Tracheostomies for respiratory failure are associated with a high inpatient mortality: a potential trigger to reconsider goals of care.

Introduction: Acute care surgeons are frequently consulted for tracheostomy placement in the intensive care unit (ICU). Tracheostomy may facilitate ventilator weaning and improve physical comfort. Short-term outcomes after tracheostomy are not well studied. We hypothesize that a high proportion of ICU patients who underwent tracheostomy died prior to discharge. These data will help guide clinical decision-making at a key pivot point in care. Methods: We identified 177 mixed ICU patients who received a tracheostomy for respiratory failure between January 2013 and December 2018. We excluded patients with trauma. Patient information was collected and comparisons made with univariable and multivariable statistics. Results: Of the 177 patients who underwent a tracheostomy for respiratory failure, 45% were women, median age was 63 (51-71) years. Of this group 18% died prior to discharge, 63% were discharged to a care facility and only 16% discharged home. Compared with survivors, patients with tracheostomies who died during their admission were older, age 69 (64-76) versus 61 (49-71) years (p<0.01) on univariable analysis. In this model, no single comorbid condition or length of stay (LOS) variable was predictive of death before discharge. A multivariable model controlling for covariation similarly identified age, as well as a longer ICU LOS of 34 (20-49) versus 23 (16-31) days (p=0.003) as factors associated with increased likelihood of death before discharge. Conclusions: Tracheostomy placement in a mixed ICU population is associated with a nearly 20% inpatient mortality and the vast majority of surviving patients were discharged to a care facility. This suggests that the need for tracheostomy could be considered a trigger for re-evaluation of patient goals. The high risk of death due to underlying illness and high intensity care after their hospitalization emphasize the need for clear advanced care planning discussions around the time of tracheostomy placement. Level of Evidence: Level IV, Retrospective cohort study.

Risk Stratification in Primary Care: Value-Based Contributions of Provider Adjudication.

BACKGROUND: In primary care risk stratification, automated algorithms do not consider the same factors as providers. The process of adjudication, in which providers review and adjust algorithm-derived risk scores, may improve the prediction of adverse outcomes. OBJECTIVE: We assessed the patient factors that influenced provider adjudication behavior and evaluated the performance of an adjudicated risk model against a commercial algorithm. DESIGN: (1) Structured interviews with primary care providers (PCP) and multivariable regression analysis and (2) receiver operating characteristic curves (ROC) with sensitivity analyses. PARTICIPANTS: Primary care patients aged 18 years and older with an adjudicated risk score. APPROACH AND MAIN MEASURES: (1) Themes from structured interviews and discrete variables associated with provider adjudication behavior; (2) comparison of concordance statistics and sensitivities between risk models. KEY RESULTS: 47,940 patients were adjudicated by PCPs in 2018. Interviews revealed that, in adjudication, providers consider disease severity, presence of self-management skills, behavioral health, and whether a risk score is actionable. Provider up-scoring from the algorithmic risk score was significantly associated with patient male sex (OR 1.24, CI 1.15-1.34), age > 65 (OR 2.55, CI 2.24-2.91), Black race (1.26, CI 1.02-1.55), polypharmacy >10 medications (OR 4.87, CI 4.27-5.56), a positive depression screen (OR 1.57, CI 1.43-1.72), and hemoglobin A1c >9 (OR 1.89, CI 1.52-2.33). Overall, the adjudicated risk model performed better than the commercial algorithm for all outcomes: ED visits (c-statistic 0.689 vs. 0.684, p < 0.01), hospital admissions (c-statistic 0.663 vs. 0.649, p < 0.01), and death (c-statistic 0.753 vs. 0.721, p < 0.01). When limited to males or seniors, the adjudicated models displayed either improved or non-inferior performance compared to the commercial model. CONCLUSIONS: Provider adjudication of risk stratification improves model performance because providers have a personal understanding of their patients and are able to apply their training to clinical decision-making.

Association of the Mandatory Medicare Bundled Payment With Joint Replacement Outcomes in Hospitals With Disadvantaged Patients.

Importance: Medicare's Comprehensive Care for Joint Replacement (CJR) model rewards or penalizes hospitals on the basis of meeting spending benchmarks that do not account for patients' preexisting social and medical complexity or high expenses associated with serving disadvantaged populations such as dual-eligible patients (ie, those enrolled in both Medicare and Medicaid). The CJR model may have different implications for hospitals serving a high percentage of dual-eligible patients (termed high-dual) and hospitals serving a low percentage of dual-eligible patients (termed low-dual). Objective: To examine changes associated with the CJR model among high-dual or low-dual hospitals in 2016 to 2017. Design, Setting, and Participants: This cohort study comprised 3 analyses of high-dual or low-dual hospitals (n = 1165) serving patients with hip or knee joint replacements (n = 768 224) in 67 treatment metropolitan statistical areas (MSAs) selected for CJR participation and 103 control MSAs. The study used Medicare claims data and public reports from 2012 to 2017. Data analysis was conducted from February 1, 2019, to August 31, 2019. Exposures: The CJR model holds participating hospitals accountable for the spending and quality of care during care episodes for patients with hip or knee joint replacement, including hospitalization and 90 days after discharge. Main Outcomes and Measures: The primary outcomes were total episode spending, discharge to institutional postacute care facility, and readmission within the 90-day postdischarge period; bonus and penalty payments for each hospital; and reductions in per-episode spending required to receive a bonus for each hospital. Results: In total, 1165 hospitals (291 high-dual and 874 low-dual) and 768 224 patients with joint replacement (494 013 women [64.3%]; mean [SD] age, 76 [7] years) were included. An episode-level triple-difference analysis indicated that total spending under the CJR model decreased at high-dual hospitals (by $851; 95% CI, -$1556 to -$146; P = .02) and low-dual hospitals (by $567; 95% CI, -$933 to -$202; P = .003). The size of decreases did not differ between the 2 groups (difference, -$284; 95% CI, -$981 to $413; P = .42). Discharge to institutional postacute care settings and readmission did not change among both hospital groups. High-dual hospitals were less likely to receive a bonus compared with low-dual hospitals (40.3% vs 59.1% in 2016; 56.9% vs 76.0% in 2017). To receive a bonus, high-dual hospitals would be required to reduce spending by $887 to $2231 per episode, compared with only $89 to $215 for low-dual hospitals. Conclusions and Relevance: The study found that high- and low-dual hospitals made changes in care after CJR implementation, and the magnitude of these changes did not differ between the 2 groups. However, high-dual hospitals were less likely to receive a bonus for spending cuts. Spending benchmarks for CJR would require high-dual hospitals to reduce spending more substantially to receive a financial incentive.

Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: a Propensity-Matched Analysis.

BACKGROUND: Hospitalizations due to medical and surgical complications of substance use disorder (SUD) are rising. Most hospitals lack systems to treat SUD, and most people with SUD do not engage in treatment after discharge. OBJECTIVE: Determine the effect of a hospital-based addiction medicine consult service, the Improving Addiction Care Team (IMPACT), on post-hospital SUD treatment engagement. DESIGN: Cohort study using multivariable analysis of Oregon Medicaid claims comparing IMPACT patients with propensity-matched controls. PARTICIPANTS: 18-64-year-old Oregon Medicaid beneficiaries with SUD, hospitalized at an Oregon hospital between July 1, 2015, and September 30, 2016. IMPACT patients (n = 208) were matched to controls (n = 416) using a propensity score that accounted for SUD, gender, age, race, residence region, and diagnoses. INTERVENTIONS: IMPACT included hospital-based consultation care from an interdisciplinary team of addiction medicine physicians, social workers, and peers with lived experience in recovery. IMPACT met patients during hospitalization; offered pharmacotherapy, behavioral treatments, and harm reduction services; and supported linkages to SUD treatment after discharge. OUTCOMES: Healthcare Effectiveness Data and Information Set (HEDIS) measure of SUD treatment engagement, defined as two or more claims on two separate days for SUD care within 34 days of discharge. RESULTS: Only 17.2% of all patients were engaged in SUD treatment before hospitalization. IMPACT patients engaged in SUD treatment following discharge more frequently than controls (38.9% vs. 23.3%, p < 0.01; aOR 2.15, 95% confidence interval [CI] 1.29-3.58). IMPACT participation remained associated with SUD treatment engagement when limiting the sample to people who were not engaged in treatment prior to hospitalization (aOR 2.63; 95% CI 1.46-4.72). CONCLUSIONS: Hospital-based addiction medicine consultation can improve SUD treatment engagement, which is associated with reduced substance use, mortality, and other important clinical outcomes. National expansion of such models represents an opportunity to address an enduring gap in the SUD treatment continuum.

Higher Quality, Lower Cost with an Innovative Geriatrics Consultation Service.

OBJECTIVES: To design a value-driven, interprofessional inpatient geriatric consultation program coordinated with systems-level changes and studied outcomes and costs. DESIGN: Propensity-matched case-control study of older adults hospitalized at an academic medical center (AMC) who did or did not receive geriatric consultation. SETTING: Single tertiary-care AMC in Portland, Oregon. PARTICIPANTS: Adults aged 70 and older who received an inpatient geriatric consultation (n=464) and propensity-matched controls admitted before development of the consultation program (n=2,381). Pre- and postintervention controls were also incorporated into cost difference-in-difference analyses. MEASUREMENTS: Daily charges, total charges, length of stay (LOS), 30-day readmission, intensive care unit (ICU) days, Foley catheter days, total medication doses per day, high-risk medication doses per day, advance directive and Physician Orders for Life Sustaining Treatment (POLST) documentation, restraint orders, discharge to home, and mortality. RESULTS: On average, individuals who received a geriatric consultation had $611 lower charges per day than those without a consultation (p=.02). They spent on average 0.36 fewer days in the ICU (p<.001). They were less likely to have restraint orders (20.0% vs 27.9%, p<0.001), more likely to have a POLST (58.2% vs 44.6%, p<.001), and more likely to be discharged to home (33.4% vs 28.2%, p=.03). They received fewer doses of antipsychotics, benzodiazepines, and antiemetics (10, 5, and 7 fewer doses per 100 patient-days, respectively) and had lower in-hospital mortality (2.4% vs 4%, p=.01). There was no difference in hospital LOS or 30-day readmission. CONCLUSION: Our consultation program resulted in significant reductions in daily charges, ICU days, potentially inappropriate medication use, and use of physical restraints and increased end-of-life planning. This model has potential for dissemination to other institutions operating in resource-scarce, value-driven settings.

Dental insurance and dental care among working-age adults: differences by type and complexity of disability.

OBJECTIVES: People with disabilities experience barriers to dental care, which may vary depending on type of disability and disability complexity (e.g., impact on activities of daily living). The purpose of this study was to examine differences in dental insurance, receipt of dental checkups, and delayed and unmet needs for dental care by type and complexity of disability. METHODS: We conducted cross-sectional analysis of 2002-2011 data from the Medical Expenditure Panel Survey. Multivariable logistic regression analyses compared adults ages 18-64 in five disability type groups (physical, cognitive, vision, hearing, or multiple disabilities) to those with no disabilities, and compared people with complex activity limitations to those without complex limitations. RESULTS: All disability types except hearing had significantly higher adjusted odds of being without dental insurance, as did people with complex activity limitations. All disability groups except those with cognitive disabilities had increased odds of receiving dental checkups less than once a year. Similarly, all disability groups were at increased risk of both delayed and unmet needs for dental care. Odds ratios were generally highest for people with multiple types of disabilities. CONCLUSIONS: There are significant disparities in having dental insurance and receiving dental care for adults with disabilities, especially those with multiple types of disabilities, after controlling for socioeconomic and demographic differences. Further, disparities in care were apparent even when controlling for presence of dental insurance.

Food Insecurity, Hunger, and Obesity Among Informal Caregivers.

INTRODUCTION: Increasing numbers of US residents rely on informal caregiving from friends and family members. Caregiving can have substantial health and financial impacts on caregivers. This study addressed whether those impacts include adverse nutritional states. Specifically, we examined household food insecurity, individual hunger, and obesity among caregivers compared with noncaregivers. METHODS: We analyzed 2012 Behavioral Risk Factor Surveillance System data from Oregon. The Caregiving Module was administered to a random subset of 2,872 respondents. Module respondents included 2,278 noncaregivers and 594 caregivers providing care or assistance to a friend or family member with a health problem or disability. We used multivariable logistic regression to assess associations between caregiving status and each of our dependent variables. RESULTS: Caregivers had significantly greater odds of reporting household food insecurity (odds ratio [OR] = 2.10, P = .003) and personal hunger (OR = 2.89, P = .002), even after controlling for income and other correlates of food insecurity. There were no significant differences in obesity between caregivers and noncaregivers. CONCLUSION: Caregiving is associated with increased risk of food insecurity and hunger in Oregon, suggesting that careful attention to the nutritional profile of households with family caregivers is needed in this population.

Disparities in dental care associated with disability and race and ethnicity.

BACKGROUND: Both racial and ethnic and disability-related disparities in dental care exist, yet little is known about the cumulative effect of these 2 characteristics. The purpose of this study was to determine how the combination of disability and race and ethnicity is associated with dental examinations, delays in receiving needed care, and inability to obtain needed care among noninstitutionalized working-age adults in the United States. METHODS: The authors conducted cross-sectional analyses of Medical Expenditure Panel Survey data pooled across the years 2002 to 2012, yielding a sample of 208,548. Multivariable logistic regression analyses were used to examine the association of disability (including physical, sensory, and cognitive limitations) and race and ethnicity with each of the dependent variables. RESULTS: Compared with non-Hispanic whites, other racial and ethnic groups were less likely to receive annual dental examinations. There were significant disparities for people with disabilities in receipt of examinations, delays in obtaining needed care, and being unable to obtain needed care. The combination of disability status and membership in an underserved racial or ethnic group was associated with a greater magnitude of disparity in all 3 areas, especially for American Indian, Alaska Native, and multiracial people with disabilities. CONCLUSIONS: Community-dwelling adults with disabilities in underserved racial and ethnic groups have higher levels of delayed and unmet needs for dental care and lower receipt of routine dental examinations. PRACTICAL IMPLICATIONS: As the United States population ages and grows more diverse, the population of people with disabilities in underserved racial and ethnic groups will expand. Dentists need to be aware of, and be prepared to address, the needs of these people.

Disparities in receipt of breast and cervical cancer screening for rural women age 18 to 64 with disabilities.

BACKGROUND: Previous research has found breast and cervical cancer screening disparities between women with and without disabilities, and between women living in rural versus urban areas. Living in a rural area may add to the barriers women with disabilities experience when attempting to obtain screening for breast and cervical cancer. The purpose of this study was to examine the combination of disability status and rurality in association with receipt of breast and cervical cancer screening among women age 18 to 64 in the United States. METHODS: We conducted cross-sectional analyses of data from the Medical Expenditure Panel Survey, using pooled annual data files from 2002 through 2008. We compared recent receipt of breast and cervical cancer screening among four groups: 1) urban women without disabilities, 2) urban women with disabilities, 3) rural women without disabilities, and 4) rural women with disabilities. FINDINGS: Overall, women with disabilities were less likely to be up to date with mammograms and Pap tests compared with women with no disabilities. Similarly, women in rural areas were less likely to have received breast or cervical cancer screening within recommended timeframes. Women who both had a disability and lived in a rural area were the least likely to be current with screening. CONCLUSIONS: Our findings suggest that living in rural regions compounds disparities in receipt of cancer screening among women with disabilities. Increased attention is needed to improve receipt of cancer screening among rural women with disabilities.

Subgroup differences in having a usual source of health care among working-age adults with and without disabilities.

BACKGROUND: Having a usual source of health care is positively associated with regular health maintenance visits and receipt of preventive services. People with disabilities are, overall, more likely than those without disabilities to have a usual source of care (USC). However, the population of people with disabilities is quite heterogenous, and some segments of the population may have less access to a USC than others. OBJECTIVE: To determine whether there are significant subgroup differences in having a USC within the U.S. population of working-age adults with disabilities, and to compare adults with and without disabilities while controlling for other subgroup differences. METHODS: We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. We performed both bivariate and multivariate logistic regression analyses to examine the relationship of sociodemographic and disability subgroup variables with having a USC. RESULTS: Within the disability population, individuals who were younger; male; Black, Hispanic, or other (non-White) race; less educated; of lower income; or uninsured for part or all of the year were significantly less likely to have a USC. These differences mirrored those among adults without disabilities. When controlling for these differences, people with physical, hearing, or multiple disabilities had greater odds of having a USC than people without disabilities, but those with vision or cognitive limitations did not differ significantly from the non-disabled referent group. CONCLUSIONS: Disparities among people with and without disabilities are similar, underscoring the need for attention to disparities within the disability population.

Usual source of care and unmet health care needs: interaction of disability with race and ethnicity.

BACKGROUND: Having a usual source of care (USC) and having unmet health care needs have been found to vary in relation to sociodemographic differences in the US population, including race, ethnicity, and disability status. People in underserved racial and ethnic groups who also have a disability may experience a complex mix of health care advantages and disparities. However, little is known about this intersection. OBJECTIVE: To determine how disability status, combined with membership in an underserved racial or ethnic group, is associated with having a USC and unmet health care needs. METHODS: We conducted multivariate regression analyses of 2002-2010 data from the Medical Expenditure Panel Survey, focused on working age adults (18-64 y). RESULTS: Although most racial and ethnic groups were less likely to have a USC than non-Hispanic whites, people with disabilities were more likely to have a USC; Hispanics with basic activity limitations were the only disability group with elevated odds of lacking a USC. Conversely, disability was strongly associated with unmet health care needs, but we did not find inflated impacts of both having a disability and belonging to an underserved racial or ethnic group. CONCLUSIONS: We found limited evidence of interaction or additive effects of disability and race/ethnicity but did confirm separate disparities for each. Ongoing research is needed to track both disability-related and racial/ethnic disparities, to determine whether increased insurance coverage, provider training, care coordination, and other efforts under the Affordable Care Act lead to reductions in disparities.

Rural disparities in receipt of colorectal cancer screening among adults ages 50-64 with disabilities.

BACKGROUND: Colorectal cancer is the third leading cause of cancer deaths in the United States. Early detection can reduce mortality; however, only 59% of U.S. adults age 50 and over meet recommended colorectal cancer screening guidelines. Studies in the general population have observed that rural residents are less likely to have received colorectal cancer screening than residents of urban areas. OBJECTIVE: To determine whether urban/rural disparities in colorectal cancer screening exist among people with disabilities, similar to the disparities found in the general population. METHODS: We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. We conducted logistic regression analyses to examine the relationship between urban/rural residence and ever having received screening for colorectal cancer (via colonoscopy, sigmoidoscopy, or fecal occult blood test). RESULTS: Among U.S. adults ages 50-64 with disabilities, those living in rural areas were significantly less likely to have ever received any type of screening for colorectal cancer. The urban/rural difference was statistically significant regardless of whether or not we controlled for demographic, socioeconomic, health, and health care access variables. CONCLUSIONS: Disparity in screening for colorectal cancer places rural residents with disabilities at greater risk for late stage diagnosis and mortality relative to people with disabilities in urban areas. Thus, there is a need for strategies to improve screening among people with disabilities in rural areas.

Disparities in health care access and receipt of preventive services by disability type: analysis of the medical expenditure panel survey.

OBJECTIVE: To examine differences in access to health care and receipt of clinical preventive services by type of disability among working-age adults with disabilities. DATA SOURCE: Secondary analysis of Medical Expenditure Panel Survey (MEPS) data from 2002 to 2008. STUDY DESIGN: We conducted cross-sectional logistic regression analyses comparing people with different types of disabilities on health insurance status and type; presence of a usual source of health care; delayed or forgone care; and receipt of dental checkups and cancer screening. DATA COLLECTION: We pooled annualized MEPS data files across years. Our analytic sample consisted of adults (18-64 years) with physical, sensory, or cognitive disabilities and nonmissing data for all variables of interest. PRINCIPAL FINDINGS: Individuals with hearing impairment had better health care access and receipt than people with other disability types. People with multiple types of limitations were especially likely to have health care access problems and unmet health care needs. CONCLUSIONS: There are differences in health care access and receipt of preventive care depending on what type of disability people have. More in-depth research is needed to identify specific causes of these disparities and assess interventions to address health care barriers for particular disability groups.

Health outcome disparities among subgroups of people with disabilities: a scoping review.

BACKGROUND: A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population. However, the population of people with disabilities is quite diverse. Thus, it is important to understand health differences between subgroups of people with disabilities in order to most effectively target interventions to address disparities. An initial step in this process is reviewing and synthesizing available research addressing these subgroup differences. OBJECTIVES: To conduct a scoping review of literature to describe recent research activity that has examined health outcome disparities within populations of people with disabilities. METHODS: We searched for relevant articles in MEDLINE, PsycINFO, and CINAHL databases. Three staff independently reviewed abstracts according to inclusion criteria. Two authors then independently extracted data from each included article. RESULTS: For many of the health outcomes of interest, there was no published literature in relation to key disparity factors (e.g. race, income) within the population of people with disabilities. The health outcomes most frequently examined were diabetes and heart disease. The most frequently examined disparity factors were the type of disabling condition and gender. CONCLUSIONS: There are significant gaps in available research. Building a body of research that identifies disparities and potentially vulnerable subgroups may improve understanding of the causes of disparities and contribute to efforts to improve quality of life and health outcomes for individuals with disabilities.

Breast and cervical cancer screening disparities associated with disability severity.

BACKGROUND: Prior research has noted disparities between women with and without disabilities in receipt of timely screening for breast and cervical cancer. Some studies suggest greater disparities for women with more severe disabilities, but the research to date has yielded inconsistent findings. Our purpose was to further examine differences in receipt of breast and cervical cancer screening in relation to severity of disability. METHODS: We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. Logistic regression analyses examined whether Pap smears and mammograms had been received within the recommended timeframe according to U.S. Preventive Services Task Force Guidelines. We compared four groups of women aged 18 to 64 years, categorized by presence and complexity of disability: 1) No limitations, 2) basic action difficulties only, 3) complex activity limitations only, and 4) both basic and complex activity limitations. FINDINGS: Women both with and without disabilities fell short of Healthy People 2020 goals for breast and cervical cancer screening. Overall, women with disabilities were less likely to be up to date with both mammograms and Pap tests. The magnitude of disparities was greater for women with complex limitations. Disparities in Pap testing, but not mammography, remained significant when controlling for demographic, geographic, and socioeconomic factors. CONCLUSIONS: Women with more complex or severe disability were less likely to be up to date with breast and cervical cancer screenings. Targeted efforts are needed to reduce barriers to breast and cervical cancer screening for women with significant disabilities, especially those who also experience other socioecological disadvantages.

Disparities in chronic conditions and health status by type of disability.

BACKGROUND: Prior research has established health disparities between people with and without disabilities. However, disparities within the disability population, such as those related to type of disability, have been much less studied. OBJECTIVE: To examine differences in chronic conditions and health status between subgroups of people with different types of disability. METHODS: We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. Logistic regression analyses considered disparity from three perspectives: 1) basic differences, unadjusted for other factors; 2) controlling for key demographic and health covariates; and 3) controlling for a larger set of demographic variables and socioeconomic status as well as health and access to healthcare. RESULTS: Individuals with vision, physical, cognitive, or multiple disability types fared worse than people with hearing impairment on most health outcomes. This was most consistently true for people with multiple disabilities. Even when all covariates were accounted for, people with multiple types of disability were significantly more likely (p < 0.05) than those with hearing impairment (reference group) to report every poor health outcome with the exception of BMI ≥ 25 and lung disease. CONCLUSIONS: While many of the differences between disability types were reduced when controlling for other factors, some differences remained significant. This argues for a more individualized approach to understanding and preventing chronic conditions and poor health in specific disability groups.

The relationship between vehicle roof crush and head, neck and spine injury in rollover crashes.

BACKGROUND: It is well established that rollover crashes are associated with a higher risk of serious injury and death than other types of crashes. Some of the most serious injuries that can result from a rollover crash are those to the head, neck and spine. The mechanism of injury to these body parts in a rollover is a matter of dispute in the literature. Some authors have concluded that the magnitude of vehicle roof deformation or vertical roof crush resulting from a rollover crash is not causally associated with head and neck injury severity, while others offer support for a causal association between roof crush and the degree of injury. A better understanding of the cause of serious injuries resulting from rollover crashes is important for improving injury prevention. METHODS: This study utilized data from the National Automotive Sampling System--Crashworthiness Data System (NASS-CDS) for the years 1997 through 2007. Both cross-sectional and matched case-control designs along with a new composite injury metric termed the Head, Neck and Spine New Injury Severity Score (HNS-NISS) were used to analyze these data. RESULTS: The cross-sectional analysis demonstrated a 64% (95% CI: 26-114%) increase in the odds of a life-threatening injury as estimated by the HNS-NISS with every 10 cm of increased roof crush. The results of the matched case-control analysis demonstrated a 44% (95% CI: 8-91%) increase in the odds of sustaining any injury to the head, neck or spine with every 10 cm increase in roof crush. CONCLUSION: These results lend statistical support to a causal association between roof crush and head, neck and spine injury severity. Though they do not constitute definitive proof, they do contradict previously published theories suggesting that roof deformation is unrelated to such injuries.