Trends in helmet use by motorcycle riders in the decades following the repeal of mandatory helmet laws.

Several US states repealed universal motorcycle helmet laws in the 1990s and 2000s. The purpose of this study was to examine national trends in helmet use among adult trauma patients with motorcycle-related injuries. We hypothesized that motorcycle helmet use declined over time. We retrospectively analyzed the National Trauma Data Bank's National Sample Program for 2003-2010. We also obtained data on US motorcycle fatalities reported in the Fatality Analysis Reporting System and population data from the U.S. Census Bureau to calculate motorcycle-related fatality rates over time. A total of 255,914 patients met inclusion criteria, of whom 148,524 (58%) were helmeted. During the study period, helmet use increased from 56% in 2003 to 60% in 2010 (p < 0.001). However, motorcycle-related fatality rates also increased in states with and without universal helmet laws. Nationally, rates of helmet use have increased. However, fatalities due to motorcycle crashes have also increased during the same period.

Post-trauma mortality increase at age 60: a cutoff for defining elderly?

BACKGROUND: There has been an increasing emphasis on identifying elderly trauma patients. However, definitions based solely on age vary widely, ranging from age 55 to 80 years, hampering optimal trauma management for older patients. The goal of this study was to develop an objective, data-driven definition for "elderly" in trauma care by evaluating mortality risk as a function of age. METHODS: We conducted a retrospective analysis of 872,861 adult (≥18 years) patients from the National Trauma Data Bank's National Sample Program from 2003 to 2010. The primary outcome was risk-adjusted in-hospital mortality determined using multivariate logistic regression. Contribution of age to mortality was investigated through step-wise regression and percent of R2 attributable to age. We searched for straight-line trends in mortality rate at each age using the spline function of Statistical Analysis Software. RESULTS: Statistically significant increases in mortality rate were noted at ages 37, 60, and 78. Age was found to contribute 10% to mortality compared with greater than 80% for Glasgow coma scale and injury severity score combined. CONCLUSIONS: Our findings suggest using age 60 years as a data-driven definition of "elderly" in trauma.

The Hispanic paradox: does it exist in the injured?

BACKGROUND: Hispanics have similar or lower all-cause mortality rates in the general population than non-Hispanic whites (NHWs), despite higher risks associated with lower socioeconomic status, hence termed the "Hispanic Paradox." It is unknown if this paradox exists in the injured. We hypothesized that Hispanic trauma patients have equivalent or lower risk-adjusted mortality and observed-to-expected mortality ratios than other racial/ethnic groups. METHODS: Retrospective analysis of adult patients from the 2010 National Trauma Data Bank was performed. Hispanic patients were compared with NHWs and African Americans (AAs) to assess in-hospital mortality risk in each group. RESULTS: Compared with NHWs, Hispanic patients had lower unadjusted risk of mortality. After adjusting for potential confounders, the difference was no longer statistically significant. Mortality risk was significantly lower for Hispanic patients compared with AAs in both crude and adjusted models. Hispanic patients had significantly lower observed-to-expected mortality ratios than NHWs and AAs. CONCLUSION: Despite reports of racial/ethnic disparities in trauma outcomes, Hispanic patients are not at greater risk of death than NHW patients in a nationwide representative sample of trauma patients.

Distracted driving: prevalence, problems, and prevention.

While the number of motor vehicle crashes has declined over the years, crashes resulting from distracted driving are increasing in the United States resulting in significant morbidity and mortality. The national public seems to be aware of the dangers associated with using technology while driving, but continues to engage in this dangerous behaviour, and may be unaware of or underestimate the impact of cell phone use on their own driving performance. Problems associated with distracted driving are not limited to novice or teenage drivers; multifaceted universal prevention efforts aimed at impacting large segments of the population may have the greatest impact. Legislation limiting drivers' cell phone use has had little impact, possibly due to low regulation and enforcement. Behaviour change programmes, improved vehicle safety, and public awareness campaigns have been developed as potential preventive efforts to reduce accidents caused by distracted drivers.

The correlation of family physician work with submitted codes and fees.

OBJECTIVES: The income disparity between primary care and other physicians has been attributed in part to the evaluation and management (E/M) rules written by CMS. The purpose of this study was to examine the relationship between family physicians' work and their actual coding practices and fees collected under these widely used rules. STUDY DESIGN: This was a direct observational time-motion study. METHODS: A diverse group of 15 family physicians were shadowed over consecutive patient visits at their ambulatory practices, usually for a half-day of clinic. Data about each visit were recorded, including time parameters; number of issues covered; number of labs, images, and chronic prescriptions ordered; the physician fee code from the Current Procedural Terminology (CPT) system that was submitted; the actual payer for each patient; and the actual fee collected. The primary outcome was the correlation between the time spent for each patient's care and coding/financial measures. RESULTS: The average total time a physician spent per patient including documentation time was 20.0 minutes. The average fee collected was $101.40, including patient co-pays. The correlation between the actual fee collected and the physician's time spent working on each patient's behalf was poor (R2 = 0.137, P < .001). There was a wide variation in times and fees for each CPT code category. CONCLUSIONS: The existing E/M rules and CPT coding system have created office visit fees that correlate poorly with family physician work. These findings provide another justification for disruptive primary care payment reform.

Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Femur fractures are common among trauma patients and are typically seen in patients with multiple injuries resulting from high-energy mechanisms. Internal fixation with intramedullary nailing is the ideal method of treatment; however, there is no consensus regarding the optimal timing for internal fixation. We critically evaluated the literature regarding the benefit of early (<24 hours) versus late (>24 hours) open reduction and internal fixation of open or closed femur fractures on mortality, infection, and venous thromboembolism (VTE) in trauma patients. METHODS: A subcommittee of the Practice Management Guideline Committee of the Eastern Association for the Surgery of Trauma conducted a systematic review and meta-analysis for the earlier question. RevMan software was used to generate forest plots. Grading of Recommendations, Assessment, Development, and Evaluations methodology was used to rate the quality of the evidence, using GRADEpro software to create evidence tables. RESULTS: No significant reduction in mortality was associated with early stabilization, with a risk ratio (RR) of 0.74 (95% confidence interval [CI], 0.50-1.08). The quality of evidence was rated as "low." No significant reduction in infection (RR, 0.4; 95% CI, 0.10-1.6) or VTE (RR, 0.63; 95% CI, 0.37-1.07) was associated with early stabilization. The quality of evidence was rated "low." CONCLUSION: In trauma patients with open or closed femur fractures, we suggest early (<24 hours) open reduction and internal fracture fixation. This recommendation is conditional because the strength of the evidence is low. Early stabilization of femur fractures shows a trend (statistically insignificant) toward lower risk of infection, mortality, and VTE. Therefore, the panel concludes the desirable effects of early femur fracture stabilization probably outweigh the undesirable effects in most patients.

Can trauma surgeons manage mild traumatic brain injuries?

BACKGROUND: Current practices suggest that patients with mild traumatic brain injuries (MTBI) receive neurosurgical consultations, while less than 1% require neurosurgical intervention. We implemented a policy of selective neurosurgical consultation with the hypothesis that trauma surgeons alone may manage such patients with no impact on patient outcomes. METHODS: Data from a level I trauma registry were analyzed. Patients with MTBI resulting in an intracranial hemorrhage of 1 cm or less and a Glasgow Coma Score of 13 or greater were included. Patients with additional intracranial injuries were excluded. Multivariate regression was used to determine the relationship between neurosurgical management and good neurologic outcomes, while controlling for injury severity, demographics, and comorbidities. RESULTS: Implementation of the neurosurgical policy significantly reduced the number of such consults (94% before vs 65% after, P < .002). Multivariate analysis revealed that neurosurgical consultation was not associated with neurologic outcomes of patients. CONCLUSIONS: Implementation of a selective neurosurgical consultation policy for patients with MTBI reduced neurosurgical consultations without any impact on patient outcomes, suggesting that trauma surgeons can effectively manage these patients.

Local access to care programs increase trauma patient follow-up compliance.

BACKGROUND: Inadequate follow-up of uninsured trauma patients after discharge remains a major challenge for trauma programs. Local access to care programs (LACPs) have been developed to improve access to health care to the uninsured. We hypothesized that enrollment in LACP would improve postdischarge follow-up of uninsured trauma patients. METHODS: Study population consisted of 5,830 uninsured trauma patients from 2006 to 2011, treated at a large urban level-I trauma center. Patients with burn injuries, transfers to another acute-care facility, and those who died or who left against medical advice were excluded. Patients who enrolled in our LACP were compared with those who did not to determine the relationship between enrollment in LACP and postdischarge follow-up, while controlling for injury severity, demographics, and discharge disposition. RESULTS: Patients in LACP were significantly more likely to schedule follow-up appointments after discharge (odds ratio = 1.78; 95% confidence interval, 1.51 to 2.10) and to comply with them (odds ratio = 2.44; 95% confidence interval, 1.98 to 2.99). However, 30-day readmission rates were similar in the 2 groups (1.1% vs 1.9%). CONCLUSIONS: Enrollment in the LACP was associated with improved postdischarge follow-up but not readmissions.