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Ayoung-Chee PR, Gore AV, Bruns B, Knowlton LM, Nahmias J, Davis KA, Leichtle S, Ross SW, Scherer LR, Velopulos C, Martin RS, Staudenmayer KL. Value in Acute Care Surgery, Part 3: Defining Value in Acute Surgical Care - It Depends on the Perspective. J Trauma Acute Care Surg 2024:01586154-990000000-00699. [PMID: 38706096 DOI: 10.1097/ta.0000000000004347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
ABSTRACT The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the healthcare system - the patient, the healthcare organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints.
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Affiliation(s)
| | - Amy V Gore
- Department of Surgery, Rutgers New Jersey Medical School
| | - Brandon Bruns
- Department of Surgery, University of Texas, Southwestern Medical Center
| | - Lisa M Knowlton
- Department of Surgery, Stanford University School of Medicine
| | | | | | - Stefan Leichtle
- Department of Surgery, University of Virginia School of Medicine
| | - Samuel W Ross
- Department of Surgery, Wake Forest School of Medicine
| | - L R Scherer
- Department of Surgery, Idaho College of Osteopathic Medicine
| | - Catherine Velopulos
- Department of Surgery, University of Colorado Denver, Anschutz Medical Campus
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Zogg CK, Falvey JR, Kodadek LM, Staudenmayer KL, Davis KA. The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients. J Trauma Acute Care Surg 2024; 96:400-408. [PMID: 37962136 PMCID: PMC10922165 DOI: 10.1097/ta.0000000000004191] [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: 11/15/2023]
Abstract
BACKGROUND When presenting for emergency general surgery (EGS) care, older adults frequently experience increased risk of adverse outcomes owing to factors related to age ("geriatric vulnerability") and the social determinants of health unique to the places in which they live ("neighborhood vulnerability"). Little is known about how such factors collectively influence adverse outcomes. We sought to explore how the interaction between geriatric and neighborhood vulnerability influences EGS outcomes among older adults. METHODS Older adults, 65 years or older, hospitalized with an AAST-defined EGS condition were identified in the 2016 to 2019, 2021 Florida State Inpatient Database. Latent variable models combined the influence of patient age, multimorbidity, and Hospital Frailty Risk Score into a single metric of "geriatric vulnerability." Variations in geriatric vulnerability were then compared across differences in "neighborhood vulnerability" as measured by variations in Area Deprivation Index, Social Vulnerability Index, and their corresponding subthemes (e.g., access to transportation). RESULTS A total of 448,968 older adults were included. For patients living in the least vulnerable neighborhoods, increasing geriatric vulnerability resulted in up to six times greater risk of death (30-day risk-adjusted hazards ratio [HR], 6.32; 95% confidence interval [CI], 4.49-8.89). The effect was more than doubled among patients living in the most vulnerable neighborhoods, where increasing geriatric vulnerability resulted in up to 15 times greater risk of death (30-day risk-adjusted HR, 15.12; 95% CI, 12.57-18.19). When restricted to racial/ethnic minority patients, the multiplicative effect was four-times as high, resulting in corresponding 30-day HRs for mortality of 11.53 (95% CI, 4.51-29.44) versus 40.67 (95% CI, 22.73-72.78). Similar patterns were seen for death within 365 days. CONCLUSION Both geriatric and neighborhood vulnerability have been shown to affect prehospital risk among older patients. The results of this study build on that work, presenting the first in-depth look at the powerful multiplicative interaction between these two factors. The results show that where a patient resides can fundamentally alter expected outcomes for EGS care such that otherwise less vulnerable patients become functionally equivalent to those who are, at baseline, more aged, more frail, and more sick. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, MD
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Lisa M. Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, CT
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Zogg CK, Cooper Z, Peduzzi P, Falvey JR, Castillo-Angeles M, Kodadek LM, Staudenmayer KL, Davis KA, Tinetti ME, Lichtman JH. Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality. JAMA Surg 2023; 158:e234856. [PMID: 37792354 PMCID: PMC10551815 DOI: 10.1001/jamasurg.2023.4856] [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: 04/27/2023] [Accepted: 07/11/2023] [Indexed: 10/05/2023]
Abstract
Importance Lack of knowledge about longer-term outcomes remains a critical blind spot for trauma systems. Recent efforts have expanded trauma quality evaluation to include a broader array of postdischarge quality metrics. It remains unknown how such quality metrics should be used. Objective To examine the utility of implementing recommended postdischarge quality metrics as a composite score and ascertain how composite score performance compares with that of in-hospital mortality for evaluating associations with hospital-level factors. Design, Setting, and Participants This national hospital-level quality assessment evaluated hospital-level care quality using 100% Medicare fee-for-service claims of older adults (aged ≥65 years) hospitalized with primary diagnoses of trauma, hip fracture, and severe traumatic brain injury (TBI) between January 1, 2014, and December 31, 2015. Hospitals with annual volumes encompassing 10 or more of each diagnosis were included. The data analysis was performed between January 1, 2021, and December 31, 2022. Exposures Reliability-adjusted quality metrics used to calculate composite scores included hospital-specific performance on mortality, readmission, and patients' average number of healthy days at home (HDAH) within 30, 90, and 365 days among older adults hospitalized with all forms of trauma, hip fracture, and severe TBI. Main Outcomes and Measures Associations with hospital-level factors were compared using volume-weighted multivariable logistic regression. Results A total of 573 554 older adults (mean [SD] age, 83.1 [8.3] years; 64.8% female; 35.2% male) from 1234 hospitals were included. All 27 reliability-adjusted postdischarge quality metrics significantly contributed to the composite score. The most important drivers were 30- and 90-day readmission, patients' average number of HDAH within 365 days, and 365-day mortality among all trauma patients. Associations with hospital-level factors revealed predominantly anticipated trends when older adult trauma quality was evaluated using composite scores (eg, worst performance was associated with decreased older adult trauma volume [odds ratio, 0.89; 95% CI, 0.88-0.90]). Results for in-hospital mortality showed inverted associations for each considered hospital-level factor and suggested that compared with nontrauma centers, level 1 trauma centers had a 17 times higher risk-adjusted odds of worst (highest quantile) vs best (lowest quintile) performance (odds ratio, 17.08; 95% CI, 16.17-18.05). Conclusions and Relevance The study results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care. Composite scores appear to offer a promising means by which postdischarge quality metrics could be used.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Peter Peduzzi
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Jason R. Falvey
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore, Maryland
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Manuel Castillo-Angeles
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Harvard TH Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Lisa M. Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Kimberly A. Davis
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Mary E. Tinetti
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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Zeineddin A, Tominaga GT, Crandall M, Almeida M, Schuster KM, Jawad G, Maqbool B, Sheffield AC, Dhillon NK, Radow BS, Moorman ML, Martin ND, Jacovides CL, Lowry D, Kaups K, Horwood CR, Werner NL, Proaño-Zamudio JA, Kaafarani HMA, Marshall WA, Haines LN, Schaffer KB, Staudenmayer KL, Kozar RA. Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale. J Trauma Acute Care Surg 2023; 95:213-219. [PMID: 37072893 DOI: 10.1097/ta.0000000000003969] [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: 04/20/2023]
Abstract
INTRODUCTION The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes. METHODS This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion. RESULTS We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13). CONCLUSION This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Ahmad Zeineddin
- From the Department of Surgery (A.Z.), Howard University Hospital, Washington, DC; Department of Surgery (A.Z., N.K.D., R.A.K.), Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (M.A., K.M.S.), Yale University, New Haven, Connecticut; Department of Surgery (G.J., B.M.), University of New Mexico Health Science Center, Albuquerque, New Mexico; Department of Surgery (M.C., A.C.S.), College of Medicine, University of Florida, Jacksonville, Florida; Department of Surgery (B.S.R., M.L.M.), University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Surgery (N.D.M., C.L.J.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.L., K.K.), Community Regional Medical Center, UCSF Fresno, Fresno, California; Department of Surgery (C.R.H., N.L.W.), Denver Health, Denver, Colorado; Department of Surgery (J.A.P.-Z., H.M.A.K.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (W.A.M., L.N.H.), University of California San Diego Health, San Diego; Department of Surgery (G.T.T., K.B.S.), Scripps Memorial Hospital, La Jolla; and Department of Surgery (K.L.S.), Stanford University, Stanford, California
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Knowlton LM, Butler WJ, Dumas RP, Bankhead BK, Meizoso JP, Bruns B, Van Gent JM, Kaafarani HMA, Martin MJ, Namias N, Stein DM, Tadlock MD, Martin RS, Staudenmayer KL, Gurney JM. Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development. Trauma Surg Acute Care Open 2023; 8:e001049. [PMID: 36866105 PMCID: PMC9972450 DOI: 10.1136/tsaco-2022-001049] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/11/2023] [Indexed: 03/03/2023] Open
Abstract
Across disciplines, mentorship has been recognized as a key to success. Acute care surgeons, focused on the care of trauma surgery, emergency general surgery and surgical critical care, practice in a wide variety of settings and have unique mentorship needs across all phases of their career. Recognizing the need for robust mentorship and professional development, the American Association for the Surgery of Trauma (AAST) convened an expert panel entitled 'The Power of Mentorship' at the 81st annual meeting in September 2022 (Chicago, Illinois). This was a collaboration between the AAST Associate Member Council (consisting of surgical resident, fellow and junior faculty members), the AAST Military Liaison Committee, and the AAST Healthcare Economics Committee. Led by two moderators, the panel consisted of five real-life mentor-mentee pairs. They addressed the following realms of mentorship: clinical, research, executive leadership and career development, mentorship through professional societies, and mentorship for military-trained surgeons. Recommendations, as well as pearls and pitfalls, are summarized below.
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Affiliation(s)
- Lisa Marie Knowlton
- Division of General Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California, USA,Stanford University School of Medicine, Department of Surgery, Stanford, California, USA
| | | | | | - Brittany K Bankhead
- Division of Trauma, Burns, and Critical Care, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Brandon Bruns
- Department of Surgery, UT Southwestern Medical School, Dallas, Texas, USA
| | - Jan-Michael Van Gent
- Division of Trauma and Surgical Critical Care, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | | | - Matthew J Martin
- Division of Trauma and Surgical Critical Care, LAC USC Medical Center, Los Angeles, California, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Deborah M. Stein
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Matthew D Tadlock
- 1st Medical Battalion, 1st Marine Logistics Group, US Naval Hospital Camp Pendleton, Camp Pendleton, California, USA
| | - R Shayn Martin
- Department of Surgery, Division of Acute Care Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristan L Staudenmayer
- Division of General Surgery, Section of Acute Care Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer M Gurney
- Department of Trauma Surgery, San Antonio Military Medical Center, Fort Sam Houston, Texas, USA
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Staudenmayer KL. Comment for article "Predictors of Hospital Bypass for Rural Residents Seeking Common Elective Surgery": Surgical bypass: A problem or a symptom? Surgery 2023; 173:278-279. [PMID: 36163087 DOI: 10.1016/j.surg.2022.08.023] [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: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 02/01/2023]
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Zogg CK, Staudenmayer KL, Kodadek LM, Davis KA. Reconceptualizing high-quality emergency general surgery care: Non-mortality-based quality metrics enable meaningful and consistent assessment. J Trauma Acute Care Surg 2023; 94:68-77. [PMID: 36245079 PMCID: PMC9805506 DOI: 10.1097/ta.0000000000003818] [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: 02/07/2023]
Abstract
BACKGROUND Ongoing efforts to promote quality-improvement in emergency general surgery (EGS) have made substantial strides but lack clear definitions of what constitutes "high-quality" EGS care. To address this concern, we developed a novel set of five non-mortality-based quality metrics broadly applicable to the care of all EGS patients and sought to discern whether (1) they can be used to identify groups of best-performing EGS hospitals, (2) results are similar for simple versus complex EGS severity in both adult (18-64 years) and older adult (≥65 years) populations, and (3) best performance is associated with differences in hospital-level factors. METHODS Patients hospitalized with 1-of-16 American Association for the Surgery of Trauma-defined EGS conditions were identified in the 2019 Nationwide Readmissions Database. They were stratified by age/severity into four cohorts: simple adults, complex adults, simple older adults, complex older adults. Within each cohort, risk-adjusted hierarchical models were used to calculate condition-specific risk-standardized quality metrics. K-means cluster analysis identified hospitals with similar performance, and multinomial regression identified predictors of resultant "best/average/worst" EGS care. RESULTS A total of 1,130,496 admissions from 984 hospitals were included (40.6% simple adults, 13.5% complex adults, 39.5% simple older adults, and 6.4% complex older adults). Within each cohort, K-means cluster analysis identified three groups ("best/average/worst"). Cluster assignment was highly conserved with 95.3% of hospitals assigned to the same cluster in each cohort. It was associated with consistently best/average/worst performance across differences in outcomes (5×) and EGS conditions (16×). When examined for associations with hospital-level factors, best-performing hospitals were those with the largest EGS volume, greatest extent of patient frailty, and most complicated underlying patient case-mix. CONCLUSION Use of non-mortality-based quality metrics appears to offer a needed promising means of evaluating high-quality EGS care. The results underscore the importance of accounting for outcomes applicable to all EGS patients when designing quality-improvement initiatives and suggest that, given the consistency of best-performing hospitals, natural EGS centers-of-excellence could exist. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Lisa M. Kodadek
- Department of Surgery, Yale School of Medicine, New Haven, CT
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Park C, Bharija A, Mesias M, Mitchell A, Krishna P, Storr-Street N, Brown A, Martin M, Lu AC, Staudenmayer KL. Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury. JAMA Surg 2022; 157:676-683. [PMID: 35675065 PMCID: PMC9178494 DOI: 10.1001/jamasurg.2022.1556] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [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: 09/28/2021] [Accepted: 03/13/2022] [Indexed: 12/19/2022]
Abstract
Importance Older adults (age ≥65 years) are at risk for high rates of delirium and poor outcomes; however, how to improve outcomes is still being explored. Objective To assess whether implementation of a geriatric trauma clinical pathway was associated with reduced rates of delirium in older adults with traumatic injury. Design, Setting, and Participants A retrospective case-control study of electronic health records of patients aged 65 years or older with traumatic injury from 2018 to 2020 was conducted at a single level I trauma center. Eligible patients were age 65 years or older admitted to the trauma service and who did not undergo an operation. Intervention The implementation of a clinical pathway based on geriatric best practices, which included order sets, guidelines, automated consultations, and escalation pathways executed by a multidisciplinary team. Main Outcomes and Measures The primary outcome was delirium. The secondary outcome was hospital length of stay. Process measures for pathway compliance were also assessed. Results Of the 859 eligible patients, 712 patients were included in the analysis (442 [62.1%] in the baseline group; 270 [37.9%] in the postimplementation group; mean [SD] age: 81.4 [9.1] years; 394 [55.3%] were female). The mechanism of injury was not different between groups, with 247 in the baseline group (55.9%) and 162 in the postimplementation group (60.0%) (P = .43) experiencing a fall. Injuries were minor or moderate in both groups (261 in baseline group [59.0%] and 168 in postimplementation group [62.2%]; P = .87). The adjusted odds ratio for delirium in the postimplementation cohort was 0.54 (95% CI, 0.37-0.80; P < .001). Goals of care documentation improved significantly in the postimplementation cohort vs the baseline cohort with regard to documented goals of care notes (53.7% in the postimplementation cohort [145 of 270] vs 16.7% in the baseline cohort [74 of 442]; P < .001) and a shortened time to discussion from presenting to the emergency department (36 hours in the postimplementation cohort vs 50 hours in the baseline cohort; P = .03). Conclusions and Relevance In this study, implementation of a multidisciplinary clinical pathway for injured older adults at a single level I trauma center was associated with improved care and clinical outcomes. Interventions such as these may have utility in this vulnerable population, and findings should be confirmed across multiple centers.
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Affiliation(s)
- Caroline Park
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Ankur Bharija
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
- Geriatrics, Linus Health, Waltham, Massachusetts
| | - Matthew Mesias
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Ann Mitchell
- Patient Care Services, Professional Practice, Stanford, California
| | | | - Nannette Storr-Street
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Alyssa Brown
- Department of Rehabilitation, Stanford University, Stanford, California
| | - Marina Martin
- Section of Geriatrics, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California
| | - Amy C. Lu
- Department of Quality Administration, University of California, San Francisco
| | - Kristan L. Staudenmayer
- Division of General Surgery, Department of Surgery, Stanford School of Medicine, Stanford, California
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Ross SW, Reinke CE, Ingraham AM, Holena DN, Havens JM, Hemmila MR, Sakran JV, Staudenmayer KL, Napolitano LM, Coimbra R. Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues. J Am Coll Surg 2022; 234:214-225. [PMID: 35213443 DOI: 10.1097/xcs.0000000000000044] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [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: 12/19/2022]
Abstract
Emergency general surgery (EGS) accounts for 11% of hospital admissions, with more than 3 million admissions per year and more than 50% of operative mortality in the US. Recent research into EGS has ignited multiple quality improvement initiatives, and the process of developing national standards and verification in EGS has been initiated. Such programs for quality improvement in EGS include registry formation, protocol and standards creation, evidenced-based protocols, disease-specific protocol implementation, regional collaboratives, targeting of high-risk procedures such as exploratory laparotomy, focus on special populations like geriatrics, and targeting improvements in high opportunity outcomes such as failure to rescue. The authors present a collective narrative review of advances in quality improvement structure in EGS in recent years and summarize plans for a national EGS registry and American College of Surgeons verification for this under-resourced area of surgery.
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Affiliation(s)
- Samuel W Ross
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Caroline E Reinke
- From Atrium Health Carolinas Medical Center, Wake Forest School of Medicine, Charlotte, NC (Ross, Reinke)
| | - Angela M Ingraham
- University of Wisconsin School of Medicine and Public Health, Madison, WI (Ingraham)
| | - Daniel N Holena
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA (Holena)
| | - Joaquim M Havens
- Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA (Havens)
| | - Mark R Hemmila
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Joseph V Sakran
- Johns Hopkins University School of Medicine, Baltimore, MD (Sakran)
| | | | - Lena M Napolitano
- University of Michigan School of Medicine, Ann Arbor, MI (Hemmila, Napolitano)
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Loma Linda, CA (Coimbra)
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Martin RS, Lester ELW, Ross SW, Davis KA, Tres Scherer LR, Minei JP, Staudenmayer KL. Value in acute care surgery, Part 1: Methods of quantifying cost. J Trauma Acute Care Surg 2022; 92:e1-e9. [PMID: 34570063 DOI: 10.1097/ta.0000000000003419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.
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Affiliation(s)
- R Shayn Martin
- From the Department of Surgery (R.S.M.), Wake Forest School of Medicine, Winston-Salem, NC; Department of Surgery (E.L.W.L.), University of Alberta, Edmonton, Alberta, Canada; Department of Surgery (S.W.R.), Atrium Health, Charlotte, NC; Department of Surgery (K.A.D.), Yale School of Medicine, New Haven, Connecticut; North Star Pediatric Surgery (L.R.T.S.), Carmel, Indiana; Department of Surgery (J.P.M.), University of Texas Southwestern Medical School, Dallas, Texas; and Department of Surgery (K.L.S.), Stanford School of Medicine, Stanford, California
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Choi J, Tennakoon L, Spain DA, Staudenmayer KL. Outcome-specific Injury Scores (OSIS): Development and Validation of Tailored Prediction Tools for Injured Older Adults. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Park C, Bharija A, Staudenmayer KL. Reducing Mortality and Delirium in Injured Older Adults: Results from the Development of a Multidisciplinary Clinical Pathway. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Shah SS, Tennakoon L, O'Beirne E, Staudenmayer KL, Kothary N. The Economic Footprint of Interventional Radiology in the United States: Implications for Systems Development. J Am Coll Radiol 2020; 18:53-59. [PMID: 32918863 DOI: 10.1016/j.jacr.2020.07.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 06/17/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Despite the growing presence of interventional radiology (IR) in inpatient care, its global impact on the health care system remains uncharacterized. The aim of this study was to quantitate the use of IR services rendered to hospitalized patients in the United States and the impact on cost. METHODS The National Inpatient Sample 2016 was queried. Using the International Classification of Diseases, 10th revision, Clinical Modification/Procedure Classification System, adult inpatients who underwent routine IR procedures were identified. Unadjusted and adjusted analyses were performed. Weighted patient data are presented to provide national estimates. RESULTS Of the 29.7 million inpatient admissions in 2016, 2.3 million (7.8%) had at least one IR procedure. Patients who needed IR were older (62.8 versus 57.1 years, P < .001), were sicker on the basis of the All Patient Refined Diagnosis Related Groups (27% major or extreme versus 14% for non-IR, P < .001), and had higher inpatient mortality (8.2% versus 1.7%, P < .001). While representing 7.8% of all admissions, this cohort accounted for 18.4% ($68.4 billion) of adult inpatient health care costs and about 3 times higher mean hospitalization cost compared with other inpatients ($29,402 versus $11,062, P < .001), which remained significant even after controlling for age and All Patient Refined Diagnosis Related Group. CONCLUSIONS Approximately 1 in 10 US inpatients are treated by IR during their hospitalizations. These patients are sicker, with about 4 times higher mortality and 2.5 times greater length of stay, accounting for almost one-fifth of all health care costs. These findings suggest that IR should have a voice in discussions of means to save costs and improve patient outcomes in the United States.
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Affiliation(s)
| | - Lakshika Tennakoon
- Division of General Surgery, Department of Surgery, Stanford School of Medicine, Stanford, California
| | | | - Kristan L Staudenmayer
- Division of General Surgery, Department of Surgery, Stanford School of Medicine, Stanford, California
| | - Nishita Kothary
- Department of Radiology, Stanford School of Medicine, Stanford, California.
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Sceats LA, Kin C, Staudenmayer KL. Questioning the Higher Abscess Rate and Overall Cost of Care Associated With Nonoperative Management of Uncomplicated Acute Appendicitis-Reply. JAMA Surg 2020; 154:784-785. [PMID: 31090887 DOI: 10.1001/jamasurg.2019.1162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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)
- Lindsay A Sceats
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Cindy Kin
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Kristan L Staudenmayer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Stanford University, Stanford, California
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Sceats LA, Trickey AW, Morris AM, Kin C, Staudenmayer KL. Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients. JAMA Surg 2019; 154:141-149. [PMID: 30427983 DOI: 10.1001/jamasurg.2018.4282] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Health care professionals have shown significant interest in nonoperative management for uncomplicated appendicitis, but long-term population-level data are lacking. Objective To compare the outcomes of nonoperatively managed appendicitis against appendectomy. Design, Setting, and Participants This national retrospective cohort study used claims data from a private insurance database to compare patients admitted with uncomplicated appendicitis from January 1, 2008, through December 31, 2014, undergoing appendectomy vs nonoperative management. Coarsened exact matching was applied before multivariate analysis to reduce imbalance between groups. Data were analyzed from February 12 through May 1, 2018. Exposures Appendectomy (control arm) or nonoperative management (treatment arm). Main Outcomes and Measures Short-term primary clinical outcomes included emergency department visits, hospital readmission, abdominal abscess, and Clostridium difficile infections. Long-term primary clinical outcomes were small-bowel obstructions, incisional hernias, and appendiceal cancers. Nonoperative management failure was defined by hospital readmission with appendicitis diagnosis and an appendicitis-associated operation or procedure. Secondary outcomes included number of follow-up visits, length and cost of index hospitalization, and total cost of appendicitis-associated care. Covariates included age, sex, region, insurance plan type, admission year, and Charlson comorbidity index. Results Of 58 329 patients with uncomplicated appendicitis (52.7% men; mean [SD] age, 31.9 [16.5] years), 55 709 (95.5%) underwent appendectomy and 2620 (4.5%) underwent nonoperative management. Patients in the nonoperative management group were more likely to have appendicitis-associated readmissions (adjusted odds ratio, 2.13; 95% CI, 1.63-2.77; P < .001) and to develop an abscess (adjusted odds ratio, 1.42; 95% CI, 1.05-1.92; P = .02). Patients in the nonoperative management group required more follow-up visits in the year after index admission (unadjusted mean [SD], 1.6 [6.3] vs 0.3 [1.4] visits; adjusted +1.11 visits; P < .001) and had lower index hospitalization cost (unadjusted mean [SD], $11 502 [$9287] vs $13 551 [$10 160]; adjusted -$2117, P < .001), but total cost of appendicitis care was higher when follow-up care was considered (unadjusted, $14 934 [$31 122] vs $14 186 [$10 889]; adjusted +$785; P = .003). During a mean (SD) of 3.2 (1.7) years of follow-up, failure of nonoperative management occurred in 101 patients (3.9%); median time to recurrence was 42 days (interquartile range, 8-125 days). Among the patients who experienced treatment failure, 44 did so within 30 days. Conclusions and Relevance According to results of this study, nonoperative management failure rates were lower than previously reported. Nonoperative management was associated with higher rates of abscess, readmission, and higher overall cost of care. These data suggest that nonoperative management may not be the preferred first-line therapy for all patients with uncomplicated appendicitis.
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Affiliation(s)
- Lindsay A Sceats
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Arden M Morris
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Cindy Kin
- Stanford-Surgery Policy Improvement Research and Education (S-SPIRE) Center, Department of Surgery, Stanford University, Stanford, California
| | - Kristan L Staudenmayer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Stanford University, Stanford, California
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Nassar A, Weimer-Elder B, Kline M, Minthorn C, Staudenmayer KL, Yang R, Spain DA, Maggio P, Korndorffer JR, Johnson T. Developing an Inpatient Relationship-Centered Communication Curriculum for Surgical Teams: Pilot Study. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Madhavan S, Taylor JS, Chandler JM, Staudenmayer KL, Chao SD. Firearm Legislation Stringency and Firearm-Related Fatalities among Children in the US. J Am Coll Surg 2019; 229:150-157. [DOI: 10.1016/j.jamcollsurg.2019.02.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 11/27/2022]
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18
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Rosenberg GM, Weiser TG, Maggio PM, Browder TD, Tennakoon L, Spain DA, Staudenmayer KL. The association between angioembolization and splenic salvage for isolated splenic injuries. J Surg Res 2018; 229:150-155. [DOI: 10.1016/j.jss.2018.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/20/2018] [Accepted: 03/13/2018] [Indexed: 11/17/2022]
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Knowlton LM, Morris AM, Tennakoon L, Spain DA, Staudenmayer KL. Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals. J Am Coll Surg 2018; 227:172-180. [PMID: 29680414 DOI: 10.1016/j.jamcollsurg.2018.03.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 12/29/2017] [Revised: 03/22/2018] [Accepted: 03/23/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability. STUDY DESIGN We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin. RESULTS California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n = 4) and nonprofit-owned SNHs (64%, n = 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p < 0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively. CONCLUSIONS The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system.
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Affiliation(s)
- Lisa M Knowlton
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, CA; Stanford - Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA.
| | - Arden M Morris
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, CA; Stanford - Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA
| | - Lakshika Tennakoon
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, CA; Stanford - Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA
| | - David A Spain
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, CA; Stanford - Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA
| | - Kristan L Staudenmayer
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University, Stanford, CA; Stanford - Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, CA
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20
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Rajasingh CM, Tennakoon L, Staudenmayer KL. Self-inflicted gunshot wounds: readmission patterns. J Surg Res 2018; 223:22-28. [DOI: 10.1016/j.jss.2017.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/21/2017] [Accepted: 10/12/2017] [Indexed: 11/16/2022]
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21
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Rosenberg GM, Knowlton L, Rajasingh C, Weng Y, Maggio PM, Spain DA, Staudenmayer KL. National Readmission Patterns of Isolated Splenic Injuries Based on Initial Management Strategy. JAMA Surg 2018; 152:1119-1125. [PMID: 28768329 DOI: 10.1001/jamasurg.2017.2643] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Options for managing splenic injuries have evolved with a focus on nonoperative management. Long-term outcomes, such as readmissions and delayed splenectomy rate, are not well understood. Objective To describe the natural history of isolated splenic injuries in the United States and determine whether patterns of readmission were influenced by management strategy. Design, Setting, and Participants The Healthcare Cost and Utilization Project's Nationwide Readmission Database is an all-payer, all-ages, longitudinal administrative database that provides data on more than 35 million weighted US discharges yearly. The database was used to identify patients with isolated splenic injuries and the procedures that they received. Adult patients with isolated splenic injuries admitted from January 1 through June 30, 2013, and from January 1 through June 30, 2014, were included. Those who died during the index hospitalization or who had an additional nonsplenic injury with an Abbreviated Injury Score of 2 or greater were excluded. Univariate and mixed-effects logistic regression analysis controlling for center effect were used. Weighted numbers are reported. Exposures Initial management strategy at the time of index hospitalization, including nonprocedural management, angioembolization, and splenectomy. Main Outcomes and Measures All-cause 6-month readmission rate. Secondary outcome was delayed splenectomy rate. Results A weighted sample of 3792 patients (2146 men [56.6%] and 1646 women [43.4%]; mean [SE] age, 48.5 [0.7] years) with 5155 admission events was included. During the index hospitalization, 825 (21.8%) underwent splenectomy, 293 (7.7%) underwent angioembolization, and 2673 (70.5%) had no procedure. The overall readmission rate was 21.1% (799 patients). Readmission rates did not differ based on initial management strategy (195 patients undergoing splenectomy [23.6%], 70 undergoing angioembolism [23.9%], and 534 undergoing no procedure [20%]; P = .33). Splenectomy was performed in 36 of 799 readmitted patients (4.5%) who did not have a splenectomy at their index hospitalization, leading to an overall delayed splenectomy rate of 1.2% (36 of 2967 patients). In mixed-effects logistic regression analysis controlling for patient, injury, clinical, and hospital characteristics, the choice of splenectomy (odds ratio, 0.93; 95% CI, 0.66-1.31) vs angioembolization (odds ratio, 1.19; 95% CI, 0.72-1.97) as initial management strategy was not associated with readmission. Conclusions and Relevance This national evaluation of the natural history of isolated splenic injuries from index admission through 6 months found that approximately 1 in 5 patients are readmitted within 6 months of discharge after an isolated splenic injury. However, the chance of readmission for splenectomy after initial nonoperative management was 1.2%. This finding suggests that the current management strategies used for isolated splenic injuries in the United States are well matched to patient need.
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Affiliation(s)
- Graeme M Rosenberg
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Lisa Knowlton
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Charlotte Rajasingh
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Yingjie Weng
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, California
| | - Paul M Maggio
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - David A Spain
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
| | - Kristan L Staudenmayer
- Department of Surgery, Section of Acute Care Surgery, Stanford University, Stanford, California
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Rajasingh CM, Tennakoonc L, Spain DA, Staudenmayer KL. Risk Factors for Deliberate Self-Harm after Major Operative Procedures. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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23
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Knowlton LM, Staudenmayer KL, Spain DA, Morris AM. Financial Stability of Level I Trauma Centers within Safety Net Hospitals. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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24
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Spitzer SA, Staudenmayer KL, Weiser TG. Spitzer et al. Respond. Am J Public Health 2017; 107:e25. [DOI: 10.2105/ajph.2017.303870] [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: 11/04/2022]
Affiliation(s)
- Sarabeth A. Spitzer
- All of the authors are with Stanford University School of Medicine, Stanford, CA
| | | | - Thomas G. Weiser
- All of the authors are with Stanford University School of Medicine, Stanford, CA
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Spitzer SA, Staudenmayer KL, Tennakoon L, Spain DA, Weiser TG. Costs and Financial Burden of Initial Hospitalizations for Firearm Injuries in the United States, 2006-2014. Am J Public Health 2017; 107:770-774. [PMID: 28323465 DOI: 10.2105/ajph.2017.303684] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To quantify the inflation-adjusted costs associated with initial hospitalizations for firearm-related injuries in the United States. METHODS We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2006 to 2014. We converted charges from hospitalization to costs, which we inflation-adjusted to 2014 dollars. We used survey weights to create national estimates. RESULTS Costs for the initial inpatient hospitalization totaled $6.61 billion. The largest proportion was for patients with governmental insurance coverage, totaling $2.70 billion (40.8%) and was divided between Medicaid ($2.30 billion) and Medicare ($0.40 billion). Self-pay individuals accounted for $1.56 billion (23.6%) in costs. CONCLUSIONS From 2006 to 2014, the cost of initial hospitalizations for firearm-related injuries averaged $734.6 million per year. Medicaid paid one third and self-pay patients one quarter of the financial burden. These figures substantially underestimate true health care costs. Public health implications. Firearm-related injuries are costly to the US health care system and are particularly burdensome to government insurance and the self-paying poor.
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Affiliation(s)
- Sarabeth A Spitzer
- Sarabeth A. Spitzer is a medical student at Stanford University School of Medicine, Stanford, CA. Kristan L. Staudenmayer, Lakshika Tennakoon, David A. Spain, and Thomas G. Weiser are with the Department of Surgery, Stanford University School of Medicine
| | - Kristan L Staudenmayer
- Sarabeth A. Spitzer is a medical student at Stanford University School of Medicine, Stanford, CA. Kristan L. Staudenmayer, Lakshika Tennakoon, David A. Spain, and Thomas G. Weiser are with the Department of Surgery, Stanford University School of Medicine
| | - Lakshika Tennakoon
- Sarabeth A. Spitzer is a medical student at Stanford University School of Medicine, Stanford, CA. Kristan L. Staudenmayer, Lakshika Tennakoon, David A. Spain, and Thomas G. Weiser are with the Department of Surgery, Stanford University School of Medicine
| | - David A Spain
- Sarabeth A. Spitzer is a medical student at Stanford University School of Medicine, Stanford, CA. Kristan L. Staudenmayer, Lakshika Tennakoon, David A. Spain, and Thomas G. Weiser are with the Department of Surgery, Stanford University School of Medicine
| | - Thomas G Weiser
- Sarabeth A. Spitzer is a medical student at Stanford University School of Medicine, Stanford, CA. Kristan L. Staudenmayer, Lakshika Tennakoon, David A. Spain, and Thomas G. Weiser are with the Department of Surgery, Stanford University School of Medicine
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Shi HH, Esquivel M, Staudenmayer KL, Spain DA. Effects of mechanism of injury and patient age on outcomes in geriatric rib fracture patients. Trauma Surg Acute Care Open 2017; 2:e000074. [PMID: 29766084 PMCID: PMC5887584 DOI: 10.1136/tsaco-2016-000074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/09/2017] [Accepted: 02/12/2017] [Indexed: 11/06/2022] Open
Abstract
Background Patients older than 65 years have 2–5 times higher mortality if they sustain ≥2 rib fractures compared to younger adults. As a result, our level I trauma center guidelines suggest that older adults with rib fractures be admitted to the intensive care unit for the first 24 hours. In this study, we evaluated the outcomes associated with these guidelines. Methods We retrospectively reviewed all patients aged ≥65 years in our Trauma Registry who sustained rib fractures from January 2008 to March 2015. Data included demographics, comorbidities, injuries, length of intensive care and hospital stay (LOS), ventilator days, analgesic used, morbidity, mortality, and disposition. Results 97 patients aged ≥65 years with at least one rib fracture and an Abbreviated Injury Score of ≤2 for other regions were admitted. Falls caused 58% of the injuries, while motor vehicle collisions (MVC) accounted for 33%. Overall mortality was 4%. Patients who fell had a median hospital LOS that was 0.5 to 1 day longer than in those who suffered other mechanisms of injury or were involved in an MVC respectively. Patients aged ≥70 years had a median LOS of 4 days, twice that of those aged 65 to 69 years. Of the 87 patients with more than one rib fracture, 59 (68%) were not admitted directly to the intensive care unit (ICU) from the emergency department as recommended by our guidelines. 6 of these 59 patients (9%) were later transferred to the ICU and 2 of these patients expired. Conclusions Although overall compliance with the geriatric rib fracture guideline was low, both mortality and hospital LOS were low in this group. This suggests that the guideline could be modified to reduce ICU resource usage without compromising patient outcomes. Level of evidence Level III, retrospective cohort study.
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Affiliation(s)
- Helen H Shi
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Micaela Esquivel
- Department of Surgery, Stanford University, Stanford, California, USA
| | | | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
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27
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Mamic P, Heidenreich PA, Hedlin H, Tennakoon L, Staudenmayer KL. Hospitalized Patients with Heart Failure and Common Bacterial Infections: A Nationwide Analysis of Concomitant Clostridium Difficile Infection Rates and In-Hospital Mortality. J Card Fail 2016; 22:891-900. [PMID: 27317844 DOI: 10.1016/j.cardfail.2016.06.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/10/2016] [Accepted: 06/13/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with heart failure (HF) are frequently hospitalized with common bacterial infections. It is unknown whether they experience concomitant Clostridium difficile infection (CDI) more frequently than patients without HF, and whether CDI affects their mortality. METHODS We used 2012 National Inpatient Sample data to determine the rate of CDI and associated in-hospital mortality for hospitalized patients with comorbid HF and urinary tract infection (UTI), pneumonia (PNA), or sepsis. Univariate and multivariate analyses were performed. Weighted data are presented. RESULTS There were an estimated 5,851,582 patient hospitalizations with discharge diagnosis of UTI, PNA, or sepsis in 2012 in the United States. Of these, 23.4% had discharge diagnosis of HF. Patients with HF were on average older and had more comorbidities. CDI rates were higher in hospitalizations with discharge diagnosis of HF compared with those without HF (odds ratio 1.13, 95% confidence interval 1.10-1.16) after controlling for patient demographics and comorbidities and hospital characteristics. Among HF hospitalizations with UTI, PNA, or sepsis, those with concomitant CDI had a higher in-hospital mortality than those without concomitant CDI (odds ratio 1.81, 95% confidence interval 1.71-1.92) after controlling for the covariates outlined previously. CONCLUSIONS HF is associated with higher CDI rates among hospitalized patients with other common bacterial infections, even when adjusting for other known risk factors for CDI. Among these patients with comorbid HF, CDI is associated with markedly higher in-hospital mortality. These findings may suggest an opportunity to improve outcomes for hospitalized patients with HF and common bacterial infections, possibly through improved Clostridium difficile screening and prophylaxis protocols.
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Affiliation(s)
- Petra Mamic
- Department of Medicine, Stanford University School of Medicine, Stanford, California.
| | - Paul A Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, California; VA Palo Alto Health Care System, Palo Alto, California; Stanford Cardiovascular Institute, Stanford, California
| | - Haley Hedlin
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Lakshika Tennakoon
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Chu CH, Tennakoon L, Maggio PM, Weiser TG, Spain DA, Staudenmayer KL. Trends in the management of pelvic fractures, 2008-2010. J Surg Res 2016; 202:335-40. [PMID: 27229108 DOI: 10.1016/j.jss.2015.12.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/10/2015] [Accepted: 12/31/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Bleeding from pelvic fractures can be lethal. Angioembolization (AE) and external fixation (EXFIX) are common treatments to control bleeding, but it is not known how frequently they are used. We hypothesized that AE would be increasingly more common compared with EXFIX over time. METHODS The National Trauma Data Bank for the years from 2008-2010 were used. Patients were included in the study if they had an International Classification of Diseases, ninth edition, Clinical Modification codes for pelvic fractures and were aged ≥18 y. Patients were excluded if they had isolated acetabular fractures, were not admitted, or had minor injuries. Outcomes included receiving a procedure and in-hospital mortality. RESULTS A total of 22,568 patients met study criteria. AE and EXFIX were performed in 746 (3.3%) and 663 (2.9%) patients, respectively. AE was performed more often as the study period progressed (2.5% in 2007 to 3.7% in 2010; P < 0.001). This remained significant in adjusted analysis (odds ratio per year 1.15; P = 0.008). Having a procedure was associated with higher mortality in unadjusted analyses compared with those with no procedure (11.0% for no procedure versus 20.5% and 13.4% for AE or EXFIX, respectively; P < 0.001). In adjusted analyses, only AE remained associated with higher mortality (odds ratio 1.63; P < 0.001). CONCLUSIONS AE in severely injured pelvic fracture patients is increasing. AE is associated with higher mortality, which may reflect the fact that it is used for patients at higher risk of death. The role of AE for bleeding should be examined in future studies.
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Affiliation(s)
- Christopher H Chu
- University of South Carolina School of Medicine, Columbia, South Carolina
| | - Lakshika Tennakoon
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Paul M Maggio
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Tom G Weiser
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - David A Spain
- Department of Surgery, Stanford University Medical Center, Stanford, California
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Forrester J, Weiser TG, Maggio PM, Tennakoon L, Spain DA, Staudenmayer KL. Trauma center verification and a more inclusive system: identifying unnecessary criteria for level lll/lV centers. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sweeney TE, Salles A, Harris OA, Spain DA, Staudenmayer KL. Prediction of neurosurgical intervention after mild traumatic brain injury using the national trauma data bank. World J Emerg Surg 2015; 10:23. [PMID: 26060506 PMCID: PMC4460849 DOI: 10.1186/s13017-015-0017-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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] [Received: 02/20/2015] [Accepted: 05/29/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Patients with mild traumatic brain injury (TBI) as defined by an admission Glasgow Coma Score (GCS) of 14–15 often do not require neurosurgical interventions, but which patients will go on to require neurosurgical care has been difficult to predict. We hypothesized that injury patterns would be associated with need for eventual neurosurgical intervention in mild TBI. Methods The National Trauma Databank (2007–2012) was queried for patients with blunt injury and a diagnosis of TBI with an emergency department GCS of 14–15. Patients were stratified by age and injury type. Multiple logistic regression for neurosurgical intervention was run with patient demographics, physiologic variables, and injury diagnoses as dependent variables. Results The study included 50,496 patients, with an overall 8.8 % rate of neurosurgical intervention. Neurosurgical intervention rates varied markedly according to injury type, and were only correlated with age for patients with epidural and subdural hemorrhage. In multiple logistic regression, TBI diagnoses were predictive of need for neurosurgical interventions; moreover, after controlling for injury type and severity score, age was not significantly associated with requiring neurosurgical intervention. Conclusions We found that in mild TBI, injury pattern is associated with eventual need for neurosurgical intervention. Patients with cerebral contusion or subarachnoid hemorrhage are much less likely to require neurosurgical intervention, and the effects of age are not significant after controlling for other patient factors. Prospective studies should validate this finding so that treatment guidelines can be updated to better allocate ICU resources.
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Affiliation(s)
- Timothy E Sweeney
- Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305 USA
| | - Arghavan Salles
- Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305 USA
| | - Odette A Harris
- Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305 USA
| | - David A Spain
- Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305 USA
| | - Kristan L Staudenmayer
- Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305 USA
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31
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Kastenberg ZJ, Hurley MP, Weiser TG, Cole TS, Staudenmayer KL, Spain DA, Ratliff JK. Adding insult to injury: discontinuous insurance following spine trauma. J Bone Joint Surg Am 2015; 97:141-6. [PMID: 25609441 DOI: 10.2106/jbjs.n.00148] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects. METHODS We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population. RESULTS The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls. CONCLUSIONS Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.
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Affiliation(s)
- Zachary J Kastenberg
- Section of Trauma and Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305
| | - Michael P Hurley
- Section of Trauma and Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305
| | - Thomas G Weiser
- Section of Trauma and Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305
| | - Tyler S Cole
- Section of Trauma and Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305
| | - Kristan L Staudenmayer
- Section of Trauma and Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305
| | - David A Spain
- Section of Trauma and Critical Care, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, S067, Stanford, CA 94305
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, R291 MC 5327, Stanford, CA 94305. E-mail address:
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Gerry JM, Spain DA, Staudenmayer KL. Ground-level falls are a marker of poor outcome in the injured elderly. Am Surg 2014; 80:1171-1173. [PMID: 25347512] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Jon M Gerry
- Department of Surgery, Division of Trauma and Critical Care Surgery, Stanford University, Stanford, California, USA
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Affiliation(s)
- Jon M. Gerry
- Department of Surgery Division of Trauma and Critical Care Surgery Stanford University Stanford, California
| | - David A. Spain
- Department of Surgery Division of Trauma and Critical Care Surgery Stanford University Stanford, California
| | - Kristan L. Staudenmayer
- Department of Surgery Division of Trauma and Critical Care Surgery Stanford University Stanford, California
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Cheung BH, Delgado MK, Staudenmayer KL. Patient and trauma center characteristics associated with helicopter emergency medical services transport for patients with minor injuries in the United States. Acad Emerg Med 2014; 21:1232-9. [PMID: 25377400 DOI: 10.1111/acem.12512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 07/06/2014] [Accepted: 07/16/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Helicopter emergency medical services (EMS) transport is expensive, and previous work has shown that cost-effective use of this resource is dependent on the proportion of minor injuries flown. To understand how overtriage to helicopter EMS versus ground EMS can be reduced, it is important to understand factors associated with helicopter transport of patients with minor injuries. OBJECTIVES The aim was to characterize patient and hospital characteristics associated with helicopter transport of patients with minor injuries. METHODS This was a retrospective analysis of adults ≥18 years who were transported by helicopter to Level I/II trauma centers from 2009 through 2010 as identified in the National Trauma Data Bank. Minor injuries were defined as all injuries scored at an Abbreviated Injury Scale (AIS) score of <3. Patient and hospital characteristics associated of being flown with only minor injuries were compared in an unadjusted and adjusted fashion. Hierarchical, multivariate logistic regression was used to adjust for patient demographics, mechanism of injury, presenting physiology, injury severity, urban-rural location of injury, total EMS time, hospital characteristics, and region. RESULTS A total of 24,812 records were identified, corresponding to 76,090 helicopter transports. The proportion of helicopter transports with only minor injuries was 36% (95% confidence interval [CI] = 34% to 39%). Patient characteristics associated with being flown with minor injuries included being uninsured (odds ratio [OR] = 1.36, 95% CI = 1.26 to 1.47), injury by a fall (OR = 1.32, 95% CI = 1.20 to 1.45), or other penetrating trauma (OR = 2.52, 95% CI = 2.12 to 3.00). Being flown with minor injuries was more likely if the patient was transported to a trauma center that also received a high proportion of patients with minor injuries by ground EMS (OR = 1.89, 95% CI = 1.58 to 2.26) or a high proportion of EMS traffic by helicopter (OR = 1.35, 95% CI = 1.02 to 1.78). No significant association with urban-rural scene location or EMS transport time was found. CONCLUSIONS Better recognizing which patients with falls and penetrating trauma have serious injuries that could benefit from being flown may lead to the more cost-effective use of helicopter EMS. More research is needed to determine why patients without insurance, who are most at risk for high out-of-pocket expenses from helicopter EMS, are at higher risk for being flown when only having minor injuries. This suggests that interventions to optimize cost-effectiveness of helicopter transport will likely require an evaluation of helicopter triage guidelines in the context of regional and patient needs.
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Affiliation(s)
| | - M. Kit Delgado
- The Department of Emergency Medicine Perelman School of Medicine University of Pennsylvania Philadelphia PA
| | - Kristan L. Staudenmayer
- The Department of Surgery Division of General Surgery Stanford University School of Medicine, and the Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM) Stanford CA
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Forrester JD, Banaei N, Buchner P, Spain DA, Staudenmayer KL. Environmental Sampling for Clostridium difficile on Alcohol-Based Hand Rub Dispensers in an Academic Medical Center. Surg Infect (Larchmt) 2014; 15:581-4. [DOI: 10.1089/sur.2013.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Niaz Banaei
- Clinical Microbiology Laboratory, Stanford University, Palo Alto, California
| | - Patricia Buchner
- Clinical Microbiology Laboratory, Stanford University, Palo Alto, California
| | - David A. Spain
- Department of Surgery, Stanford University, Palo Alto, California
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Delgado MK, Yokell MA, Staudenmayer KL, Spain DA, Hernandez-Boussard T, Wang NE. Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status. JAMA Surg 2014; 149:422-30. [PMID: 24554059 DOI: 10.1001/jamasurg.2013.4398] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs). OBJECTIVES To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non–trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region. MAIN OUTCOMES AND MEASURES Inpatient admission vs transfer to another acute care facility. RESULTS In 2009, a total of 4513 observations from 636 non–trauma center EDs were available for analysis, representing a nationally weighted population of 19,312 non–trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non–trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non–teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10,000 annual ED visits). CONCLUSIONS AND RELEVANCE Patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.
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Staudenmayer KL, Hsia RY, Mann NC, Spain DA, Newgard CD. Triage of elderly trauma patients: a population-based perspective. J Am Coll Surg 2013; 217:569-76. [PMID: 24054408 DOI: 10.1016/j.jamcollsurg.2013.06.017] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [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: 12/13/2012] [Revised: 06/21/2013] [Accepted: 06/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Elderly patients are frequently undertriaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes. STUDY DESIGN This is a population-based, retrospective, cohort study of all injured adults aged 55 years or older, from 3 counties in California and 4 in Utah (2006 to 2007). Prehospital data were linked to trauma registry data, state-level discharge data, emergency department records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared with those treated at nontrauma centers. Undertriage was defined as an Injury Severity Score (ISS) >15, with transport to a nontrauma center. RESULTS There were 6,015 patients in the analysis. Patients who were taken to nontrauma centers were, on average, older (79.4 vs 70.7 years, p < 0.001), more often female (68.6% vs 50.2%, p < 0.01), and less often had an ISS >15 (2.2% vs 6.7%, p < 0.01). There were 244 patients with an ISS >15 and the undertriage rate was 32.8% (n = 80). Overall 60-day mortality for patients with an ISS >15 was 17%, with no difference between trauma and nontrauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers. CONCLUSIONS This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of undertriage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.
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Delgado MK, Staudenmayer KL, Wang NE, Spain DA, Weir S, Owens DK, Goldhaber-Fiebert JD. Cost-effectiveness of helicopter versus ground emergency medical services for trauma scene transport in the United States. Ann Emerg Med 2013; 62:351-364.e19. [PMID: 23582619 PMCID: PMC3999834 DOI: 10.1016/j.annemergmed.2013.02.025] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [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: 08/22/2012] [Revised: 02/15/2013] [Accepted: 02/26/2013] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE We determine the minimum mortality reduction that helicopter emergency medical services (EMS) should provide relative to ground EMS for the scene transport of trauma victims to offset higher costs, inherent transport risks, and inevitable overtriage of patients with minor injury. METHODS We developed a decision-analytic model to compare the costs and outcomes of helicopter versus ground EMS transport to a trauma center from a societal perspective during a patient's lifetime. We determined the mortality reduction needed to make helicopter transport cost less than $100,000 and $50,000 per quality-adjusted life-year gained compared with ground EMS. Model inputs were derived from the National Study on the Costs and Outcomes of Trauma, National Trauma Data Bank, Medicare reimbursements, and literature. We assessed robustness with probabilistic sensitivity analyses. RESULTS Helicopter EMS must provide a minimum of a 15% relative risk reduction in mortality (1.3 lives saved/100 patients with the mean characteristics of the National Study on the Costs and Outcomes of Trauma cohort) to cost less than $100,000 per quality-adjusted life-year gained and a reduction of at least 30% (3.3 lives saved/100 patients) to cost less than $50,000 per quality-adjusted life-year. Helicopter EMS becomes more cost-effective with significant reductions in patients with minor injury who are triaged to air transport or if long-term disability outcomes are improved. CONCLUSION Helicopter EMS needs to provide at least a 15% mortality reduction or a measurable improvement in long-term disability to compare favorably with other interventions considered cost-effective. Given current evidence, it is not clear that helicopter EMS achieves this mortality or disability reduction. Reducing overtriage of patients with minor injury to helicopter EMS would improve its cost-effectiveness.
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Affiliation(s)
- M. Kit Delgado
- Department of Surgery, Division of Emergency Medicine, Stanford University School of Medicine
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - Kristan L. Staudenmayer
- Department of Surgery, Division of General Surgery, Trauma/Critical Care Section, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - N. Ewen Wang
- Department of Surgery, Division of Emergency Medicine, Stanford University School of Medicine
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - David A. Spain
- Department of Surgery, Division of General Surgery, Trauma/Critical Care Section, Stanford University School of Medicine
- Stanford Investigators for Surgery, Trauma, and Emergency Medicine (SISTEM), Stanford University School of Medicine
| | - Sharada Weir
- University of Massachusetts School of Medicine, Center for Health Policy and Research, Stanford University School of Medicine
| | - Douglas K. Owens
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
- VA Palo Alto Health Care System, Palo Alto CA, Stanford University School of Medicine
| | - Jeremy D. Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine
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Abstract
We sought to determine if hypertonic saline (HTS) impacted alveolar macrophage (AM) activation and intracellular inflammatory gene signaling in a model of systemic inflammation. Rats received an intravenous administration of 4 mL/kg of 7.5% HTS or L-lactate lactated Ringer's (L-LR). They were simultaneously treated with an intraperitoneal injection of zymosan, which induces noninfectious systemic inflammation. AM were harvested by bronchoalveolar lavage 24 h after treatment. AM activation was analyzed by measurement of baseline and lipopolysaccharide (LPS)-induced TNF-alpha production. Intracellular signaling was analyzed for activation of the mitogen-activated protein kinases (MAPKs): ERK1/2, JNK, and p38. AM from HTS-treated rats produced less TNF-alpha than from L-LR-treated rats (927 +/- 335 pg/mL [SEM] vs. 3628 +/- 783 pg/mL [SEM], P = 0.001) and were also less responsive to LPS (4444 +/- 86 pg/mL [SEM] vs. 6666 +/- 91 pg/mL [SEM], P = 0.058). However, there was no difference in MAPK activation. In vivo HTS prevents excessive AM activation during systemic inflammation. This suppression is mediated through alternate pathways and does not induce the classic MAPK signaling cascade.
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Affiliation(s)
- Kristan L Staudenmayer
- Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington, USA
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