Otolaryngologist Characteristics and Outlier Use of Balloon Sinuplasty in the Medicare Population.

OBJECTIVE: Balloon sinuplasty (BSP) is associated with varied practice patterns. This study sought to identify otolaryngologist characteristics associated with BSP utilization. STUDY DESIGN: Retrospective analysis of Medicare claims data and the National Physician Compare database. METHODS: Outlier otolaryngologists were compared to non-outliers. Otolaryngologist characteristics included sex, practice size, geographic setting, years of experience, procedure setting, 10 or fewer endoscopic sinus surgeries per year for 3 or more years, and high number of services per unique Medicare beneficiary. Outlier status was defined as performing an annual total of balloon procedures of 2 standard deviations (SDs) above the mean for all otolaryngologists in the same year. RESULTS: Between January 2012 and December 2017, 1,408 otolaryngologists performed 101,662 endoscopic sinus surgeries and 97,680 BSP procedures. Sixty-six outlier otolaryngologists (4.7%) accounted for 44.3% of all BSP procedures. Outlier status was associated with practice size of 10 or fewer individual providers (OR, 5.15; 95% CI, 2.73-9.74; P < .001), performance of 10 or fewer total endoscopic sinus surgeries per year for 3 or more years (OR, 3.90; 95% CI, 1.59-9.57; P = .003), and high number of overall services per beneficiary (OR 6.70; 95% CI, 1.19-37.84; P = .031). Provider sex, years of experience, and geographic setting were not associated with outlier status. CONCLUSION: Outlier BSP patterns are associated with a few otolaryngologists who are more likely to be identified in small practices and record low numbers of endoscopic surgeries. Although BSP is an appropriate and effective tool, identification of outlier patterns may help to facilitate peer-to-peer counsel. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1340-1345, 2022.

Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery.

BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis. METHODS: We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications. RESULTS: Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas. CONCLUSIONS: Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia.

Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society.

INTRODUCTION: Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented. METHODS: Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay. RESULTS: Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel. CONCLUSION: We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.

A modified Kampala trauma score (KTS) effectively predicts mortality in trauma patients.

BACKGROUND: Mortality prediction in trauma patients has relied upon injury severity scoring tools focused on anatomical injury. This study sought to examine whether an injury severity scoring system which includes physiologic data performs as well as anatomic injury scores in mortality prediction. METHODS: Using data collected from 18 Level I trauma centers and 51 non-trauma center hospitals in the US, anatomy based injury severity scores (ISS), new injury severity scores (NISS) were calculated as were scores based on a modified version of the physiology-based Kampala trauma score (KTS). Because pre-hospital intubation, when required, is standard of care in the US, a modified KTS was calculated excluding respiratory rate. The predictive ability of the modified KTS for mortality was compared with the ISS and NISS using receiver operating characteristic (ROC) curves. RESULTS: A total of 4716 individuals were eligible for study. Each of the three scores was a statistically significant predictor of mortality. In this sample, the modified KTS significantly outperformed the ISS (AUC=0.83, 95% CI 0.81-0.84 vs. 0.77, 95% CI 0.76-0.79, respectively) and demonstrated similar predictive ability compared to the NISS (AUC=0.83, 95% CI 0.81-0.84 vs. 0.82, 95% CI 0.80-0.83, respectively). CONCLUSIONS: The modified KTS may represent a useful tool for assessing trauma mortality risk in real time, as well as in administrative data where physiologic measures are available. Further research is warranted and these findings suggest that the collection of physiologic measures in large databases may improve outcome prediction.

Helicopter overtriage in pediatric trauma.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) have been designed to provide faster access to trauma center care in cases of life-threatening injury. However, the ideal recipient population is not fully characterized, and indications for helicopter transport in pediatric trauma vary dramatically by county, state, and region. Overtriage, or unnecessary utilization, can lead to additional patient risk and expense. In this study we perform a nationwide descriptive analysis of HEMS for pediatric trauma and assess the incidence of overtriage in this group. METHODS: We reviewed records from the American College of Surgeons National Trauma Data Bank (2008-11) and included patients less than 16 years of age who were transferred from the scene of injury to a trauma center via HEMS. Overtriage was defined as patients meeting all of the following criteria: Glasgow Coma Scale (GCS) equal to 15, absence of hypotension, an Injury Severity Score (ISS) less than 9, no need for procedure or critical care, and a hospital length of stay of less than 24 hours. RESULTS: A total of 19,725 patients were identified with a mean age of 10.5 years. The majority of injuries were blunt (95.6%) and resulted from motor vehicle crashes (48%) and falls (15%). HEMS transported patients were predominately normotensive (96%), had a GCS of 15 (67%), and presented with minor injuries (ISS<9, 41%). Overall, 28 % of patients stayed in the hospital for less than 24 hours, and the incidence of overtriage was 17%. CONCLUSIONS: Helicopter overtriage is prevalent among pediatric trauma patients nationwide. The ideal model to predict need for HEMS must consider clinical outcomes in the context of judicious resource utilization. The development of guidelines for HEMS use in pediatric trauma could potentially limit unnecessary transfers while still identifying children who require trauma center care in a timely fashion.

Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?

BACKGROUND: We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation. METHODS: A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled. RESULTS: The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage. CONCLUSION: Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.

Disparities in trauma care: are fewer diagnostic tests conducted for uninsured patients with pelvic fracture?

BACKGROUND: Research from other medical specialties suggests that uninsured patients experience treatment delays, receive fewer diagnostic tests, and have reduced health literacy when compared with their insured counterparts. We hypothesized that these disparities in interventions would not be present among patients experiencing trauma. Our objective was to examine differences in diagnostic and therapeutic procedures administered to patients undergoing trauma with pelvic fractures using a national database. METHODS: A retrospective analysis was conducted using the National Trauma Data Bank (NTDB), 2002 to 2006. Patients aged 18 to 64 years who experienced blunt injuries with pelvic fractures were analyzed. Patients who were dead on arrival, those with an injury severity score (ISS) less than 9, those with traumatic brain injury, and patients with burns were excluded. The likelihood of the uninsured receiving select diagnostic and therapeutic procedures was compared with the same likelihood in the insured. Multivariate analysis for mortality was conducted, adjusting for age, sex, race, ISS, presence of shock, Glasgow Coma Scale (GCS) motor score, and mechanism of injury. RESULTS: Twenty-one thousand patients met the inclusion criteria: 82% of these patients were insured and 18% were uninsured. There was no clinical difference in ISSs (21 vs 20), but the uninsured were more likely to present in shock (P < .001). The mortality rate in the uninsured was 11.6% vs 5.0% in the insured (P < .001). The uninsured were less likely to receive vascular ultrasonography (P = .01) and computed tomography (CT) of the abdomen (P < .005). There was no difference in the rates of CT of the thorax and abdominal ultrasonography, but the uninsured were more likely to receive radiographs. There was no difference in exploratory laparotomy and fracture reduction, but uninsured patients were less likely to receive transfusions, central venous pressure (CVP) monitoring, or arterial catheterization for embolization. Insurance-based disparities were less evident in level 1 trauma centers. CONCLUSIONS: Uninsured patients with pelvic fractures get fewer diagnostic procedures compared with their insured counterparts; this disparity is much greater for more invasive and resource-intensive tests and is less apparent in level 1 trauma centers. Differences in care that patients receive after trauma may be 1 of the mechanisms that leads to insurance disparities in outcomes after trauma.

Disparities in mortality after blunt injury: does insurance type matter?

BACKGROUND: Insurance-related outcomes disparities are well-known, but associations between distinct insurance types and trauma outcomes remain unclear. Prior studies have generally merged various insurance types into broad groups. The purpose of this study is to determine the association of specific insurance types with mortality after blunt injury. MATERIALS AND METHODS: Cases of blunt injury among adults aged 18-64 y with an injury severity score >9 were identified using the 2007-2009 National Trauma Data Bank. Crude mortality was calculated for 10 insurance types. Multivariable logistic regression was employed to determine difference in odds of death between insurance types, controlling for injury severity score, Glasgow Coma Scale motor, mechanism of injury, sex, race, and hypotension. Clustering was used to account for possible inter-facility variations. RESULTS: A total of 312,312 cases met inclusion criteria. Crude mortality ranged from 3.2 to 6.0% by insurance type. Private Insurance, Blue Cross Blue Shield, Workers Compensation, and Medicaid yielded the lowest relative odds of death, while Not Billed and Self Pay yielded the highest. Compared with Private Insurance, odds of death were higher for No Fault (OR 1.25, P = 0.022), Not Billed (OR 1.77, P < 0.001), and Self Pay (OR 1.77, P < 0.001). Odds of death were higher for Medicare (OR 1.52, P < 0.001) and Other Government (OR 1.35, P = 0.049), while odds of death were lower for Medicaid (OR 0.89, P = 0.015). CONCLUSIONS: Significant differences in mortality after blunt injury were seen between insurance types, even among those commonly grouped in other studies. Policymakers may use this information to implement programs to monitor and reduce insurance-related disparities.

Alarming surge in nonsurvivable urban trauma and the case for violence prevention.

HYPOTHESIS: A growing proportion of urban trauma mortality is characterized by devastating and likely nonsurvivable injuries. DESIGN: Consecutive samples from prospectively collected registry data. SETTING: University level I trauma center. PATIENTS: All trauma patients from January 1, 2000, to March 31, 2005. MAIN OUTCOME MEASURES: Data for trauma patients, including locale of death and mechanism of injury, comparing early (years 2000 through 2003) and late (2004 and 2005) periods. RESULTS: A total of 11 051 trauma visits were registered during the study period with 366 deaths for an overall mortality of 3.3%. Penetrating injury occurred in 26.7% of patients; however, 71.9% of trauma mortalities (263 patients) died with penetrating injuries. Of the patients who died, 48.3% demonstrated severe penetrating injuries (Abbreviated Injury Score >/=4) to the head while 32.7% presented with severe penetrating chest injuries. There was a significant increase in the mortality rate over time (3.0% [early] vs 4.3% [late], P<.01). In parallel, emergency department mortality (patients dead on arrival and those not surviving to hospital admission) increased from 1.7% to 3.1% (P<.005), yet postadmission mortality remained constant (1.3% [early] vs 1.2% [late], P = .77). When emergency department mortality and the subsequent hospital mortality of patients with gunshot wounds to the head were combined, this represented 82.6% of all trauma mortalities in the late period. This was increased from 69.7% during the early period (P<.01). CONCLUSIONS: While in-hospital mortality has remained the same, the proportion of nonsurvivable traumatic injuries has increased. In a mature trauma system, this provides a compelling argument for violence prevention strategies to reduce urban trauma mortality.