The Impact of Palliative Medicine Consultation on Readmission Rates and Hospital Costs in Surgical Patients Requiring Prolonged Mechanical Ventilation.

BACKGROUND: The use of palliative care for critically ill hospitalized patients has expanded. However, it is still underutilized in surgical specialties. Postsurgical patients requiring prolonged mechanical ventilation have increased mortality and costs of care; outcomes from adding palliative care services to this population have been poorly investigated. The objective of this study was to determine the impact of palliative medicine consultation on readmission rates and hospitalization costs in postsurgical patients requiring prolonged mechanical ventilation. METHODS: The Nationwide Readmissions Database was queried for adults (> 18 years) between the years 2010 and 2014 who underwent a major operation (Healthcare Cost and Utilization Project [HCUP] data element ORPROC = 1), required mechanical ventilation for ≥ 96 consecutive hours (ICD-9-CM V46.1), and survived until discharge. Among these, patients who received a palliative medicine consultation during hospitalization were identified using the ICD-9-CM diagnosis code V66.7. RESULTS: Of 53,450 included patients, 3.4% received a palliative care consultation. Compared to patients who did not receive a palliative care consultation, patients who did receive a consultation had a lower readmission rate (14.8% vs. 24.8%, p < 0.001) and lower average cost of hospitalization during the initial admission ($109,007 vs. $124,218, p < 0.001), findings that persisted after multivariable logistic regression. CONCLUSION: Utilization of palliative care in surgical patients remains low. Palliative care consultation in postsurgical patients requiring prolonged mechanical ventilation was associated with lower cost and rate of readmission. Further work is needed to integrate palliative care services with surgical care.

Avoiding Cribari gridlock 2: The standardized triage assessment tool outperforms the Cribari matrix method in 38 adult and pediatric trauma centers.

OBJECTIVES: The Cribari Matrix Method (CMM) is the current standard to identify over/undertriage but requires manual trauma triage reviews to address its inadequacies. The Standardized Triage Assessment Tool (STAT) partially emulates triage review by combining CMM with the Need For Trauma Intervention, an indicator of major trauma. This study aimed to validate STAT in a multicenter sample. METHODS: Thirty-eight adult and pediatric US trauma centers submitted data for 97,282 encounters. Mixed models estimated the effects of overtriage and undertriage versus appropriate triage on the odds of complication, odds of discharge to a continuing care facility, and differences in length of stay for both CMM and STAT. Significance was assessed at p <0.005. RESULTS: Overtriage (53.49% vs. 30.79%) and undertriage (17.19% vs. 3.55%) rates were notably lower with STAT than with CMM. CMM and STAT had significant associations with all outcomes, with overtriages demonstrating lower injury burdens and undertriages showing higher injury burdens than appropriately triaged patients. STAT indicated significantly stronger associations with outcomes than CMM, except in odds of discharge to continuing care facility among patients who received a full trauma team activation where STAT and CMM were similar. CONCLUSIONS: This multicenter study strongly indicates STAT safely and accurately flags fewer cases for triage reviews, thereby reducing the subjectivity introduced by manual triage determinations. This may enable better refinement of activation criteria and reduced workload.

Demographics, Treatment, and Cost of Periprosthetic Femur Fractures: Fixation Versus Revision.

INTRODUCTION: Periprosthetic femur fractures (PPFX) are complications of both total hip and knee arthroplasty and may be treated with open reduction and internal fixation (ORIF) or revision arthroplasty. Differences in treatment and fracture location may be related to patient demographics and lead to differences in cost. Our study examined the effects of demographics and treatment of knee and hip PPFXs on length of stay (LOS) and cost. METHODS: Of all, 932 patients were identified with hip or knee PPFXs in the National Inpatient Sample from January 2013 to September 2015. Age, gender, race, mortality, comorbidity level, LOS, total cost, procedure type, geographic region, and hospital type were recorded. A generalized linear regression model was conducted to analyze the effect of fracture type on LOS and cost. RESULTS: Differences in gender (66% vs 83.7% female, P < .01), comorbidities (fewer in hips, P < .01), and costs (US$30 979 vs US$27 944, P < .01) were found between the hip and knee groups. Knees had significantly higher rates of ORIF treatment (80.7% vs 39.1%) and lower rates of revision arthroplasties (19.3% vs 60.9%) than hip PPFXs (P < .01). Within both groups, patients with more comorbidities, revision surgery, and blood transfusions were more likely to have a longer LOS and higher cost. CONCLUSION: Periprosthetic femur fractures patients are not homogenous and treatment varies between hip and knee locations. For knee patients, those treated with ORIF were younger, with fewer comorbidities than those treated with revision. Conversely, hip patients treated with ORIF were older, with more comorbidities than those treated with revision. Hips had higher costs than knees, and cost correlated with revision arthroplasty and more comorbidities. In both hip and knee groups, longer LOS was associated with more comorbidities and being treated in urban teaching hospitals. Total cost had the strongest associations with revision procedures as well as number of comorbidities and blood product use.

Tennessee emergency hand care distributions and disparities: Emergent hand care disparities.

BACKGROUND: Hand trauma is the most frequently treated injury in emergency departments, but presently there is a crisis of insufficient emergency coverage. This study evaluates the discrepancy of emergent and elective hand care trends based on socioeconomic factors in the state of Tennessee. METHODS: We identified 119 hospitals in Tennessee that contained operating and emergency room facilities. Of these, 111 hospitals participated in a survey to determine the availability of elective and emergency hand surgery. Wilcoxon rank-sum test or permutation chi-square test and logistic regression were used to analyze reported measures. RESULTS: Our results revealed that hospitals in counties with the lowest per capita income and median household income are less likely to have hand specialists or offer hand call. There are also significantly fewer hospitals that have hand specialists and offer hand call that are located in medically underserved areas. In the state of TN, level 1 trauma facilities are required by the Tennessee Department of Health to have staffed hand specialists and 24/7 hand call. Our study revealed that while 7/8 (87.5 %) level 1 trauma facilities have hand specialists, only 2/8 (25 %) provide 24/7 hand specialist call. CONCLUSION: Our results strongly suggest the presence of a health care disparity for hand trauma in counties with a low income and in medically underserved areas.