Comparative evaluation of the clinical laboratory-based Intermountain risk score with the Charlson and Elixhauser comorbidity indices for mortality prediction.

BACKGROUND: The Charlson and Elixhauser comorbidity indices are mortality predictors often used in clinical, administrative, and research applications. The Intermountain Mortality Risk Scores (IMRS) are validated mortality predictors that use all factors from the complete blood count and basic metabolic profile. How IMRS, Charlson, and Elixhauser relate to each other is unknown. METHODS: All inpatient admissions except obstetric patients at Intermountain Healthcare's 21 adult care hospitals from 2010-2014 (N = 197,680) were examined in a observational cohort study. The most recent admission was a patient's index encounter. Follow-up to 2018 used hospital death records, Utah death certificates, and the Social Security death master file. Three Charlson versions, 8 Elixhauser versions, and 3 IMRS formulations were evaluated in Cox regression and the one of each that was most predictive was used in dual risk score mortality analyses (in-hospital, 30-day, 1-year, and 5-year mortality). RESULTS: Indices with the strongest mortality associations and selected for dual score study were the age-adjusted Charlson, the van Walraven version of the acute Elixhauser, and the 1-year IMRS. For in-hospital mortality, Charlson (c = 0.719; HR = 4.75, 95% CI = 4.45, 5.07), Elixhauser (c = 0.783; HR = 5.79, CI = 5.41, 6.19), and IMRS (c = 0.821; HR = 17.95, CI = 15.90, 20.26) were significant predictors (p<0.001) in univariate analyses. Dual score analysis of Charlson (HR = 1.79, CI = 1.66, 1.92) with IMRS (HR = 13.10, CI = 11.53, 14.87) and of Elixhauser (HR = 3.00, CI = 2.80, 3.21) with IMRS (HR = 11.42, CI = 10.09, 12.92) found significance for both scores in each model. Results were similar for 30-day, 1-year, and 5-year mortality. CONCLUSIONS: IMRS provided the strongest ability to predict mortality, adding to and attenuating the predictive ability of the Charlson and Elixhauser indices whose mortality associations remained statistically significant. IMRS uses common, standardized, objective laboratory data and should be further evaluated for integration into mortality risk evaluations.

Impact of Critical Illness on Resource Utilization: A Comparison of Use in the Year Before and After ICU Admission.

OBJECTIVES: Increasingly, patients admitted to an ICU survive to hospital discharge; many with ongoing medical needs. The full impact of an ICU admission on an individual's resource utilization and survivorship trajectory in the United States is not clear. We sought to compare healthcare utilization among ICU survivors in each year surrounding an ICU admission. DESIGN: Retrospective cohort of patients admitted to an ICU during one calendar year (2012) in a multipayer healthcare system. We assessed mortality, hospital readmissions (categorized by ambulatory care sensitive conditions and emergency department), and outpatient visits. We compared the proportion of patients with visits during the pre-ICU year versus the post-ICU year. PATIENTS: People admitted to an Intermountain healthcare ICU for greater than 48 hours in the year 2012 INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS: Among 4,074 ICU survivors, 45% had increased resource utilization. Readmission rates at 30-day, 90-day, and 1-year were 15%, 26%, and 43%. The proportion of patients with a hospital admission increased significantly in the post-ICU period (43% vs 29%; p < 0.001). Of patients with a readmission in the post-ICU period, 24% were ambulatory care sensitive condition. Patients with increased utilization differed by socioeconomic status, insurance type, and severity of illness. Sixteen percent of patients had either an emergency department or inpatient admission, but no outpatient visits during the post-ICU period. CONCLUSIONS: An ICU admission is associated with increased resource utilization including hospital readmissions, with many due to an ambulatory care sensitive condition. Lower socioeconomic status and higher severity of illness are associated with increased resource utilization. After an ICU visit patients seem to use hospital resources over outpatient resources. Interventions to improve and coordinate care after ICU discharge are needed.

The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies.

BACKGROUND: Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. METHODS: This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. RESULTS: We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. CONCLUSION: The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment.

In-hospital outcomes and costs of surgical stabilization versus nonoperative management of severe rib fractures.

BACKGROUND: One factor that has precluded the wide adoption of surgical stabilization of rib fractures (SSRF) is the perception that it is too expensive to surgically repair an injury that will eventually heal without intervention. The purpose of this study was to compare in-hospital outcomes, costs, and charges for SSRF patients with a series of propensity-matched, nonoperatively managed rib fracture (NON-OP) patients at a single Level 1 trauma center. METHODS: All patients admitted with rib fractures between January 2009 and June 2013 were identified. Patient demographics, injury, cost, and charge data were collected. Two-to-one propensity score matching was used to identify NON-OP patients who were similar to the SSRF patients. Zero-inflated negative binomial regression was conducted to assess the relationship among SSRF, intensive care unit (ICU) length of stay (LOS), and ventilator days. Cost and charge information was compared using Wilcoxon rank-sum tests. RESULTS: A total of 411 patients (137 SSRF, 274 NON-OP) were included in the analysis. Ventilator days and ICU LOS in days were not different between the SSRF and NON-OP groups when compared using the Wilcoxon rank-sum test. Ventilator and ICU days were less for SSRF by 2.24 days and 1.62 days, respectively, using zero-inflated negative binomial analysis to exclude the large number of patients who had 0 day on the ventilator and/or in the ICU. SSRF patients had higher hospital costs and total relevant charges compared with the NON-OP patients. Subgroup analysis of patients requiring mechanical ventilation who did not have head injury showed decreased ventilator days (median, 3 days vs. 5 days; p = 0.03) and need for tracheostomy (5% vs. 23%, p = 0.02) in SSRF versus NON-OP, respectively. In this subgroup, there was no difference in hospital costs and charges between SSRF and NON-OP. CONCLUSION: SSRF patients have shorter ICU LOS and less ventilator days than NON-OP across a diverse group of patients. Hospital costs and charges for SSRF patients are higher. In mechanically ventilated patients who do not have head injury, in-hospital outcomes are better, and there is no difference in hospital costs and charges. Further prospective cost-effectiveness research will determine whether improved quality of life and ability to return to meaningful activity sooner outweighs the increased costs of the acute care episode for SSRF patients. LEVEL OF EVIDENCE: Epidemiologic study, level III.

The prevalence and impact of defensive medicine in the radiographic workup of the trauma patient: a pilot study.

BACKGROUND: Defensive medicine is estimated to cost the United States $210 billion annually. Trauma surgeons are at risk of practicing defensive medicine in the form of reflexively ordering computed tomography (CT) scans. The aim of this study is to quantify the monetary impact and radiation exposure related to the radiographic workup of trauma patients. METHODS: We conducted a prospective, observational study involving 295 trauma patients at Level I trauma center. Physicians were surveyed regarding specific CT scans ordered, likelihood of significant injuries found on scans, and which scans would have been ordered in a hypothetical, litigation-free environment. RESULTS: Four hundred sixteen of 1,097 CT scans (38%) were ordered out of defensive purposes. Nine CT scans (2.2%) that would not have been ordered resulted in a change in management. Defensively ordered CT scans resulted in nearly $120,000 in excess charges and 8.8 mSv of unnecessary radiation per patient. CONCLUSION: Defensively ordered CT scan in the workup of trauma patients is a prevalent and costly practice that exposes patients to potentially unnecessary and harmful radiation.

The Intermountain Risk Score predicts mortality in trauma patients.

PURPOSE: Intermountain Risk Score (IMRS) uses the admission complete blood count and basic metabolic profile to predict mortality. Intermountain Risk Score has been validated in medical patients but has not been evaluated in trauma. This study tested whether IMRS is predictive of mortality in a trauma population at a level I trauma center. METHODS: Admitted trauma patients with complete blood count and basic metabolic profile from October 2005 to December 2011 were evaluated. Thirty-day and 1-year IMRS were calculated using multivariable modeling. Mortality was determined using the medical record and Social Security Administration death data. RESULTS: Three thousand six hundred thirty-seven females and 5901 males were evaluated. Intermountain Risk Score was highly predictive of death at 30 days (c-statistics, c = 0.772 for females; c = 0.783 males) and 1 year (c = 0.778 for females; c = 0.831 males). Cox regression analysis, adjusted for injury severity score, blunt vs penetrating, and length of stay, showed increased mortality risks among patients in the moderate- and high-risk IMRS-defined groups at both 30 days and 1 year, with hazard ratios ranging from 4.96 to 57.88 (all P < .001). CONCLUSION: Intermountain Risk Score strongly predicts mortality in trauma patients at this single level I trauma center. The ability to accurately determine a patient's mortality risk at admission makes IMRS a potentially clinically important tool.

Selective clinical management of anterior abdominal stab wounds.

BACKGROUND: The optimal management of clinically stable patients with anterior abdominal stab wounds (AASWs) is debated. We implemented a protocol of serial clinical assessments to determine the need for laparotomy. The purpose of this study was to determine whether the approach is safe and effective. METHODS: Records of patients sustaining AASWs from 1999 to 2003 were reviewed. RESULTS: Seventy-seven patients sustained AASWs. Twenty-five were taken directly to the operating room because of hypotension (5), evisceration (7), or peritonitis (15). Seventeen patients had diagnostic peritoneal lavage (DPL) for associated thoracoabdominal wounds and 5 had local wound exploration (LWE) off protocol. The remaining 30 patients were managed with serial clinical assessments and were discharged uneventfully. CONCLUSION: Patients sustaining AASWs who present without hypotension, evisceration, or peritonitis may be managed safely under a protocol of serial clinical evaluations. This approach should be compared with LWE/DPL in a prospective, randomized multicenter trial.