"I'm Leaving": Factors That Impact Against Medical Advice Disposition Post-Trauma.

BACKGROUND: Discharge against medical advice (AMA) is an important, yet understudied, aspect of health care-particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs. OBJECTIVE: The goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment. METHODS: We performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status. RESULTS: Uninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58-2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37-2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02-1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52-0.75), Asian (OR 0.59; 95% CI 0.49-0.69), and Hispanic (OR 0.80; 95% CI 0.75-0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury. CONCLUSIONS: Insurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.

The Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injury.

BACKGROUND: Racial, ethnic, and socioeconomic disparities have been shown to exist in trauma patients. Management of blunt splenic injuries (BSIs) can include splenectomy, embolization, or nonoperative management. This study assesses the effect of race and insurance status on outcomes in patients after blunt splenic trauma. METHODS: The National Trauma Data Bank was used to study patients aged 15-89 y with BSIs from 2013 to 2015. Patients with abbreviated injury scores greater than two in nonabdominal areas, excluding extremities, were eliminated, as were patients with other concomitant abdominal injuries requiring repair. Variables of interest were compared across groups using chi-square tests, and those with significant associations were used in multivariate regression models for each outcome. RESULTS: We analyzed 13,537 BSI patients. Uninsured patients had increased odds of mortality, more splenic operations, and were less likely to have nonoperative management (P < 0.001). Uninsured patients were also twice as likely to be discharged home and three times as likely to leave against medical advice (P < 0.001). African Americans and Hispanics had higher mortality (odds ratio [OR] 2.03, CI 1.34-3.08; OR 1.58, CI 1.03-2.44, respectively). African Americans had more splenic operations (OR 1.33, CI 1.08-1.64) and were 60% less likely to receive angioembolization (CI 0.41-0.84). Hispanics had fewer splenic operations (OR 0.79, CI 0.63-0.98). CONCLUSIONS: Noteworthy differences exist in the management of splenic trauma patients based on race/ethnicity and socioeconomic status, despite controlling for demographics and injury characteristics. Insurance status and race likely affect surgical treatment plans and mortality, particularly for uninsured, black, and Hispanic patients, but further research is needed to identify the root cause of these disparities.

Socioeconomic Status Affects Outcomes After Severity-Stratified Traumatic Brain Injury.

BACKGROUND: Socioeconomic status (SES) and race have been shown to increase the incidence of being afflicted by a traumatic brain injury (TBI) resulting in worse posthospitalization outcomes. The goal of this study was to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed stratified by severity of TBI. METHODS: This was a retrospective cohort study of patients with closed head injuries using the National Trauma Data Bank (2012-2015). Multivariate logistic/linear regression models were created to determine the impact of race and insurance status in groups graded by head Abbreviated Injury Scale (AIS). RESULTS: We analyzed 131,461 TBI patients from NTDB. Uninsured patients experienced greater mortality at an AIS of 5 (odds ratio [OR] = 1.052, P = 0.001). Uninsured patients had a decreased likelihood of being discharged to inpatient rehabilitation with an increasing AIS beginning from an AIS of 2 (OR = 0.987, P = 0.008) to an AIS of 5 (OR = 0.879, P < 0.001). Black patients had an increased LOS as their AIS increased from an AIS of 2 (0.153 d, P < 0.001) to 5 (0.984 d, P < 0.001) with the largest discrepancy in LOS occurring at an AIS of 5. CONCLUSIONS: Disparities in race and SES are associated with differences in mortality, LOS, and discharge to inpatient rehabilitation. Patients with more severe TBI have the greatest divergence in treatment and outcome when stratified by race and ethnicity as well as SES.

Measuring Patterns of Surgeon Confidence Using a Novel Assessment Tool.

Confidence should increase during surgical training and practice. However, few data exist regarding confidence of surgeons across this continuum. Confidence may develop differently in clinical and personal domains, or may erode as specialization or age restricts practice. A reliable scale of confidence is needed to track this competency. A novel survey was distributed to surgeons in private and academic settings. One hundred and thirty-four respondents completed this cross-sectional survey. Surgeons reported anticipated reactions to clinical scenarios within three patient care domains (acute inpatient, nonacute inpatient, and outpatient) and in personal spheres. Confidence scores were plotted against years of experience. Curves of best fit were generated and trends assessed. A subgroup completed a second survey after four years to assess the survey's reliability over time. During residency, there is steep improvement in confidence reported by surgeons in all clinical domains, with further increase for inpatient domains during transition into practice. Confidence in personal spheres also increases quickly during residency and thereafter. The surgeon confidence scale captures the expected acquisition of confidence during early surgical experience, and will have value in following trends in surgeon confidence as training and practice patterns change.