Examining the association between military service history and outcomes after burn injury.

INTRODUCTION: The association between military service history and long-term outcomes after burn injury is unknown. This study uses data from the Burn Model System National Database to compare outcomes of individuals with and without self-reported military service history. METHODS: Outcome measures were assessed at 12 months after injury including the Veterans Rand-12 Item Health Survey/Short Form-12, Satisfaction With Life Scale, Patient Reported Outcomes Measure Information System 29, 4-D Itch scale, Post Traumatic Stress Disorder Check List - Civilian Version, self-reported Post Traumatic Stress Disorder, and employment status. This study included 675 people with burns of whom 108 reported a history of military service. RESULTS: The military service history group was more likely to be older, and male. Those with military service were most likely to be on Medicare insurance and those without military service history were most likely to be on Private Insurance/HMP/PPO. No significant differences were found between those with and without military service history in the outcome measures. CONCLUSIONS: Further research should examine differences in outcomes between civilians and those with military service history, including elements of resilience and post traumatic growth.

Development of a 30-Day Readmission Risk Calculator for the Inpatient Rehabilitation Setting.

OBJECTIVES: Readmission to acute care from the inpatient rehabilitation facility (IRF) setting is potentially preventable and an important target of quality improvement and cost savings. The objective of this study was to develop a risk calculator to predict 30-day all-cause readmissions from the IRF setting. DESIGN: Retrospective database analysis using the Uniform Data System for Medical Rehabilitation (UDSMR) from 2015 through 2019. SETTING AND PARTICIPANTS: In total, 956 US inpatient rehabilitation facilities and 1,849,768 IRF discharges comprising patients from 14 impairment groups. METHODS: Logistic regression models were developed to calculate risk-standardized 30-day all-cause hospital readmission rates for patients admitted to an IRF. Models for each impairment group were assessed using 12 common clinical and demographic variables and all but 4 models included various special variables. Models were assessed for discrimination (c-statistics), calibration (calibration plots), and internal validation (bootstrapping). A readmission risk scoring system was created for each impairment group population and was graphically validated. RESULTS: The mean age of the cohort was 68.7 (15.2) years, 50.7% were women, and 78.3% were Caucasian. Medicare was the primary payer for 73.1% of the study population. The final models for each impairment group included between 4 and 13 total predictor variables. Model c-statistics ranged from 0.65 to 0.70. There was good calibration represented for most models up to a readmission risk of 30%. Internal validation of the models using bootstrap samples revealed little bias. Point systems for determining risk of 30-day readmission were developed for each impairment group. CONCLUSIONS AND IMPLICATIONS: Multivariable risk factor algorithms based upon administrative data were developed to assess 30-day readmission risk for patients admitted from IRF. This report represents the development of a readmission risk calculator for the IRF setting, which could be instrumental in identifying high risk populations for readmission and targeting resources towards a diverse group of IRF impairment groups.

Item Pool Development for the School-Aged Life Impact Burn Recovery Evaluation Profile Computerized Adaptive Test: An Observer-Reported Outcome Assessment Measuring the Impact of Burn Injuries in School-Aged Children.

The transition from early childhood to teen years (5-12) is a critical time of development, which can be made particularly challenging by a burn injury. Assessing postburn recovery during these years is important for improving pediatric survivors' development and health outcomes. Few validated burn-specific measures exist for this age group. The purpose of this study was to generate item pools that will be used to create a future computerized adaptive test (CAT) assessing postburn recovery in school-aged children. Item pool development was guided by the previously developed School-Aged Life Impact Burn Recovery Evaluation (SA-LIBRE5-12) conceptual framework. The item pool development process involved a systematic literature review, extraction of candidate items from existing legacy measures, iterative item review during expert consensus meetings, and parent cognitive interviews. The iterative item review with experts consisted of six rounds. A total of 10 parent cognitive interviews were conducted. The three broad themes of concern were items that needed 1) clarification, needed context, or were vague, 2) age dependence and relevance, and 3) word choice. The cognitive interviews indicated that survey instructions, recall period, item stem, and response choices were interpretable by respondents. Final item pool based on parental feedback consists of 57, 81, and 60 items in physical, psychological, and family and social functioning, respectively. Developed item pools (n = 198) in three domains are consistent with the existing conceptual framework. The next step involves field testing the item pool and calibration using item response theory to develop and validate the SA-LIBRE5-12 CAT Profile.

Interpreting Life Impact Burn Recovery Evaluation Profile Scores for Use by Clinicians, Burn Survivors, and Researchers.

The Life Impact Burn Recovery Evaluation (LIBRE) Profile is a patient-reported outcome measure developed to assess social participation in adult burn survivors. This study identified numeric score cut-points that define different levels of social participation ability and described each level. An expert panel identified numeric score cut-points that distinguish different levels of social participation for the six LIBRE Profile domains. Methods employed an iterative, modified-Delphi approach, and bookmarking to review calibrated item banks. Analyses (using calibration sample data and repeated in a validation sample) examined means, SDs, and sample distributions for each level. Analyses of variance examined score differences between levels. The panel developed descriptions for each established level. Initial cut-points resulted in four levels for five domains (Social Activities, Social Interactions, Romantic Relationships, Sexual Relationships, and Work & Employment) and five levels for the sixth domain (Relationships with Family & Friends). Comparisons demonstrated significant differences between level mean scores for all domains (P < .05) except Relationships with Family & Friends. Based on follow-up surveys, Relationships with Family & Friends score cut-points were adjusted to identify four levels with significant score differences between all levels. Panelists reached consensus for level descriptions. Score cut-points and descriptions identify different levels of social participation, providing a relevant context for interpreting LIBRE Profile numeric scores. LIBRE Profile Social Participation levels will help clinicians and persons with burn injury interpret LIBRE Profile numeric scores and promote use of this important new assessment.

Inhalation injury is associated with long-term employment outcomes in the burn population: Findings from a cross-sectional examination of the Burn Model System National Database.

INTRODUCTION: Inhalation injuries carry significant acute care burden including prolonged ventilator days and length of stay. However, few studies have examined post-acute outcomes of inhalation injury survivors. This study compares the long-term outcomes of burn survivors with and without inhalation injury. METHODS: Data collected by the Burn Model System National Database from 1993 to 2019 were analyzed. Demographic and clinical characteristics for adult burn survivors with and without inhalation injury were examined. Outcomes included employment status, Short Form-12/Veterans Rand-12 Physical Composite Score (SF-12/VR-12 PCS), Short Form-12/Veterans Rand-12 Mental Composite Score (SF-12/VR-12 MCS), and Satisfaction With Life Scale (SWLS) at 24 months post-injury. Regression models were used to assess the impacts of sociodemographic and clinical covariates on long-term outcome measures. All models controlled for demographic and clinical characteristics. RESULTS: Data from 1,871 individuals were analyzed (208 with inhalation injury; 1,663 without inhalation injury). The inhalation injury population had a median age of 40.1 years, 68.8% were male, and 69% were White, non-Hispanic. Individuals that sustained an inhalation injury had larger burn size, more operations, and longer lengths of hospital stay (p<0.001). Individuals with inhalation injury were less likely to be employed at 24 months post-injury compared to survivors without inhalation injury (OR = 0.63, p = 0.028). There were no significant differences in PCS, MCS, or SWLS scores between groups in adjusted regression analyses. CONCLUSIONS: Burn survivors with inhalation injury were significantly less likely to be employed at 24 months post-injury compared to survivors without inhalation injury. However, other health-related quality of life outcomes were similar between groups. This study suggests distinct long-term outcomes in adult burn survivors with inhalation injury which may inform future resource allocation and treatment paradigms.

Geographic Variation in Outcomes After Burn Injury: A Burn Model System National Database Study.

BACKGROUND: Geography is an important yet underexplored factor that may influence the care and outcomes of burn survivors. This study aims to examine the impact of geography on physical and psychosocial function after burn injury. METHODS: Data from the Burn Model Systems National Database (1997-2015) were analyzed. Individuals 18 years and older who were alive at discharge were included. Physical and psychosocial functions were assessed at 6, 12, and 24 months postinjury using the following patient-reported outcome measures: Community Integration Questionnaire, Physical Composite Scale and Mental Composite Scale of the 12-Item Short Form Health Survey, Satisfaction with Appearance Scale, and Satisfaction with Life Scale. Descriptive statistics were generated for demographic and medical data, and mixed regression models were used to assess the impact of geography on long-term outcomes. RESULTS: The study included 469 burn survivors from the Centers for Medicare and Medicaid Services regions 10, 31 from region 8, 477 from region 6, 267 from region 3, and 41 from region 1. Participants differed significantly by region in terms of race/ethnicity, burn size, burn etiology, and acute care length of stay (P < 0.001). In adjusted mixed model regression analyses, scores of all 5 evaluated outcome measures were found to differ significantly by region (P < 0.05). CONCLUSIONS: Several long-term physical and psychosocial outcomes of burn survivors vary significantly by region. This variation is not completely explained by differences in population characteristics. Understanding these geographical differences may improve care for burn survivors and inform future policy and resource allocation.

Burn survivors injured as children exhibit resilience in long-term community integration outcomes: A life impact burn recovery evaluation (LIBRE) study.

INTRODUCTION: There is limited understanding of how burn injuries at different ages are associated with normal growth and development as well as the burn recovery process. This study provides new useful insights by comparing social participation outcomes among burn survivors injured in childhood compared with injuries sustained in middle age, and older adulthood. METHODS: Items from the development of the LIBRE profile were administered to 601 adult burn survivors with ≥5% TBSA burned or burns to critical areas (hands, feet, face, or genitals). Each item was answered on a 5-point Likert scale with higher scores denoting better outcomes. Mean scores for the 6 LIBRE profile scales (sexual relationships, family and friends, social interactions, social activities, work and employment, and romantic relationships) were compared between those burned as children (<18years) and those burned as adults (≥18years). Regression analyses were used to assess differences between groups with adjustment for demographic and clinical characteristics. RESULTS: Of the 597 burn survivors having complete data on age at injury, 165 (27.6%) sustained burn injuries as a child. Those burned as children were more frequently female than those burned as adults (57% vs 47%) and were also more frequently white non-Hispanic (89% vs 77%). Marital status and education level were similar in the two groups. Those who were burned as children had slightly higher scores on the social activities, work and employment and romantic relationships scales. However, these differences did not persist in adjusted regression analyses. CONCLUSIONS: Burn survivors who sustained injuries as a child fared at least as well as those burned as adults in a broad range of long-term social participation outcomes. The impact on long-term social participation outcomes of burn survivors was not significantly different between individuals with burns sustained during important developmental stages at young ages and those injured later in life.

Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings.

OBJECTIVES: The Centers for Medicare & Medicaid Services Nursing Home Compare (NHC) serves as the most comprehensive repository of Medicaid- and/or Medicare-certified nursing homes providing services to approximately 1.4 million US residents. A gap in the literature exists in understanding on the national level whether residents from socioeconomically disadvantaged counties experience disparities in the access to nursing homes with higher NHC star ratings. The study aimed to examine nursing home quality variations with regard to county-level socioeconomic, geographic, and metropolitan status, while adjusting for nursing home facility-level characteristics. DESIGN: Cross-sectional ecological study. SETTING AND PARTICIPANTS: 15,090 Medicaid/Medicare-certified nursing homes with nonmissing star ratings. MEASURES: Study outcomes were NHC overall, health inspection survey, nurse staffing, and quality measure star ratings. County-level measures included SES index, geographic regions, and metropolitan status. Facility-level characteristics included ownership, chain affiliation, type and length of Medicaid/Medicare certification, hospital affiliation, continuing care retirement community status, number of certified beds, and occupancy. RESULTS: Counties with average adjusted overall, nurse staffing, and quality measure star ratings below 3 stars appeared to be clustered in the South. Nursing homes located in counties with lower SES were associated with lower overall star ratings [adjusted mean stars: 3.66 to 3.84, 95% confidence interval (CI): (3.54, 3.79) to (3.73, 3.95)]. A similar pattern was observed in staffing [adjusted mean stars: 3.75 to 4.23, 95% CI: (3.54, 3.97) to (4.10, 4.35)] and quality ratings [adjusted mean stars: 3.29 to 3.52, 95% CI: (3.12, 3.47) to (3.35, 3.69)]. CONCLUSIONS: Residents in socioeconomically disadvantaged counties experience disparities in accessing nursing homes with higher star ratings. These areas may lack sufficient resources to adequately staff the facility and deliver care that meets industry quality standards. These issues are likely to persist and possibly even worsen for the lower- and middle-class geriatric population given the current uncertainty around healthcare reform.

Outcome Metrics After Burn Injury: From Patient-Reported Outcome Measures to Value-Based Health Care.

Outcomes research is important because it allows us to critically evaluate our results and strive for quality improvement, share our experiences with our colleagues, and improve the care and results delivered to the patient. This article focuses on outcomes research in burns from a historical perspective, highlights some of the current innovations, and previews future directions for outcomes-based research in burn care.

Region and Insurance Plan Type Influence Discharge Disposition After Hip and Knee Arthroplasty: Evidence From the Privately Insured US Population.

BACKGROUND: Little is known about regional variation in the use of postacute care services after elective procedures, such as total hip or knee arthroplasty (THA/TKA), and how insurance type may influence it. The goal of this study is to assess the influence of region and insurance arrangements on discharge disposition. METHODS: A representative sample of the privately insured US population with THA or TKA in 2009 or 2010 was obtained from the MarketScan database applying individual-level weights from the Medical Expenditure Panel Survey. Multivariate logistic regression was used to predict the odds of being discharged to an extended care facility (ECF) compared with being discharged home. The model adjusted for region, insurance plan type, sociodemographic characteristics, comorbidities, and length of stay. RESULTS: Large variability was observed in ECF use across the US. Patients in the Northeast were 2.5 times more likely to receive care at an ECF compared with patients in the South (odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.97-3.19). Enrollees in noncapitated plans such as fee-for-service plans or exclusive provider organizations were less likely to be discharged to an ECF compared with health maintenance organizations/preferred provider organizations with capitation enrollees (OR = 0.74, 95% CI: 0.57-0.94; OR = 0.49, 95% CI: 0.34-0.74, respectively). CONCLUSION: Region and private insurance plan arrangements are related to extended care use among THA and TKA patients. Understanding regional variation in discharge disposition provides policy makers with important information as to where to focus new tests of hip and knee procedures such as same day arthroplasty.

Patient cost-sharing and insurance arrangements are associated with hospital readmissions after abdominal surgery: Implications for access and quality health care.

BACKGROUND: Readmission rates after operative procedures are used increasingly as a measure of hospital care quality. Patient access to care may influence readmission rates. The objective of this study was to determine the relationship between patient cost-sharing, insurance arrangements, and the risk of postoperative readmissions. METHODS: Using the MarketScan Research Database (n = 121,002), we examined privately insured, nonelderly patients who underwent abdominal surgery in 2010. The main outcome measures were risk-adjusted unplanned readmissions within 7 days and 30 days of discharge. Odds of readmissions were compared with multivariable logistic regression models. RESULTS: In adjusted models, $1,284 increase in patient out-of-pocket payments during index admission (a difference of one standard deviation) was associated with 19% decrease in the odds of 7-day readmission (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.78-0.85) and 17% decrease in the odds of 30-day readmission (OR 0.83, 95% CI 0.81-0.86). Patients in the noncapitated point-of-service plans (OR 1.19, 95% CI 1.07-1.33), preferred provider organization plans (OR 1.11, 95% CI 1.03-1.19), and high-deductible plans (OR 1.12, 95% CI 1.00-1.26) were more likely to be readmitted within 30 days compared with patients in the capitated health maintenance organization and point-of-service plans. CONCLUSION: Among privately insured, nonelderly patients, increased patient cost-sharing was associated with lower odds of 7-day and 30-day readmission after abdominal surgery. Insurance arrangements also were significantly associated with postoperative readmissions. Patient cost sharing and insurance arrangements need consideration in the provision of equitable access for quality care.

Functional Status Predicts Acute Care Readmissions from Inpatient Rehabilitation in the Stroke Population.

OBJECTIVE: Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissions in the inpatient rehabilitation stroke population compared with medical comorbidities using a large, administrative data set. METHODS: A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed examining stroke patients admitted to inpatient rehabilitation facilities. A Basic Model for predicting acute care readmission risk based on age and functional status was compared with models incorporating functional status and medical comorbidities (Basic-Plus) or models including age and medical comorbidities alone (Age-Comorbidity). C-statistics were compared to evaluate model performance. FINDINGS: There were a total of 803,124 patients: 88,187 (11%) patients were transferred back to an acute hospital: 22,247 (2.8%) within 3 days, 43,481 (5.4%) within 7 days, and 85,431 (10.6%) within 30 days. The C-statistics for the Basic Model were 0.701, 0.672, and 0.682 at days 3, 7, and 30 respectively. As compared to the Basic Model, the best-performing Basic-Plus model was the Basic+Elixhauser model with C-statistics differences of +0.011, +0.011, and + 0.012, and the best-performing Age-Comorbidity model was the Age+Elixhauser model with C-statistic differences of -0.124, -0.098, and -0.098 at days 3, 7, and 30 respectively. CONCLUSIONS: Readmission models for the inpatient rehabilitation stroke population based on functional status and age showed better predictive ability than models based on medical comorbidities.

Functional Status Outperforms Comorbidities in Predicting Acute Care Readmissions in Medically Complex Patients.

OBJECTIVE: To examine functional status versus medical comorbidities as predictors of acute care readmissions in medically complex patients. DESIGN: Retrospective database study. SETTING: U.S. inpatient rehabilitation facilities. PARTICIPANTS: Subjects included 120,957 patients in the Uniform Data System for Medical Rehabilitation admitted to inpatient rehabilitation facilities under the medically complex impairment group code between 2002 and 2011. INTERVENTIONS: A Basic Model based on gender and functional status was developed using logistic regression to predict the odds of 3-, 7-, and 30-day readmission from inpatient rehabilitation facilities to acute care hospitals. Functional status was measured by the FIM(®) motor score. The Basic Model was compared to six other predictive models-three Basic Plus Models that added a comorbidity measure to the Basic Model and three Gender-Comorbidity Models that included only gender and a comorbidity measure. The three comorbidity measures used were the Elixhauser index, Deyo-Charlson index, and Medicare comorbidity tier system. The c-statistic was the primary measure of model performance. MAIN OUTCOME MEASURES: We investigated 3-, 7-, and 30-day readmission to acute care hospitals from inpatient rehabilitation facilities. RESULTS: Basic Model c-statistics predicting 3-, 7-, and 30-day readmissions were 0.69, 0.64, and 0.65, respectively. The best-performing Basic Plus Model (Basic+Elixhauser) c-statistics were only 0.02 better than the Basic Model, and the best-performing Gender-Comorbidity Model (Gender+Elixhauser) c-statistics were more than 0.07 worse than the Basic Model. CONCLUSIONS: Readmission models based on functional status consistently outperform models based on medical comorbidities. There is opportunity to improve current national readmission risk models to more accurately predict readmissions by incorporating functional data.

Functional Status and Hospital Readmissions Using the Medical Expenditure Panel Survey.

BACKGROUND: Hospital readmissions are expensive and they may signal poor quality of care. Whether functional status is related to hospital readmissions using a representative U.S sample remains unexplored . OBJECTIVE: We aimed to assess the relationship between functional status and all-cause 30-day hospital readmissions using a representative sample of the US population. DESIGN: This was a retrospective observational study (2003-2011). PATIENTS: The study included 3,772 patients who completed the SF-12 before being hospitalized. Three hundred and eighteen (8.4%) were readmitted within 30 days after being discharged. MEASUREMENTS: The Medical Expenditure Panel Survey (MEPS) was employed. Functional status was measured with the Short-Form 12-Item Health Survey Version 2® (SF-12). The probability of being readmitted was estimated using a logistic model controlling for demographic characteristics, comorbid conditions, insurance coverage, physical (PCS) and mental (MCS) summaries of the SF-12, reason for hospitalization, length of hospital stay, region, and residential area. RESULTS: A one-unit difference in PCS reduced the odds of readmission by 2% (odds ratio 0.98 [95% CI, 0.97 to 0.99]; p < 0.001), which implies an 18% reduction in the odds of readmissions for a ten-unit difference (one standard deviation) in PCS. The c-statistic of the model was 0.72. CONCLUSION: Baseline physical function is associated with hospital readmissions. The SF-12 improves the ability to identify patients at high risk of hospital readmission.

What's in a Name? Recent Key Projects of the Committee on Organization and Delivery of Burn Care.

The Committee for the Organization and Delivery of Burn Care (ODBC) was charged by President Palmieri and the American Burn Association (ABA) Board of Directors with presenting a plenary session at the 45th Meeting of the ABA in Palm Springs, CA, in 2013. The objective of the plenary session was to inform the membership about the wide range of the activities performed by the ODBC committee. The hope was that this session would encourage active involvement within the ABA as a means to improve the delivery of future burn care. Selected current activities were summarized by key leaders of each project and highlighted in the plenary session. The history of the committee, current projects in disaster management, regionalization, best practice guidelines, federal partnerships, product development, new technologies, electronic medical records, and manpower issues in the burn workforce were summarized. The ODBC committee is a keystone committee of the ABA. It is tasked by the ABA leadership with addressing and leading progress in many areas that constitute current challenges in the delivery of burn care.