Value in Acute Care Surgery, Part 3: Defining Value in Acute Surgical Care - It Depends on the Perspective.

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.

The interaction between geriatric and neighborhood vulnerability: Delineating prehospital risk among older adult emergency general surgery patients.

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.

Changes in Older Adult Trauma Quality When Evaluated Using Longer-Term Outcomes vs In-Hospital Mortality.

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.

Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale.

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.

Power of mentorship for civilian and military acute care surgeons: identifying and leveraging opportunities for longitudinal professional development.

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.

Reconceptualizing high-quality emergency general surgery care: Non-mortality-based quality metrics enable meaningful and consistent assessment.

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.

Association Between Implementation of a Geriatric Trauma Clinical Pathway and Changes in Rates of Delirium in Older Adults With Traumatic Injury.

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.

Value in acute care surgery, part 2: Defining and measuring quality outcomes.

ABSTRACT: The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.

Emergency General Surgery Quality Improvement: A Review of Recommended Structure and Key Issues.

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.

Value in acute care surgery, Part 1: Methods of quantifying cost.

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.

The Economic Footprint of Interventional Radiology in the United States: Implications for Systems Development.

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.

Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume.

BACKGROUND: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE: Epidemiological, level III.

Firearm Legislation Stringency and Firearm-Related Fatalities among Children in the US.

BACKGROUND: Firearm-related injuries are the second leading cause of pediatric deaths in the US. We sought to evaluate the effectiveness of both state child access prevention (CAP) laws and gun regulations on pediatric firearm mortality. We hypothesized that states with more stringent firearm legislation had lower pediatric firearm mortality. STUDY DESIGN: We used 2014-2015 firearm mortality data from the Web-Based Injury Statistics Query and Reporting System, 2014 Brady scores (used to quantify stringency of state gun regulations) and CAP laws. State-level covariates were obtained from government sources, including the Bureau of Labor Statistics and the Department of Education. Spearman rank correlations and linear regression were used to determine the relationship between overall pediatric firearm mortality and gun regulations. We also examined the relationship between gun regulations and firearm-related homicides and suicides. RESULTS: Annually, there were approximately 2,715 pediatric firearm fatalities among children; 62.1% were homicides and 31.4% suicides. There was a moderate negative correlation between states' firearm legislation stringency and overall pediatric firearm mortality (ρ = -0.66; p < 0.001), and between CAP laws and firearm suicide rates (ρ = -0.56; p < 0.001). After controlling for poverty, unemployment, substance abuse, and the number of registered firearms, the association between firearm legislation stringency and overall pediatric firearm mortality remained significant (p = 0.04). The association between CAP laws and firearm suicide rate remained significant after controlling for socioeconomic factors, registered firearms, and other firearm legislation (p = 0.04). CONCLUSIONS: Strict gun legislation and CAP laws are associated with fewer pediatric firearm fatalities and firearm suicides, respectively, though no such association was identified with pediatric firearm homicides. Although more studies are needed to determine causality, state-level legislation could play an important role in reducing pediatric firearm-related deaths.

Nonoperative Management of Uncomplicated Appendicitis Among Privately Insured Patients.

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.

Interhospital variability in time to discharge to rehabilitation among insured trauma patients.

BACKGROUND: Hospital costs are partly a function of length of stay (LOS), which can be impacted by the local availability of postacute care (PAC) resources (inpatient rehabilitation and skilled nursing facilities), particularly for injured patients. We hypothesized that LOS for trauma patients destined for PAC would be variable based on insurance type and hospitals from which they are discharged. METHODS: We used the 2014 to 2015 National Inpatient Sample from the Healthcare Cost and Utilization Project. We included all adult admissions with a primary diagnosis of trauma (International Classification of Diseases, 9th Revision, Clinical Modification codes), who were insured and discharged to PAC. We then ranked hospitals based upon mean LOS and divided them into quartiles to determine differences. The primary outcome was inpatient LOS; secondary outcome was cost. RESULTS: There are 958,005 trauma patients that met the inclusion criteria. Mean LOS varied based upon insurance type (Medicaid vs. Private vs. Medicare: 12.7 days vs. 8.8 days and 5.7 days; p < 0.001). Shortest LOS hospitals had a marginal variation in LOS (Medicaid vs. Private vs. Medicare: 5.5 days vs. 4.8 days vs. 4.2 days; p < 0.001). Longest LOS hospitals had mean LOS that varied substantially (16.4 days vs. 11.0 days vs. 6.7 days; p < 0.001). Multivariate regression controlling for patient and hospital characteristics revealed that Medicaid patients spent Medicaid patients spent an additional 0.4 days in shortest LOS hospitals and an additional 2.6 days in longest LOS hospitals (p < 0.001). The average daily cost of inpatient care was US $3,500 (SD, US $132). Even with conservative estimates, Medicaid patients at hospitals without easy access to rehabilitation incur significant additional inpatient costs over $10,000 in some hospitals. CONCLUSION: Prolonged LOS is likely a function of access to postacute facilities, which is largely out of the hands of trauma centers. Efficiencies in care are magnified by access to postacute beds, suggesting that increased availability of rehabilitation facilities, particularly for Medicaid patients, might help to reduce LOS. LEVEL OF EVIDENCE: Epidemiologic, level III; care management, level IV.

The economic footprint of acute care surgery in the United States: Implications for systems development.

BACKGROUND: Acute care surgery (ACS) comprises trauma, surgical critical care, and emergency general surgery (EGS), encompassing both operative and nonoperative conditions. While the burden of EGS and trauma has been separately considered, the global footprint of ACS has not been fully characterized. We sought to characterize the costs and scope of influence of ACS-related conditions. We hypothesized that ACS patients comprise a substantial portion of the US inpatient population. We further hypothesized that ACS patients differ from other surgical and non-surgical patients across patient characteristics. METHODS: We queried the National Inpatient Sample 2014, a nationally representative database for inpatient hospitalizations. To capture all adult ACS patients, we included adult admissions with any International Classification of Diseases-9th Rev.-Clinical Modification diagnosis of trauma or an International Classification of Diseases-9th Rev.-Clinical Modification diagnosis for one of the 16 AAST-defined EGS conditions. Weighted patient data were presented to provide national estimates. RESULTS: Of the 29.2 million adult patients admitted to US hospitals, approximately 5.9 million (20%) patients had an ACS diagnosis. ACS patients accounted for US $85.8 billion, or 25% of total US inpatient costs (US $341 billion). When comparing ACS to non-ACS inpatient populations, ACS patients had higher rates of health care utilization with longer lengths of stay (5.9 days vs. 4.5 days, p < 0.001), and higher mean costs (US $14,466 vs. US $10,951, p < 0.001. Of all inpatients undergoing an operative procedure, 27% were patients with an ACS diagnosis. Overall, 3,186 (70%) of US hospitals cared for both trauma and EGS patients. CONCLUSION: Acute care surgery patients comprise 20% of the inpatient population, but 25% of total inpatient costs in the United States. In addition to being costly, they overall have higher health care utilization and worse outcomes. This suggests that there is an opportunity to improve clinical trajectory for ACS patients that in turn, can affect the overall US health care costs. LEVEL OF EVIDENCE: Epidemiologic, level III.

The association between angioembolization and splenic salvage for isolated splenic injuries.

BACKGROUND: Recent data suggest improved splenic salvage rates when angioembolization (AE) is routinely employed for high-grade splenic injuries; however, protocols and salvage rates vary among centers. MATERIALS/METHODS: Adult patients with isolated splenic injuries were identified using the National Trauma Data Bank, 2013-2014. Patients were excluded if they underwent immediate splenectomy or died in the emergency department. To characterize patterns of AE, trauma centers were grouped into quartiles based on frequency of AE use. Unadjusted analyses and mixed-effects logistical regression controlling for center effects were performed. RESULTS: Five thousand and ninety three adult patients were identified. Overall, 705 (13.8%) underwent AE and 290 (5.7%) required a splenectomy. In unadjusted comparisons, splenectomy rates were lower for patients with severe spleen injuries who underwent AE (7% versus 11%, P = 0.02). In mixed-effect logistical regression patients with severe splenic injuries undergoing AE had a lower odds ratio (OR) for splenectomy (OR = 0.67, P = 0.04). Patients treated at centers in the highest quartile of AE use had a lower OR for splenectomy (OR = 0.58, P = 0.02). CONCLUSIONS: The use of AE in patients with isolated severe splenic injuries is associated with decreased splenectomy rates. There is an association between centers that perform AE frequently and reduced splenectomy rates.

Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals.

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.