Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial.

BACKGROUND: Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin. METHODS: This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales. RESULTS: The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001). CONCLUSIONS: Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis. LEVEL OF EVIDENCE: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Splenic artery angioembolization for high-grade splenic injury: Are we wasting money?

BACKGROUND: Non-operative management (NOM) is accepted treatment of splenic injury, but this may fail leading to splenectomy. Splenic artery embolization (SAE) may improve rate of salvage. The purpose is to determine the cost-utility of the addition of SAE for high-grade splenic injuries. METHODS: A cost-utility analysis was developed to compared NOM to SAE in patients with blunt splenic injury. Sensitivity analysis was completed to account for uncertainty. Utility outcome was quality-adjusted life years (QALY). RESULTS: For patients with grade III, IV and V injury NOM is the dominant strategy. The probability of NOM being the more cost-effective strategy is 87.5% in patients with grade V splenic injury. SAE is not the favored strategy unless the probability of failure of NOM is greater than 70.0%. CONCLUSION: For grade III-V injuries, NOM without SAE yields more quality-adjusted life years. NOM without SAE is the most cost-effective strategy for high-grade splenic injuries.

Lifting the burden: State Medicaid expansion reduces financial risk for the injured.

BACKGROUND: Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain because of high out-of-pocket (OOP) health care costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington (WA) state, which extended coverage to more than 600,000 WA residents, was associated with a reduction in financial risk among trauma patients. METHODS: We analyzed all trauma patients aged 18 to 64 years admitted to the sole level 1 trauma center in WA from 2012 to 2017. We defined 2012 to 2013 as the prepolicy period and 2014 to 2017 as the postpolicy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate postsubsistence income and OOP expenses for our sample and then applied these two estimates to determine catastrophic health expenditure (CHE) risk as defined by the World Health Organization (OOP health expenses ≥40% of estimated household postsubsistence income). RESULTS: A total of 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0%, and the uninsured rate decreased from 19.2% to 3.7% (p < 0.001 for both). There was no significant change in private insurance coverage. Medicaid expansion was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and less than 0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p < 0.01). CONCLUSION: State ME led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers. LEVEL OF EVIDENCE: Economic analysis, level II.

Fellowship training in extracorporeal life support: Characterization and educational needs assessment.

PURPOSE: Adult Extracorporeal Life Support (ECLS) use is rapidly increasing. The structure of fellowship ECLS education is unknown. We sought to define current ECLS education and identify curricular needs. MATERIALS AND METHODS: An anonymous survey with Likert, binary and free response questions was sent to Critical Care Program Directors (CCPDs). RESULTS: A total of 103 CCPDs responded, a response rate of 31. ECLS training was provided by 64% (66/103) of fellowships. Importantly, 50% (52/103) of CCPDs agreed or strongly agreed that fellows should be competent in ECLS and 70% (72/103) agreed or strongly agreed that ECLS will be an important part of critical care in the next 10years. Only 28% (29/103) and 37% (38/103) of CCPDs agreed or strongly agreed their fellows could independently manage veno-arterial or veno-venous ECLS, respectively. Formal ECLS education was 5h or less in 85% (88/103) of programs. Desired curricular improvements were: simulation 50% (51/103), patient volume 47% (48/103), and didactics 44% (45/103). CONCLUSIONS: CCPDs identified ECLS as a critical care skill, but believe that a minority of fellows are prepared for independent practice. Simulation, formal didactics and clinical volume are key needs. These data will guide the development of ECLS curriculum.

A comparison of prognosis calculators for geriatric trauma: A Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium study.

BACKGROUND: The nine-center Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium has validated the Geriatric Trauma Outcome Score (GTOS) as a prognosis calculator for injured elders. We compared GTOS' performance to that of the Trauma Injury Severity Score (TRISS) in a multicenter sample. METHODS: Three Prognostic Assessment of Life and Limitations After Trauma in the Elderly centers not submitting subjects to the GTOS validation study identified subjects aged 65 years to 102 years admitted from 2000 to 2013. GTOS was specified using the formula [GTOS = age + (Injury Severity Score [ISS] × 2.5) + 22 (if transfused packed red cells (PRC) at 24 hours)]. TRISS uses the Revised Trauma Score (RTS), dichotomizes age (<55 years = 0 and ≥55 years = 1), and was specified using the updated 1995 beta coefficients. TRISS Penetrating was specified as [TRISSP = -2.5355 + (0.9934 × RTS) + (-0.0651 × ISS) + (-1.1360 × Age)]. TRISS Blunt was specified as [TRISSB = -0.4499 + (0.8085 × RTS Total) + (-0.0835 × ISS) + (-1.7430 × Age)]. Each then became the sole predictor in a separate logistic regression model to estimate probability of mortality. Model performances were evaluated using misclassification rate, Brier score, and area under the curve. RESULTS: Demographics (mean + SD) of subjects with complete data (N = 10,894) were age, 78.3 years ± 8.1 years; ISS, 10.9 ± 8.4; RTS = 7.5 ± 1.1; mortality = 6.9%; blunt mechanism = 98.6%; 3.1 % of subjects received PRCs. The penetrating trauma subsample (n = 150) had a higher mortality rate of 20.0%. The misclassification rates for the models were GTOS, 0.065; TRISSB, 0.051; and TRISSP, 0.120. Brier scores were GTOS, 0.052; TRISSB, 0.041; and TRISSP, 0.084. The area under the curves were GTOS, 0.844; TRISSB, 0.889; and TRISSP, 0.897. CONCLUSION: GTOS and TRISS function similarly and accurately in predicting probability of death for injured elders. GTOS has the advantages of a single formula, fewer variables, and no reliance on data collected in the emergency room or by other observers. LEVEL OF EVIDENCE: Prognostic, level II.

Assessment of functional limitation after necrotizing soft tissue infection.

Previous literature on necrotizing soft tissue infections (NSTIs) has focused on its diagnosis and high mortality, but to our knowledge, none have reported on the functional outcomes of patients surviving this devastating disease. The purpose of this study was to evaluate the management and assess factors associated with decreased physical function in patients who survived this life-threatening infection. A retrospective review was conducted on patients treated for NSTI in whom an evaluation of functional status was performed between 2002 and 2006. Measurements were based on the American Medical Association Guides of impairment rating, and categorized into a functional class from "minimal or no limitation" to "severe limitation." Multivariate analyses were performed to discern independent factors associated with functional limitation. Final disposition status after discharge was also recorded. A total of 297 patients were treated for NSTI during this time. Of these, 119 (41%) patients met inclusion criteria for review. Mean number of débridements and coverage procedures were 3.4 and 2.0, respectively. Although mean percent functional limitation was 7.1, which is classified as "minimal or no limitation," 30% of patients had "mild" to "severe" functional limitation. Extremity involvement was independently associated with a higher functional limitation class (P < .01). Functional limitation may challenge recovery from NSTI in many survivors. In this series, the involvement of an extremity predicted a higher functional limitation class at the time of discharge. Development of validated functional assessment tools and accurate longitudinal follow-up are necessary to measure the functional impact of NSTI.

Negative appendectomy and imaging accuracy in the Washington State Surgical Care and Outcomes Assessment Program.

OBJECTIVE: To evaluate negative appendectomy (NA) and the relationship of NA and computed tomography (CT) and/or ultrasound (US). SUMMARY BACKGROUND INFORMATION: NA may be influenced by the use and accuracy of preoperative CT/US. The Surgical Care and Outcomes Assessment Program (SCOAP) gathers chart-abstracted process of care data (such as CT/US accuracy) for general surgical procedures (including appendectomy) at most Washington State hospitals. METHODS: We determined the prevalence of NA and CT/US concordance at the 15 SCOAP hospitals with >50 consecutive patients undergoing appendectomy (2006-2007). RESULTS: The number of patients who underwent urgent appendectomies was 3540. The percentage of patients who had imaging (CT-91%) was 86% (women-89%, men-83%). The use of imaging ranged across hospitals from 56% to 97%. There was 91% agreement between imaging and pathology report findings (92.3%-CT and 82.4%-US). The overall rate of NA was 6% (women-8%, men-4%). The prevalence of NA was 9.8% among patients having no imaging, 8.1% among those having an US, and 4.5% in those having a CT. Among patients with NA, CT/US was obtained in 75%; correct in 10% and incorrect or ambiguous in 65%. Higher rates of NA were correlated with lower rates of CT/US concordance (r = -0.57). There was no significant difference in rates of perforation between those with (17%) and without (15%) imaging (P = 0.2). There were significant increases in the use of CT/US and decreases in NA over the time period (P < 0.01). CONCLUSIONS: The prevalence of NA at SCOAP hospitals decreased significantly. Variation in NA between hospitals was linked closely to CT/US accuracy suggesting CT/US accuracy should be considered a measure of quality in the care of patients with presumed appendicitis.