Variations in Cost and Readmissions of Patients in the Bundled Payment for Care Improvement Bundle for Hip and Femur Fractures.

INTRODUCTION: The Bundled Payment for Care Improvement (BPCI) for hip and femur fractures is an effort to increase care quality and coordination at a lower cost. The bundle includes all patients undergoing an operative fixation of a hip or femur fracture (diagnosis-related group codes 480-482). This study aims to investigate variance in the hospital cost and readmission rates for patients within the bundle. MATERIALS AND METHODS: The study is a retrospective analysis of patients ≥65 years old billed for a diagnosis-related groups 480-482 in 2016 in the National Readmission Database. Cost of admission and length of stay were compared between patients who were or were not readmitted. Regression analysis was used to determine the effects of the primary procedure code and anatomical location of the femur fracture on costs, length of stay, and readmission rates. RESULTS: Patients that were readmitted within 90 days of surgery had an increased cost on initial admission ($18,427 vs $16,844, P < .0001), and an increased length of stay (6.24 vs 5.42, P < .0001). When stratified by procedure, patients varied in readmission rates (20.7% vs 19.6% vs 21.8%), initial cost, and length of stay (LOS). Stratification by anatomical location also led to variation in readmission rates (20.7% vs 18.3% vs 20.6%), initial cost, and LOS. CONCLUSION: The hip and femur fractures bundle includes a great number of procedures with variance in cost, readmission, and length of stay. This amount of variation may make standardization difficult and may put the hospital at potential financial risk.

Morning report decreases length of stay in trauma patients.

BACKGROUND: Modern acute care surgery (ACS) programs depend on consistent patient hand-offs to facilitate care, as most programs have transitioned to shift-based coverage. We sought to determine the impact of implementing a morning report (MR) model on patient outcomes in the trauma service of a tertiary care center. METHODS: The University of Arkansas for Medical Sciences (UAMS) Division of ACS implemented MR in October 2015, which consists of the trauma day team, the emergency general surgery day team, and a combined night float team. This study queried the UAMS Trauma Registry and the Arkansas Clinical Data Repository for all patients meeting the National Trauma Data Bank inclusion criteria from January 1, 2011 to April 30, 2018. Bivariate frequency statistics and generalized linear model were run using STATA V.14.2. RESULTS: A total of 11 253 patients (pre-MR, n=6556; post-MR, n=4697) were analyzed in this study. The generalized linear model indicates that implementation of MR resulted in a significant decrease in length of stay (LOS) in trauma patients. DISCUSSION: This study describes an approach to improving patient outcomes in a trauma surgery service of a tertiary care center. The data show how an MR session can allow for patients to get out of the hospital faster; however, broader implications of these sessions have yet to be studied. Further work is needed to describe the decisions being made that allow for a decreased LOS, what dynamics exist between the attendings and the residents in these sessions, and if these sessions can show some of the same benefits in other surgical services. LEVEL OF EVIDENCE: Level 4, Care Management.

Influence of a province-wide trauma system on motor vehicle collision process of trauma care and mortality: a 10-year follow-up evaluation.

BACKGROUND: Mature trauma systems have evolved to respond to major injury-related morbidity and mortality. Studies of mature trauma systems have demonstrated improved survival, especially among seriously injured patients. From 1995 to 1998, a province-wide trauma system was implemented in the province of Nova Scotia. We measured the proportion of admissions to a tertiary level trauma centre and the proportion of in-hospital deaths among patients with major injuries as a result of a motor vehicle collisions (MVCs) before and 10 years after provincial trauma systems implementation. METHODS: We identified major trauma patients aged 16 years and older using external cause of injury codes pertaining to MVCs from population-based hospital claims and vital statistics data. Individuals who were admitted to hospital or died because of an MVC in 1993-1994 (preimplementation), were compared with those who were admitted to hospital or died in 2003-2005 (postimplementation). RESULTS: Postimplementation, there was a 9% increase in the number of seriously injured individuals with primary admission to tertiary care. This increase was statistically significant even after we adjusted for age, head injury and municipality of residence (relative risk [RR] 1.09, 95% confidence interval [CI] 1.04-1.14). The probability of dying while in hospital in the postimplementation period decreased by 29% (adjusted RR 0.57, 95% CI 0.32-1.03), although this difference was not statistically significant. CONCLUSION: Individuals seriously injured in MVCs in Nova Scotia were more likely to be admitted to tertiary care after the implementation of a province-wide trauma system. There was a trend toward decreased mortality, but further research is warranted to confirm the survival benefit and delineate other contributing factors.

The epidemiology of surgically treated acute subdural and epidural hematomas in patients with head injuries: a population-based study.

BACKGROUND: The purpose of this paper is to review the population-based epidemiology of surgically treated post-traumatic epidural hematomas (EDHs) and/or subdural hematomas (SDHs) among patients who presented to the single neurosurgical centre in Nova Scotia. METHODS: We included all patients aged 16 years or older who presented to the tertiary care hospital with acute post-traumatic EDHs and/or SDHs between May 23, 1996, and May 22, 2005, and who were surgically treated. We generated an initial cohort from the provincial trauma registry and reviewed a total of 152 charts for possible inclusion; 70 (46%) patients met the study criteria. We performed a blinded, explicit chart review using a standardized data collection form, and we generated descriptive statistics. RESULTS: Of the patients who had surgery, 34 (49%) presented with SDHs, 23 (33%) presented with EDHs and 13 (19%) presented with both conditions. The median age was 45 years, and 80% of the cohort was male. The major mechanisms of injury were falls (51%), motor vehicle collisions (30%) and assault (11%). More than half (61%) of patients were transferred from referring hospitals while the remainder (39%) arrived directly without an intermediate facility. There were 18 postoperative deaths (26%). Forty-four of 70 patients (63%) had associated good outcomes at 6 months (Glasgow Outcome Scale). CONCLUSION: Acute post-traumatic EDHs and/or SDHs are relatively rare (0.83/100,000 population per annum) and are generally associated with good outcomes. Death was more likely among older, more severely injured patients and among those who required surgery for SDH rather than EDH.