Systematic Literature Review of Health-Related Quality-of-Life Measures for Caregivers of Older Adult Trauma Patients

INTRODUCTION

As the older adult population increases, hospitals treat more older adults with injuries. After leaving, these patients suffer from decreased mobility and independence, relying on care from others. Family members often assume this responsibility, mostly informally and unpaid. Caregivers of other older adult populations have increased stress and decreased caregiver-related quality of life (CRQoL). Validated CRQoL measures are essential to capture their unique experiences. Our objective was to review existing CRQoL measures and their validity in caregivers of older adult trauma patients.

METHODS

A professional librarian searched published literature from the inception of databases through August 12, 2022 in MEDLINE (via PubMed), Embase (via Elsevier), and CINAHL Complete (via EBSCO). We identified 1063 unique studies of CRQoL in caregivers for adults with injury and performed a systematic review following COnsensus-based Standards for the selection of health Measurement Instruments guidelines for CRQoL measures.

RESULTS

From the 66 studies included, we identified 54 health-related quality-of-life measures and 60 domains capturing caregiver-centered concerns. The majority (83%) of measures included six or fewer CRQoL content domains. Six measures were used in caregivers of older adults with single-system injuries. There were no validated CRQoL measures among caregivers of older adult trauma patients with multisystem injuries.

CONCLUSIONS

While many measures exist to assess healthcare-related quality of life, few, if any, adequately assess concerns among caregivers of older adult trauma patients. We found that CRQoL domains, including mental health, emotional health, social functioning, and relationships, are most commonly assessed among caregivers. Future measures should focus on reliability and validity in this specific population to guide interventions.

Outcomes by time-to-OR for penetrating abdominal trauma patients

INTRODUCTION

Time-To-OR is a critical process measure for trauma performance. However, this measure has not consistently demonstrated improvement in outcome.

STUDY DESIGN

Using TQIP, we identified facilities by 75th percentile time-to-OR to categorize slow, average, and fast hospitals. Using a GEE model, we calculated odds of mortality for all penetrating abdominal trauma patients, firearm injuries only, and patients with major complication by facility speed. We additionally estimated odds of mortality at the patient level.

RESULTS

Odds of mortality for patients at slow facilities was 1.095; 95% CI: 0.746, 1.608; p = 0.64 compared to average. Fast facility OR = 0.941; 95% CI: 0.780, 1.133; p = 0.52. At the patient-level each additional minute of time-to-OR was associated with 1.5% decreased odds of in-hospital mortality (OR 0.985; 95% CI:0.981, 0.989; p < 0.001). For firearm-only patients, facility speed was not associated with odds of in-hospital mortality (p-value = 0.61). Person-level time-to-OR was associated with 1.8% decreased odds of in-hospital mortality (OR 0.982; 95% CI: 0.977, 0.987; p < 0.001) with each additional minute of time-to-OR. Similarly, failure-to-rescue analysis showed no difference in in-hospital mortality at the patient level (p = 0.62) and 0.4% decreased odds of in-hospital mortality with each additional minute of time-to-OR at the patient level (OR 0.996; 95% CI: 0.993, 0.999; p = 0.004).

CONCLUSION

Despite the use of time-to-OR as a metric of trauma performance, there is little evidence for improvement in mortality or complication rate with improved time-to-OR at the facility or patient level. Performance metrics for trauma should be developed that more appropriately approximate patient outcome.

Where Are the Children? A Thematic Analysis of State, Territory, and Tribal Organization Comprehensive Cancer Control Plans

BACKGROUND

The Center for Disease Control's Comprehensive Cancer Control Program (CCCP) funds initiatives in fifty states, the District of Columbia, seven U.S. territories, and seven tribal organizations to prevent and control cancer. These initiatives influence policy, care, research, and advocacy for cancer treatment. We performed an analysis of CCCP plans for states, U.S. territories, and tribal organizations to understand the extent of inclusion of pediatric cancer care.

METHODS

We conducted a thematic and quantitative analysis of CCCP plans for states, U.S. territories, and tribal organizations. Plans were assessed by two reviewers and scored for discussion of cancer prevention, risk factors, early detection and screening, treatment and innovation, access, barriers to care, and survivorship in childhood cancer.

RESULTS

Plans from fifty states, the District of Columbia, seven territories, seven tribal organizations, and one Pacific Regional (USAPI) plan were reviewed, for a total of sixty-six plans. Up-to-date CCCP plans were available through the CDC or state websites for 74% of states, 57% of territories, and 71% of tribal organizations; older plans were available for all groups without up-to-date CCCP plans. While all plans referenced children, most did so in the context of childhood exposures influencing adult cancer risks (e.g., sun, tobacco, HPV). Few plans contained a section dedicated to childhood cancer (30% states, 14.3% territories, 14.3% tribes). A minority of plans specifically discussed early detection and screening (14% states, 0% territories, 14.3% tribes), treatment and innovation (32% states, 0% territories, 28.6% tribes), access to cancer care (38% states, 28.6% territories, 28.6% tribes), reducing barriers to cancer care (28% states, 42.9% territories, 28.6% tribes), and pediatric cancer survivorship (42% states, 0% territories, 28.6% tribes).

CONCLUSIONS

Promoting inclusion of pediatric cancer in CCPs will help to standardize pediatric cancer care, eliminate treatment disparities across state lines, and allow for comprehensive understanding of pediatric oncology.

LEVEL OF EVIDENCE

Level IV.

Going beyond the means: Exploring the role of bias from digital determinants of health in technologies

BACKGROUND

In light of recent retrospective studies revealing evidence of disparities in access to medical technology and of bias in measurements, this narrative review assesses digital determinants of health (DDoH) in both technologies and medical formulae that demonstrate either evidence of bias or suboptimal performance, identifies potential mechanisms behind such bias, and proposes potential methods or avenues that can guide future efforts to address these disparities.

APPROACH

Mechanisms are broadly grouped into physical and biological biases (e.g., pulse oximetry, non-contact infrared thermometry [NCIT]), interaction of human factors and cultural practices (e.g., electroencephalography [EEG]), and interpretation bias (e.g, pulmonary function tests [PFT], optical coherence tomography [OCT], and Humphrey visual field [HVF] testing). This review scope specifically excludes technologies incorporating artificial intelligence and machine learning. For each technology, we identify both clinical and research recommendations.

CONCLUSIONS

Many of the DDoH mechanisms encountered in medical technologies and formulae result in lower accuracy or lower validity when applied to patients outside the initial scope of development or validation. Our clinical recommendations caution clinical users in completely trusting result validity and suggest correlating with other measurement modalities robust to the DDoH mechanism (e.g., arterial blood gas for pulse oximetry, core temperatures for NCIT). Our research recommendations suggest not only increasing diversity in development and validation, but also awareness in the modalities of diversity required (e.g., skin pigmentation for pulse oximetry but skin pigmentation and sex/hormonal variation for NCIT). By increasing diversity that better reflects patients in all scenarios of use, we can mitigate DDoH mechanisms and increase trust and validity in clinical practice and research.

The impact of hypertonic saline on damage control laparotomy after penetrating abdominal trauma

PURPOSE

The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements.

METHODS

We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30 mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72 h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey's comparison, and student's t, and Fischer's exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution.

RESULTS

Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37 h ± 14.21 vs 59.05 h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24 h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48 h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72 h, peak sodium (Na) concentration (146.2 mEq/L ± 2.94 vs 142.8 mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1 mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days.

CONCLUSIONS

HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm.

LEVEL OF EVIDENCE

Level III.

Lipid emulsions in parenteral nutrition: does it matter?

PURPOSE OF REVIEW

Recently, clinicians have shown interest in switching patients to nonsoybean-based intravenous lipid emulsion (ILE) formulas for parental nutrition (PN) due to adverse outcomes related to high Omega-6 content in soybean oil (SO) ILE's. This review summarizes recent literature on improved clinical outcomes with new Omega-6 lipid-sparing ILE's in PN management.

RECENT FINDINGS

Although there is a paucity of large-scale studies directly comparing Omega-6 lipid sparing ILE's with SO-based lipid emulsion use in PN in ICU patients, there is strong translational and meta-analysis evidence to suggest that lipid formulations containing fish oil (FO) and/or olive oil (OO) have favorable effects on immune function and improve clinical outcomes in ICU populations.

SUMMARY

More research is needed to directly compare omega-6-sparing PN formulas with FO and/or OO versus traditional SO ILE's. However, current evidence is promising for improved outcomes using newer ILE's including reduced infections, shorter lengths of stay, and reduced costs.

Risk of Surgical Intervention in Children with Diagnoses of Cancer and Preoperative Malnutrition: A National Analysis

BACKGROUND

Perioperative nutrition is a critical component of appropriate healing and recovery after surgery. We sought to identify perioperative risk in children with cancer and low preoperative hypoalbuminemia undergoing surgical intervention.

METHODS

We queried the 2015-2019 NSQIP-Peds datasets for children with a primary diagnosis of renal or hepatic malignancy undergoing surgical resection. Postoperative outcomes were evaluated for comparative risk between patients with low albumin (albumin<3.0 g/dL) and normal albumin within 30 days of their surgical procedure. Univariate analysis and multivariable logistic regression were conducted to identify perioperative risk in patients with hypoalbuminemia.

RESULTS

We identified 360 children with primary diagnosis of hepatic malignancy and 896 children with renal malignancy undergoing surgical resection. Of these, 77 children had hypoalbuminemia. Patients with renal or hepatic malignancy diagnosis and low albumin levels were more likely to experience postoperative dehiscence, need for TPN at discharge, postoperative bleeding or transfusion, unplanned reoperation, and unplanned readmission, based on univariate analysis (all P > 0.05). Postoperative bleeding, need for nutritional support at discharge, and unplanned readmission were each associated with hypoalbuminemia.

CONCLUSION

We demonstrate that low preoperative albumin is associated with significant perioperative risk. More attention should focus on perioperative nutritional status of children with cancer who are undergoing major resections.

Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma

BACKGROUND

The kidney is the most frequently injured component of the genitourinary system, accounting for 5% of all trauma cases. Several guidelines by different societies address the management of urological trauma. However, unanswered questions remain regarding optimal use of angioembolization in hemodynamically stable patients, indications for operative exploration of stable retroperitoneal hematomas and renal salvage techniques in the setting of hemodynamic instability, and imaging practices for patients undergoing non-operative management. We performed a systematic review, meta-analysis, and developed evidence-based recommendations to answer these questions in both blunt and penetrating renal trauma.

METHODS

The working group formulated four population, intervention, comparator, outcome (PICO) questions regarding the following topics: (1) angioembolization (AE) usage in hemodynamically stable patients with evidence of ongoing bleeding; (2) surgical approach to stable zone II hematomas (exploration vs. no exploration) in hemodynamically unstable patients and (3) surgical technique (nephrectomy vs. kidney preservation) for expanding zone II hematomas in hemodynamically unstable patients; (4) frequency of repeat imaging (routine or symptom based) in high-grade traumatic renal injuries. A systematic review and meta-analysis of currently available evidence was performed. RevMan 5 (Cochran Collaboration) and GRADEpro (Grade Working Group) software were used. Recommendations were voted on by working group members and concurrence was obtained for each final recommendation.

RESULTS

A total of 20 articles were identified and analyzed. Two prospective studies were encountered; the majority were retrospective, single-institution studies. Not all outcomes projected by PICO questions were reported in all studies. Meta-analysis was performed for all PICO questions except PICO 3 secondary to the discrepant patient populations included in those studies. PICO 1 had the greatest number of articles included in the meta-analysis with nine studies; yet, due to differences in study design, no critical outcomes emerged; similar differences among a smaller set of articles prevented observation of critical outcomes for PICO 4. Analyses of PICOs 2 and 3 favored a non-invasive or minimally invasive approach in-line with current international practice trends.

CONCLUSION

In hemodynamically stable adult patients with clinical or radiographic evidence of ongoing bleeding, no recommendation could be made regarding the role of AE vs. observation. In hemodynamically unstable adult patients, we conditionally recommend no renal exploration vs. renal exploration in stable zone II hematomas. In hemodynamically unstable adult patients, we conditionally recommend kidney preserving techniques vs. nephrectomy in expanding zone II hematomas. No recommendation could be made for the optimal timing of repeat imaging in high grade renal injury.

LEVEL OF EVIDENCE

Guideline; systematic review, level III.

Trajectories of Palliative Care Needs in the ICU and Long-Term Psychological Distress Symptoms

OBJECTIVES

While palliative care needs are assumed to improve during ICU care, few empiric data exist on need trajectories or their impact on long-term outcomes. We aimed to describe trajectories of palliative care needs during ICU care and to determine if changes in needs over 1 week was associated with similar changes in psychological distress symptoms at 3 months.

DESIGN

Prospective cohort study.

SETTING

Six adult medical and surgical ICUs.

PARTICIPANTS

Patients receiving mechanical ventilation for greater than or equal to 2 days and their family members.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the 13-item Needs at the End-of-Life Screening Tool (NEST; total score range 0-130) completed by family members at baseline, 3, and 7 days. The Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Post-Traumatic Stress Scale (PTSS) were completed at baseline and 3 months. General linear models were used to estimate differences in distress symptoms by change in need (NEST improvement ≥ 10 points or not). One-hundred fifty-nine family members participated (median age, 54.0 yr [interquartile range (IQR), 44.0-63.0 yr], 125 [78.6%] female, 54 [34.0%] African American). At 7 days, 53 (33%) a serious level of overall need and 35 (22%) ranked greater than or equal to 1 individual need at the highest severity level. NEST scores improved greater than or equal to 10 points in only 47 (30%). Median NEST scores were 22 (IQR, 12-40) at baseline and 19 (IQR, 9-37) at 7 days (change, -2.0; IQR, -11.0 to 5.0; p = 0.12). There were no differences in PHQ-9, GAD-7, or PTSS change scores by change in NEST score (all p > 0.15).

CONCLUSIONS

Serious palliative care needs were common and persistent among families during ICU care. Improvement in needs was not associated with less psychological distress at 3 months. Serious needs may be commonly underrecognized in current practice.

Vaccination after spleen embolization: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Angioembolization is an important adjunct in the non-operative management of adult trauma patients with splenic injury. Multiple studies have shown that angioembolization may increase the non-operative splenic salvage rate for patients with high-grade splenic injuries. We performed a systematic review and developed evidence-based recommendations regarding the need for post-splenectomy vaccinations after splenic embolization in trauma patients.

METHODS

A systematic review and meta-analysis of currently available evidence were performed utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

Nine studies were identified and analyzed. A total of 240 embolization patients were compared to 443 control patients who neither underwent splenectomy nor were embolized. There was no statistical difference between the splenic immune function of embolized and control patients. In addition, a total of 3974 splenectomy patients was compared with 686 embolization patients. Embolization patients had fewer infectious complications and a greater degree of preserved splenic immune function.

CONCLUSION

In adult trauma patients who have undergone splenic angioembolization, we conditionally recommend against routine post-splenectomy vaccinations.

STUDY TYPE

systematic review/meta-analysis Level of evidence: level III.

Palliative care phenotypes among critically ill patients and family members: intensive care unit prospective cohort study

OBJECTIVE

Because the heterogeneity of patients in intensive care units (ICUs) and family members represents a challenge to palliative care delivery, we aimed to determine if distinct phenotypes of palliative care needs exist.

METHODS

Prospective cohort study conducted among family members of adult patients undergoing mechanical ventilation in six medical and surgical ICUs. The primary outcome was palliative care need measured by the Needs at the End-of-Life Screening Tool (NEST, range from 0 (no need) to 130 (highest need)) completed 3 days after ICU admission. We also assessed quality of communication, clinician-family relationship and patient centredness of care. Latent class analysis of the NEST's 13 items was used to identify groups with similar patterns of serious palliative care needs.

RESULTS

Among 257 family members, latent class analysis yielded a four-class model including complex communication needs (n=26, 10%; median NEST score 68.0), family spiritual and cultural needs (n=21, 8%; 40.0) and patient and family stress needs (n=43, 31%; 31.0), as well as a fourth group with fewer serious needs (n=167, 65%; 14.0). Interclass differences existed in quality of communication (median range 4.0-10.0, p<0.001), favourable clinician-family relationship (range 34.6%-98.2%, p<0.001) and both the patient centredness of care Eliciting Concerns (median range 4.0-5.0, p<0.001) and Decision-Making (median range 2.3-4.5, p<0.001) scales.

CONCLUSIONS

Four novel phenotypes of palliative care need were identified among ICU family members with distinct differences in the severity of needs and perceived quality of the clinician-family interaction. Knowledge of need class may help to inform the development of more person-centred models of ICU-based palliative care.

Racial and Ethnic Differences in the Prevalence of Do-Not-Resuscitate Orders among Older Adults with Severe Traumatic Brain Injury

Background

Older adults suffering from traumatic brain injury (TBI) are subject to higher injury burden and mortality. Do Not Resuscitate (DNR) orders are used to provide care aligned with patient wishes, but they may not be equitably distributed across racial/ethnic groups. We examined racial/ethnic differences in the prevalence of DNR orders at hospital admission in older patients with severe TBI.

Methods

We conducted a retrospective cohort study using the National Trauma Databank (NTDB) between 2007 to 2016. We examined patients ≥ 65 years with severe TBI. For our primary aim, the exposure was race/ethnicity and outcome was the presence of a documented DNR at hospital admission. We conducted an exploratory analysis of hospital outcomes including hospital mortality, discharge to hospice, and healthcare utilization (intracranial pressure monitor placement, hospital LOS, and duration of mechanical ventilation).

Results

Compared to White patients, Black patients (OR 0.48, 95% CI 0.35-0.64), Hispanic patients (OR 0.54, 95% CI 0.40-0.70), and Asian patients (OR 0.63, 95% CI 0.44-0.90) had decreased odds of having a DNR order at hospital admission. Patients with DNRs had increased odds of hospital mortality (OR 2.16, 95% CI 1.94-2.42), discharge to hospice (OR 2.08, 95% CI 1.75-2.46), shorter hospital LOS (−2.07 days, 95% CI −3.07 to −1.08) and duration of mechanical ventilation (−1.09 days, 95% CI −1.52 to −0.67). There was no significant difference in the utilization of ICP monitoring (OR 0.94, 95% CI 0.78-1.12).

Conclusions

We found significant racial and ethnic differences in the utilization of DNR orders among older patients with severe TBI. Additionally. DNR orders at hospital admission were associated with increased in-hospital mortality, increased hospice utilization, and decreased healthcare utilization. Future studies should examine mechanisms underlying race-based differences in DNR utilization.

Improving mortality in older adult trauma patients: Are we doing better?

BACKGROUND

Older adult trauma is associated with high morbidity and mortality. Individuals older than 65 years are expected to make up more than 21% of the total population and almost 39% of trauma admissions by 2050. Our objective was to perform a national review of older adult trauma mortality and identify associated risk factors to highlight potential areas for improvement in quality of care.

MATERIALS AND METHODS

This is a retrospective cohort study of the National Trauma Data Bank including all patients age ≥65 years with at least one International Classification of Diseases, Ninth Revision, Clinical Modification trauma code admitted to a Level I or II US trauma center between 2007 and 2015. Variables examined included demographics, comorbidities, emergency department vitals, injury characteristics, and trauma center characteristics. Multilevel mixed-effect logistic regression was performed to identify independent risk factors of in-hospital mortality.

RESULTS

There were 1,492,759 patients included in this study. The number of older adult trauma patients increased from 88,056 in 2007 to 158,929 in 2015 (p > 0.001). Adjusted in-hospital mortality decreased in 2014 to 2015 (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.86-0.91) when compared with 2007 to 2009. Admission to a university hospital was protective (OR, 0.83; 95% CI, 0.74-0.93) as compared with a community hospital admission. There was no difference in mortality risk between Level II and Level I admission (OR, 1.00; 95% CI, 0.92-1.08). The strongest trauma-related risk factor for in-patient mortality was pancreas/bowel injury (OR, 2.25; 95% CI, 2.04-2.49).

CONCLUSION

Mortality in older trauma patients is decreasing over time, indicating an improvement in the quality of trauma care. The outcomes of university based hospitals can be used as national benchmarks to guide quality metrics.

LEVEL OF EVIDENCE

Therapeutic/Care Management, Level IV.

Acute Care Resource Use After Elective Surgery in the United States: Implications During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic created pressure to delay inpatient elective surgery to increase US health care capacity. This study examined the extent to which common inpatient elective operations consume acute care resources.

METHODS

This cross-sectional study used the Premier Healthcare Database to examine the distribution of inpatient elective operations in the United States from the fourth quarter of 2015 through the second quarter of 2018. Primary outcomes were measures of acute care use after 4 common elective operations: joint replacement, spinal fusion, bariatric surgery, and coronary artery bypass grafting. A framework for matching changing demand with changes in supply was created by overlaying acute care data with publicly available outbreak capacity data.

RESULTS

Elective coronary artery bypass grafting (n = 117 423) had the highest acute care use: 92.8% of patients used intensive care unit beds, 89.1% required postoperative mechanical ventilation, 41.0% required red blood cell transfusions, and 13.3% were readmitted within 90 days of surgery. Acute care use was also substantial after spinal fusion (n = 203 789): 8.3% of patients used intensive care unit beds, 2.2% required postoperative mechanical ventilation, 9.2% required red blood cell transfusions, and 9.3% were readmitted within 90 days of surgery. An example of a framework for matching hospital demand with elective surgery supply is provided.

CONCLUSIONS

Acute care needs after elective surgery in the United States are consistent and predictable. When these data are overlaid with national hospital capacity models, rational decisions regarding matching supply to demand can be achieved to meet changing needs.

Acute Respiratory Distress Syndrome (ARDS) after trauma: Improving incidence, but increasing mortality

PURPOSE

Acute Respiratory Distress Syndrome (ARDS) is an infrequent, yet morbid inflammatory complication in injury victims. With the current project we sought to estimate trends in incidence, determine outcomes, and identify risk factors for ARDS and related mortality.

MATERIALS & METHODS

The national Trauma Quality Improvement Program dataset (2010-2014) was queried. Demographics, injury characteristics and outcomes were compared between patients who developed ARDS and those who did not. Logistic regression models were fitted for the development of ARDS and mortality respectively, adjusting for relevant confounders.

RESULTS

In the studied 808,195 TQIP patients, incidence of ARDS decreased over the study years (3-1.1%, p < 0.001), but related mortality increased (18.-21%, p = 0.001). ARDS patients spent an additional 14.7 ± 10.3 days in the hospital, 9.7 ± 7.9 in the ICU, and 6.6 ± 9.4 on mechanical ventilation (all p < 0.001). Older age, male gender, African American race increased risk for ARDS. Age, male gender, lower GCS and higher ISS also increased mortality risk among ARDS patients. Several pre-existing comorbidities including chronic alcohol use, diabetes, smoking, and respiratory disease also increased risk.

CONCLUSION

Although the incidence of ARDS after trauma appears to be declining, mortality is on the rise.

Improving racial disparities in unmet palliative care needs among intensive care unit family members with a needs-targeted app intervention: The ICUconnect randomized clinical trial

INTRODUCTION

The technologies used to treat the millions who receive care in intensive care unit (ICUs) each year have steadily advanced. However, the quality of ICU-based communication has remained suboptimal, particularly concerning for Black patients and their family members. Therefore we developed a mobile app intervention for ICU clinicians and family members called ICUconnect that assists with delivering need-based care.

OBJECTIVE

To describe the methods and early experiences of a clustered randomized clinical trial (RCT) being conducted to compare ICUconnect vs. usual care.

METHODS AND ANALYSIS

The goal of this two-arm, parallel group clustered RCT is to determine the clinical impact of the ICUconnect intervention in improving outcomes overall and for each racial subgroup on reducing racial disparities in core palliative care outcomes over a 3-month follow up period. ICU attending physicians are randomized to either ICUconnect or usual care, with outcomes obtained from family members of ICU patients. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 3 days post-randomization. Secondary outcomes include goal concordance of care and interpersonal processes of care at 3 days post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use hierarchical linear models to compare outcomes between the ICUconnect and usual care arms within all participants and assess for differential intervention effects in Blacks and Whites by adding a patient-race interaction term. We hypothesize that both compared to usual care as well as among Blacks compared to Whites, ICUconnect will reduce unmet palliative care needs, psychological distress and healthcare resource utilization while improving goal concordance and interpersonal processes of care. In this manuscript, we also describe steps taken to adapt the ICUconnect intervention to the COVID-19 pandemic healthcare setting.

ENROLLMENT STATUS

A total of 36 (90%) of 40 ICU physicians have been randomized and 83 (52%) of 160 patient-family dyads have been enrolled to date. Enrollment will continue until the end of 2021.

Point-Counterpoint: Indirect Calorimetry Is Essential for Optimal Nutrition Therapy in the Intensive Care Unit

Iatrogenic malnutrition and underfeeding are ubiquitous in intensive care units (ICUs) worldwide for prolonged periods after ICU admission. A major driver leading to the lack of emphasis on timely ICU nutrition delivery is lack of objective data to guide nutrition care. If we are to ultimately overcome current fundamental challenges to effective ICU nutrition delivery, we must all adopt routine objective, longitudinal measurement of energy targets via indirect calorimetry (IC). Key evidence supporting the routine use of IC in the ICU includes (1) universal societal ICU nutrition guidelines recommending IC to determine energy requirements; (2) data showing predictive equations or body weight calculations that are consistently inaccurate and correlate poorly with measured energy expenditure, ultimately leading to routine overfeeding and underfeeding, which are both associated with poor ICU outcomes; (3) recent development and worldwide availability of a new validated, accurate, easy-to-use IC device; and (4) recent data in ICU patients with coronavirus disease 2019 (COVID-19) showing progressive hypermetabolism throughout ICU stay, emphasizing the inaccuracy of predictive equations and marked day-to-day variability in nutrition needs. Thus, given the availability of a new validated IC device, these findings emphasize that routine longitudinal IC measures should be considered the new standard of care for ICU and post-ICU nutrition delivery. As we would not deliver vasopressors without accurate blood pressure measurements, the ICU community is only likely to embrace an increased focus on the importance of early nutrition delivery when we can consistently provide objective IC measures to ensure personalized nutrition care delivers the right nutrition dose, in the right patient, at the right time to optimize clinical outcomes.

IL-10 and class 1 histone deacetylases act synergistically and independently on the secretion of proinflammatory mediators in alveolar macrophages

Introduction

Anti-inflammatory cytokine IL-10 suppresses pro-inflammatory IL-12b expression after Lipopolysaccharide (LPS) stimulation in colonic macrophages, as part of the innate immunity Toll-Like Receptor (TLR)-NF-κB activation system. This homeostatic mechanism limits excess inflammation in the intestinal mucosa, as it constantly interacts with the gut flora. This effect is reversed with Histone Deacetylase 3 (HDAC3), a class I HDAC, siRNA, suggesting it is mediated through HDAC3. Given alveolar macrophages’ prominent role in Acute Lung Injury (ALI), we aim to determine whether a similar regulatory mechanism exists in the typically sterile pulmonary microenvironment.

Methods

Levels of mRNA and protein for IL-10, and IL-12b were determined by qPCR and ELISA/Western Blot respectively in naïve and LPS-stimulated alveolar macrophages. Expression of the NF-κB intermediaries was also similarly assessed. Experiments were repeated with AS101 (an IL-10 protein synthesis inhibitor), MS-275 (a selective class 1 HDAC inhibitor), or both.

Results

LPS stimulation upregulated all proinflammatory mediators assayed in this study. In the presence of LPS, inhibition of IL-10 and/or class 1 HDACs resulted in both synergistic and independent effects on these signaling molecules. Quantitative reverse-transcriptase PCR on key components of the TLR4 signaling cascade demonstrated significant diversity in IL-10 and related gene expression in the presence of LPS. Inhibition of IL-10 secretion and/or class 1 HDACs in the presence of LPS independently affected the transcription of MyD88, IRAK1, Rela and the NF-κB p50 subunit. Interestingly, by quantitative ELISA inhibition of IL-10 secretion and/or class 1 HDACs in the presence of LPS independently affected the secretion of not only IL-10, IL-12b, and TNFα, but also proinflammatory mediators CXCL2, IL-6, and MIF. These results suggest that IL-10 and class 1 HDAC activity regulate both independent and synergistic mechanisms of proinflammatory cytokine/chemokine signaling.

Conclusions

Alveolar macrophages after inflammatory stimulation upregulate both IL-10 and IL-12b production, in a highly class 1 HDAC-dependent manner. Class 1 HDACs appear to help maintain the balance between the pro- and anti-inflammatory IL-12b and IL-10 respectively. Class 1 HDACs may be considered as targets for the macrophage-initiated pulmonary inflammation in ALI in a preclinical setting.

Operationalizing needs-focused palliative care for older adults in intensive care units: Design of and rationale for the PCplanner randomized clinical trial

INTRODUCTION

The number of older adults who receive life support in an intensive care unit (ICU), now 2 million per year, is increasing while survival remains unchanged. Because the quality of ICU-based palliative care is highly variable, we developed a mobile app intervention that integrates into the electronic health records (EHR) system called PCplanner (Palliative Care planner) with the goal of improving collaborative primary and specialist palliative care delivery in ICU settings.

OBJECTIVE

To describe the methods of a randomized clinical trial (RCT) being conducted to compare PCplanner vs. usual care.

METHODS AND ANALYSIS

The goal of this two-arm, parallel group mixed methods RCT is to determine the clinical impact of the PCplanner intervention on outcomes of interest to patients, family members, clinicians, and policymakers over a 3-month follow up period. The primary outcome is change in unmet palliative care needs measured by the NEST instrument between baseline and 1 week post-randomization. Secondary outcomes include goal concordance of care, patient-centeredness of care, and quality of communication at 1 week post-randomization; length of stay; as well as symptoms of depression, anxiety, and post-traumatic stress disorder at 3 months post-randomization. We will use general linear models for repeated measures to compare outcomes across the main effects and interactions of the factors. We hypothesize that compared to usual care, PCplanner will have a greater impact on the quality of ICU-based palliative care delivery across domains of core palliative care needs, psychological distress, patient-centeredness, and healthcare resource utilization.

"I'm Leaving": Factors That Impact Against Medical Advice Disposition Post-Trauma

BACKGROUND

Discharge against medical advice (AMA) is an important, yet understudied, aspect of health care-particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs.

OBJECTIVE

The goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment.

METHODS

We performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status.

RESULTS

Uninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58-2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37-2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02-1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52-0.75), Asian (OR 0.59; 95% CI 0.49-0.69), and Hispanic (OR 0.80; 95% CI 0.75-0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury.

CONCLUSIONS

Insurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.

Fractured pediatric central venous catheters - Repair or replace?

INTRODUCTION

Central venous catheter (CVC) fracture is a common complication. The aim of this study is to examine risk factors resulting in CVC fracture and compare outcomes of children undergoing CVC repair versus replacement.

METHODS

A retrospective chart review was conducted from 2000 to 2016 for children with tunneled CVCs. Children with CVC fractures were compared to those without to identify risk factors resulting in fracture. Children with fractured CVCs were divided into repair or replacement treatment groups and outcomes compared. A logistic regression model determined independent predictors of CVC-associated bloodstream infections (CLABSI) after fracture.

RESULTS

In the 236 children with CVCs, the fracture rate was 29.2%. Fractured CVCs were more common with double lumen CVC (p = 0.040) and children whose indication was total parenteral nutrition (p = 0.003). Given children often underwent multiple repairs or replacements. 98 CVC repairs and 41 replacements were analyzed. CVC replacements had longer durability than repair (181.98 vs. 98.9 days, p = 0.038). There were no differences in CLABSI incidence for repair vs. replacement (OR 0.5 CI 0.05-4.97) after controlling for other factors.

CONCLUSIONS

CVC fracture is a frequent complication in children with tunneled CVCs. CVC repair has no increased incidence of CLABSI but eliminates the intraoperative and anesthetic risks of CVC replacement.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level III.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013-2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88-6.69) (OR: 11.24; 95% CI: 8.53-13.95), more time spent in ICU (2.73; 1.70-3.76) (7.98; 6.10-9.87), and increased risk for surgical site infection (1.32; 1.03-1.68) (2.54; 1.71-3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013–2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88–6.69) (OR: 11.24; 95% CI: 8.53–13.95), more time spent in ICU (2.73; 1.70–3.76) (7.98; 6.10–9.87), and increased risk for surgical site infection (1.32; 1.03–1.68) (2.54; 1.71–3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.

Using epistemic network analysis to identify targets for educational interventions in trauma team communication

BACKGROUND

Epistemic Network Analysis (ENA) is a technique for modeling and comparing the structure of connections between elements in coded data. We hypothesized that connections among team discourse elements as modeled by ENA would predict the quality of team performance in trauma simulation.

METHODS

The Modified Non-technical Skills Scale for Trauma (T-NOTECHS) was used to score a simulation-based trauma team resuscitation. Sixteen teams of 5 trainees participated. Dialogue was coded using Verbal Response Modes (VRM), a speech classification system. ENA was used to model the connections between VRM codes. ENA models of teams with lesser T-NOTECHS scores (n = 9, mean = 16.98, standard deviation [SD] = 1.45) were compared with models of teams with greater T-NOTECHS scores (n = 7, mean = 21.02, SD = 1.09).

RESULTS

Teams had different patterns of connections among VRM speech form codes with regard to connections among questions and edifications (meanHIGH = 0.115, meanLOW = -0.089; t = 2.21; P = .046, Cohen d = 1.021). Greater-scoring groups had stronger connections between stating information and providing acknowledgments, confirmation, or advising. Lesser-scoring groups had a stronger connection between asking questions and stating information. Discourse data suggest that this pattern reflected increased uncertainty. Lesser-scoring groups also had stronger connections from edifications to disclosures (revealing thoughts, feelings, and intentions) and interpretations (explaining, judging, and evaluating the behavior of others).

CONCLUSION

ENA is a novel and valid method to assess communication among trauma teams. Differences in communication among higher- and lower-performing teams appear to result from the ways teams use questions. ENA allowed us to identify targets for improvement related to the use of questions and stating information by team members.

Efficacy of motivational interviewing and cognitive behavioral therapy for anxiety and depression symptoms following traumatic brain injury

BACKGROUND

Anxiety and depression are common following traumatic brain injury (TBI), often co-occurring. This study evaluated the efficacy of a 9-week cognitive behavioral therapy (CBT) program in reducing anxiety and depression and whether a three-session motivational interviewing (MI) preparatory intervention increased treatment response.

METHOD

A randomized parallel three-group design was employed. Following diagnosis of anxiety and/or depression using the Structured Clinical Interview for DSM-IV, 75 participants with mild-severe TBI (mean age 42.2 years, mean post-traumatic amnesia 22 days) were randomly assigned to an Adapted CBT group: (1) MI + CBT (n = 26), or (2) non-directive counseling (NDC) + CBT (n = 26); or a (3) waitlist control (WC, n = 23) group. Groups did not differ in baseline demographics, injury severity, anxiety or depression. MI and CBT interventions were guided by manuals adapted for individuals with TBI. Three CBT booster sessions were provided at week 21 to intervention groups.

RESULTS

Using intention-to-treat analyses, random-effects regressions controlling for baseline scores revealed that Adapted CBT groups (MI + CBT and NDC + CBT) showed significantly greater reduction in anxiety on the Hospital Anxiety and Depression Scale [95% confidence interval (CI) -2.07 to -0.06] and depression on the Depression Anxiety and Stress Scale (95% CI -5.61 to -0.12) (primary outcomes), and greater gains in psychosocial functioning on Sydney Psychosocial Reintegration Scale (95% CI 0.04-3.69) (secondary outcome) over 30 weeks post-baseline relative to WC. The group receiving MI + CBT did not show greater gains than the group receiving NDC + CBT.

CONCLUSIONS

Findings suggest that modified CBT with booster sessions over extended periods may alleviate anxiety and depression following TBI.

Effects of obesity on health-related quality of life in juvenile-onset systemic lupus erythematosus

OBJECTIVE

This study evaluated the effects of obesity on health-related quality of life (HRQOL) measures in juvenile-onset systemic lupus erythematosus (jSLE).

METHODS

Obesity was defined as a body mass index (BMI) ≥ 95 th percentile according to the Sex-specific Center for Disease Control BMI-For-Age Charts and determined in a multicenter cohort of jSLE patients. In this secondary analysis, the domain and summary scores of the Pediatric Quality of Life (PedsQL) Inventory and the Child Health Questionnaire (CHQ) of obese jSLE patients were compared to those of non-obese jSLE patients as well as historical obese and non-obese healthy controls. Mixed-effects modeling was performed to evaluate the relationship between obesity and HRQOL measures.

RESULTS

Among the 202 jSLE patients, 25% (n = 51) were obese. Obesity had a significant negative impact on HRQOL in jSLE, even after adjusting for differences in current corticosteroid use, disease activity, disease damage, gender and race between groups. Obese jSLE patients had lower physical functioning compared to non-obese jSLE patients, and to non-obese and obese healthy controls. Compared to their non-obese counterparts, obese jSLE patients also had worse school functioning, more pain, worse social functioning and emotional functioning. Parents of obese jSLE patients worry more. The CHQ scores for obese jSLE patients were also worse compared to non-obese jSLE patients in several other domains.

CONCLUSION

Our study demonstrates the detrimental effects of obesity on patient-reported outcomes in jSLE. This supports the importance of weight management for the therapeutic plan of jSLE.

New high dielectric constant materials for tailoring the B1+ distribution at high magnetic fields

The spatial distribution of electromagnetic fields within the human body can be tailored using external dielectric materials. Here, we introduce a new material with high dielectric constant, and also low background MRI signal. The material is based upon metal titanates, which can be made into a geometrically-formable suspension in de-ionized water. The material properties of the suspension are characterized from 100 to 400 MHz. Results obtained at 7 T show a significant increase in image intensity in areas such as the temporal lobe and base of the brain with the new material placed around the head, and improved performance compared to purely water-based gels.

High Q calcium titanate cylindrical dielectric resonators for magnetic resonance microimaging

At high magnetic fields radiation losses, wavelength effects, self-resonance, and the high resistance of typical components all contribute to increased losses in conventional RF coil designs. High permittivity ceramic dielectric resonators create strong uniform magnetic fields in a compact structure at high frequencies and can potentially solve some of the challenges of high field coil design. In this study an NMR probe was constructed for operation at 600 MHz (14.1T) using an inductively fed CaTiO(3) (relative permittivity of 156) cylindrical hollow bore dielectric resonator. The design has an unmatched Q value greater than 2000, and the electric field is largely confined to the dielectric itself, with near zero values in the hollow bore which accommodates the sample. Experimental and simulation mapping of the RF field show good agreement, with the ceramic resonator giving a pulse width approximately 25% less than a loop gap resonator of similar inner dimensions. High resolution images, with voxel dimensions less than 50 microm(3), have been acquired from fixed zebrafish samples, showing excellent delineation of several fine structures.

GODIVA2: interactive visualization of environmental data on the Web

GODIVA2 is a dynamic website that provides visual access to several terabytes of physically distributed, four-dimensional environmental data. It allows users to explore large datasets interactively without the need to install new software or download and understand complex data. Through the use of open international standards, GODIVA2 maintains a high level of interoperability with third-party systems, allowing diverse datasets to be mutually compared. Scientists can use the system to search for features in large datasets and to diagnose the output from numerical simulations and data processing algorithms. Data providers around Europe have adopted GODIVA2 as an INSPIRE-compliant dynamic quick-view system for providing visual access to their data.

Running climate models on grids using G-Rex

Compute grids are used widely in many areas of environmental science, but there has been limited uptake of grid computing by the climate modelling community, partly because the characteristics of many climate models make them difficult to use with popular grid middleware systems. In particular, climate models usually produce large volumes of output data, and running them also involves complicated workflows implemented as shell scripts. A new grid middleware system that is well suited to climate modelling applications is presented in this paper. Grid Remote Execution (G-Rex) allows climate models to be deployed as Web services on remote computer systems and then launched and controlled as if they were running on the user's own computer. Output from the model is transferred back to the user while the run is in progress, to prevent it from accumulating on the remote system and to allow the user to monitor the model. G-Rex has a representational state transfer (REST) architectural style, featuring a Java client program that can easily be incorporated into existing scientific workflow scripts. Some technical details of G-Rex are presented, with examples of its use by climate modellers.

Morbidity of anastomotic leaks in patients undergoing Roux-en-Y gastric bypass

OBJECTIVE

To document the effect of anastomotic leaks on morbidity and mortality after Roux-en-Y gastric bypass (RYGB) for obesity.

DESIGN

Prospectively collected data on 840 consecutive patients who underwent RYGB between 1998 and 2005. Multivariate logistic regression analysis was used to determine the effect of anastomotic leaks on postoperative morbidity independent of sex, age, preoperative body mass index, access (open vs laparoscopic), calendar year of RYGB, and comorbidities. P < .05 was considered significant.

RESULTS

A total of 36 patients (4.3%) developed leaks after RYGB. Patients who developed anastomotic leaks had a significantly higher overall complication rate (61% vs 20%, P < .001), mortality (14% vs 4%, P = .01), and duration of hospital stay (24.5 vs 4.5 days, P < .001) compared with patients who did not develop leaks. In a multivariate logistic regression model, anastomotic leaks increased the likelihood of mortality (odds ratio [OR], 15; 95% confidence interval [CI], 3-80; P = .002) and overall complications (OR, 6; 95% CI, 3-13; P < .001), specifically sepsis (OR, 27; 95% CI, 2-472; P = .02), renal failure (OR, 16; 95% CI, 3-99; P = .003), small-bowel obstruction (OR, 11; 95% CI, 2-68; P = .008), internal hernia (OR, 10; 95% CI, 2-51; P = .008), thromboembolism (OR, 9; 95% CI, 3-27; P < .001), and incisional hernia (OR, 5; 95% CI, 2-13; P = .001).

CONCLUSIONS

Anastomotic leaks significantly increase the likelihood of developing additional life-threatening complications after RYGB. Close and aggressive monitoring is recommended for early detection and management of added complications, should they occur.

A state-wide review of contemporary outcomes of gastric bypass in Florida: does provider volume impact outcomes?

OBJECTIVES

To report contemporary outcomes of gastric bypass for obesity and to assess the relationship between provider volume and outcomes.

BACKGROUND

Certain Florida-based insurers are denying patients access to bariatric surgery because of alleged high morbidity and mortality.

SETTINGS AND PATIENTS

The prospectively collected and mandatory-reported Florida-wide hospital discharge database was analyzed. Restrictive procedures such as adjustable gastric banding and gastroplasty were excluded.

RESULTS

The overall complication and in-hospital mortality rates in 19,174 patients who underwent gastric bypass from 1999 to 2003 were 9.3% (8.9-9.7) and 0.28% (0.21-0.36), respectively. Age and male gender were associated with increased duration of hospital stay (P < 0.001), increased in-hospital complications [age: odds ratio (OR) = 1.11, CI: 1.08-1.13; male: OR = 1.53, CI: 0.36-1.72] and increased in-hospital mortality (age: OR = 1.51, CI: 1.32-1.73; male: CI = 2.66, CI: 1.53-4.63), all P < 0.001. The odds of in-hospital complications significantly increased with diminishing surgeon or hospital procedure volume (surgeon: OR = 2.0, CI: 1.3-3.1; P < 0.001, 1-5 procedures relative to >500 procedures; hospital volume: OR = 2.1, CI: 1.2-3.5; P < 0.001, 1-9 procedures relative to >500 procedures). The percent change of in-hospital mortality in later years of the study was lowest, indicating higher mortality rates, for surgeons or hospitals with fewer (< or =100) compared with higher (> or =500) procedures.

CONCLUSION

Increased utilization of bariatric surgery in Florida is associated with overall favorable short-term outcomes. Older age and male gender were associated with increased morbidity and mortality. Surgeon and hospital procedure volume have an inverse relationship with in-hospital complications and mortality.