Racial and ethnic disparities in lower extremity amputation: Assessing the role of frailty in older adults.

BACKGROUND: Frailty is a state of decreased physiologic reserve contributing to functional decline and is associated with adverse surgical outcomes, particularly in the elderly. Racial disparities have been reported previously both in frail individuals and in limb-salvage patients. Our goal was to assess whether race and ethnicity are disproportionately linked to frailty status in geriatric patients undergoing lower-limb amputation, leading to an increased risk of complications. METHODS: A 3-year analysis was conducted of the National Surgical Quality Improvement Program database and included all geriatric (age ≥65 years) patients who underwent amputation of the lower limb. The frailty index was calculated using the 11-factor modified frailty index with a cutoff limit of 0.27 defined for frail status. Outcomes were 30-day complications, mortality, and readmissions. Multivariate regression analysis was performed. RESULTS: A total of 4,218 geriatric patients underwent surgical amputation of a lower extremity (above knee: 41%; below knee: 59%). Of these patients, 29% were frail, 26% were African American, and 9% were Hispanic. Being African American (odds ratio: 1.6 [1.3-1.9]) and Hispanic (odds ratio: 1.1 [1.05-2.5]) was independently associated with frail status. Frail African Americans had a higher likelihood of 30-day complications (odds ratio: 3.2 [1.9-4.4]) and 30-day readmissions (odds ratio: 2.9 [1.8-3.6]) when compared with nonfrail individuals. Similarly, frail Hispanics had higher 30-day complications (odds ratio: 2.6 [1.9-3.1]) and 30-day readmissions (odds ratio: 1.4 [1.1-2.7]) compared with nonfrail Hispanics/Latinos. CONCLUSION: African American and Hispanic geriatric patients undergoing lower-limb amputation are at increased risk for frailty status and, as a result, increased associated operative complications. These disparities exist regardless of age, sex, comorbid conditions, and location of amputation. Further studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors, decrease frailty, and improve outcomes.

Racial disparities and socioeconomic status in the incidence of colorectal cancer in Arizona.

BACKGROUND: The prevalence of racial and socioeconomic disparities in the development of colorectal cancer (CRC) is well known; however, statewide variability exits across the United States. The aim of our study was to determine the overall incidence, socioeconomic and racial disparities in the development of CRC in the state of Arizona. METHODS: We performed a 16-year (1995 to 2011) retrospective review of the Arizona Cancer Registry including all patients with CRC. Patient demographics, stage of CRC disease, and patient outcomes were recorded. The outcome measures were incidence of CRC and the difference in racial and economic characteristics among patients. Logistic regression analysis was performed to identify factors associated with the incidence of CRC. RESULTS: A total of 40,314 patients with CRC were included of which 16% (n = 6,450) were stage IV. The overall incidence of CRC decreased 17% over the study period. The highest incidence rates were seen in White non-Hispanic and African American populations. Right-sided tumors were more common in White non-Hispanic and African Americans whereas American Indians had higher incidence of rectal tumors and Asian/Pacific Islanders more commonly had left-sided tumors. African Americans had the highest occurrence (42.8%) of more advanced disease (stage III and stage IV). A negative correlation existed between socioeconomic status and the incidence of CRC. CONCLUSIONS: Overall CRC incidence decreased in Arizona by 17%, with greatest decrease rate among, White non-Hispanic and African American populations. Educated patients with higher economic earnings experienced a lower decrease in the incidence of CRC.

Improving Hospital Quality and Costs in Nonoperative Traumatic Brain Injury: The Role of Acute Care Surgeons.

IMPORTANCE: The role of acute care surgeons is evolving; however, no guidelines exist for the selective treatment of patients with traumatic brain injury (TBI) exclusively by acute care surgeons. We implemented the Brain Injury Guidelines (BIG) for managing TBI at our institution on March 1, 2012. OBJECTIVE: To compare the outcomes in patients with TBI before and after implementation of the BIG protocol. DESIGN, SETTING, AND PARTICIPANTS: We conducted a 2-year analysis of our prospectively maintained database of all patients with TBI (findings of skull fracture and/or intracranial hemorrhage on an initial computed tomographic scan of the head) who presented to our level I trauma center. The pre-BIG group included patients with TBI from March 1, 2011, through February 29, 2012, and the post-BIG group included patients from July 1, 2012, through June 30, 2013. MAIN OUTCOMES AND MEASURES: The primary outcome measures were patients with repeated computed tomography of the head and neurosurgical consultations. Secondary outcome measures were findings of progression of intracranial hemorrhage on repeated computed tomographic scans, neurosurgical intervention, hospital admission, intensive care unit admission, hospital and intensive care unit length of stay, 30-day readmission rate, and hospital costs per patient. RESULTS: A total of 796 patients (415 in the pre-BIG group and 381 in the post-BIG group) were included. There was a significant reduction (19.0%) in the rate of neurosurgical consultation (post-BIG group, 273 patients [71.7%]; pre-BIG group, 376 [90.6%]; P < .001), repeated computed tomography of the head (post-BIG group, 255 patients [66.9%]; pre-BIG group, 381 patients [91.8%]; P < .001), hospital (post-BIG group, 330 [86.6%]; pre-BIG group, 398 [95.9%]; P < .001) and intensive care unit admission (post-BIG group, 202 [53.0%]; pre-BIG group, 257 [61.9%]; P = .01), hospital length of stay (post-BIG group, 5.4 [4.5] days; pre-BIG group, 6.1 [4.8] days; P = .03), and hospital costs per patient ($4772 per patient; P = .03) with implementation of BIG. There was no difference in the in-hospital mortality rate (post-BIG group, 62 patients [16.3%]; pre-BIG group, 69 patients [16.6%]; P = .89), progression of intracranial hemorrhage on repeated scans (post-BIG group, 41 patients [10.8%]; pre-BIG group, 59 patients [14.2%]; P = .14), neurosurgical intervention (post-BIG group, 61 patients [16.0%]; pre-BIG group, 59 patients [14.2%]; P = .48), and 30-day readmission rate (post-BIG group, 31 patients [8.1%]; pre-BIG group, 37 patients [8.9%]; P = .69) after implementation of BIG. CONCLUSIONS AND RELEVANCE: Implementation of BIG is safe and cost-effective. BIG defines the management of TBI without the need for neurosurgical consultation and unnecessary imaging. Establishing a national, multi-institutional study implementing the BIG protocol is warranted.

Validating trauma-specific frailty index for geriatric trauma patients: a prospective analysis.

BACKGROUND: The Frailty Index has been shown to predict discharge disposition in geriatric patients. The aim of this study was to validate the modified 15-variable Trauma-Specific Frailty Index (TSFI) to predict discharge disposition in geriatric trauma patients. We hypothesized that TSFI can predict discharge disposition in geriatric trauma patients. STUDY DESIGN: We performed a 2-year (2011-2013) prospective analysis of all geriatric trauma patients presenting to our Level I trauma center. Patient discharge disposition was dichotomized into unfavorable (discharge to skilled nursing facility or death) and favorable (discharge to home or rehabilitation center) discharge disposition. Patients were evaluated using the developed 15-variable TSFI. Multivariate logistic regression was performed to identify factors that predict unfavorable discharge disposition. RESULTS: A total of 200 patients were enrolled for validation of TSFI. Mean age was 77 ± 12.1 years, median Injury Severity Score was 15 (interquartile range [IQR] 9 to 20), median Glasgow Coma Scale score was 14 (IQR 13 to 15), and median Frailty Index score was 0.20 (IQR 0.17 to 0.28); 29.5% (n = 59) patients had unfavorable discharge. After adjusting for age, sex, Injury Severity Score, Head Abbreviated Injury Scale, and vitals on admission, Frailty Index (odds ratio = 1.5; 95% CI, 1.1-2.5) was the only significant predictor for unfavorable discharge disposition. Age (odds ratio = 1.2; 95% CI, 0.9-3.1; p = 0.2) was not predictive of unfavorable discharge disposition. CONCLUSIONS: The 15-variable TSFI is an independent predictor of unfavorable discharge disposition in geriatric trauma patients. The Trauma-Specific Frailty Index is an effective tool that can aid clinicians in planning discharge disposition of geriatric trauma patients. LEVEL OF EVIDENCE: II Prognostic Studies-Investigating the Effect of a Patient Characteristic on the Outcome of Disease.

Superiority of frailty over age in predicting outcomes among geriatric trauma patients: a prospective analysis.

IMPORTANCE: The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. OBJECTIVE: To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. DESIGN, SETTING, AND PARTICIPANTS: A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. MAIN OUTCOMES AND MEASURES: The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. RESULTS: In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. CONCLUSIONS AND RELEVANCE: The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.

Prothrombin complex concentrate use in coagulopathy of lethal brain injuries increases organ donation.

Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration (P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10) patients. Of these seven patients, consent for donation was obtained in six patients and resulted in 19 solid organs being procured. The cost of PCC per patient was $1022 ± 544. PCC effectively reveres coagulopathy associated with lethal traumatic brain injury and enabled patients to proceed to organ donation. Although various methodologies exist for the treatment of coagulopathy to facilitate organ donation, PCC provides a rapid and cost-effective therapy for reversal of coagulopathy in patients with lethal traumatic brain injuries.