29-15.99), any complication (OR, 1.85; 95% CI, 1.08-3.16), and pulmonary complications (OR, 5.79; 95% CI, 2.02-16.54) compared with COV- patients. CONCLUSION Patients with concomitant traumatic injury and COVID-19 infection have elevated risks of morbidity and mortality. Trauma centers must incorporate an understanding of these risks into patient and family counseling and resource allocation during this pandemic. LEVEL OF EVIDENCE Level II, Prognostic Study.
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Affiliation(s)
- Elinore J Kaufman
- From the Division of Traumatology, Surgical Critical Care, and Emergency Surgery (E.J.K.), University of Pennsylvania, Philadelphia; Department of Surgery (A.W.O.), Reading Hospital and Medical Center, Reading; Division of Trauma and Acute Care Surgery (M.D.C.), Lehigh Valley Health Network, Allentown; Department of Surgery (G.W.), University of Pennsylvania, Philadelphia; Department of Surgery (A.R.), Crozer-Chester Medical Center Upland; Department of Research & Innovation (S.P.S.), St. Luke's University Health Network, Bethlehem; and Division of Traumatology, Surgical Critical Care, and Emergency Surgery (N.D.M.), University of Pennsylvania, Philadelphia, Pennsylvania
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