Hospital charges associated with "never events": comparison of anterior cervical discectomy and fusion, posterior lumbar interbody fusion, and lumbar laminectomy to total joint arthroplasty.

OBJECTIVE Beginning in 2008, the Centers for Medicare and Medicaid Service (CMS) determined that certain hospital-acquired adverse events such as surgical site infection (SSI) following spine surgery should never occur. The following year, they expanded the ruling to include deep vein thrombosis (DVT) and pulmonary embolism (PE) following total joint arthroplasty. Due to their ruling that "never events" are not the payers' responsibility, CMS insists that the costs of managing these complications be borne by hospitals and health care providers, rather than billings to health care payers for additional care required in their management. Data comparing the expected costs of such adverse events in patients undergoing spine and orthopedic surgery have not previously been reported. METHODS The California State Inpatient Database (CA-SID) from 2008 to 2009 was used for the analysis. All patients with primary procedure codes indicating anterior cervical discectomy and fusion (ACDF), posterior lumbar interbody fusion (PLIF), lumbar laminectomy (LL), total knee replacement (TKR), and total hip replacement (THR) were analyzed. Patients with diagnostic and/or treatment codes for DVT, PE, and SSI were separated from patients without these complication codes. Patients with more than 1 primary procedure code or more than 1 complication code were excluded. Median charges for treatment from primary surgery through 3 months postoperatively were calculated. RESULTS The incidence of the examined adverse events was lowest for ACDF (0.6% DVT, 0.1% PE, and 0.03% SSI) and highest for TKA (1.3% DVT, 0.3% PE, 0.6% SSI). Median inpatient charges for uncomplicated LL was $51,817, compared with $73,432 for ACDF, $143,601 for PLIF, $74,459 for THR, and $70,116 for TKR. Charges for patients with DVT ranged from $108,387 for TKR (1.5 times greater than index) to $313,536 for ACDF (4.3 times greater than index). Charges for patients with PE ranged from $127,958 for TKR (1.8 times greater than index) to $246,637 for PLIF (1.7 times greater than index). Charges for patients with SSI ranged from $168,964 for TKR (2.4 times greater than index) to $385,753 for PLIF (2.7 times greater than index). CONCLUSIONS Although incidence rates are low, adverse events of spinal procedures substantially increase the cost of care. Charges for patients experiencing DVT, PE, and SSI increased in this study by factors ranging from 1.8 to 4.3 times those for patients without such complications across 5 common spinal and orthopedic procedures. Cost projections by health care providers will need to incorporate expected costs of added care for patients experiencing such complications, assuming that the cost burden of such events continues to shift from payers to providers.

Incidence and cost of treating axis fractures in the United States from 2000 to 2010.

STUDY DESIGN: Retrospective database analysis. OBJECTIVE: To examine the incidence of hospitalization, treatment, and cost of caring for patients with axis (C2) fractures. SUMMARY OF BACKGROUND DATA: The incidence of C2 fractures in the elderly seems to be increasing, however, a comprehensive analysis of the incidence, treatment, and cost of treating C2 fractures has not been previously reported. METHODS: The Nationwide Inpatient Sample from 2000 to 2010 was used to identify patients with C2 fracture without neurological injury (International Classification of Disease, Ninth Revision, Clinical Modification code 805.02). Examined variables included age, International Classification of Disease, Ninth Revision, Clinical Modification injury severity score, comorbidities, mortality, hospital length of stay, treatments, and total inpatient hospitalization charge. Charges were adjusted for inflation to 2010 US dollars as well as for cost-to-charge ratios. RESULTS: In total, 31,129 patients with C2 fracture were identified. From 2000 to 2010 the incidence of C2 fracture hospitalization increased in all age groups (P < 0.0001). The most rapid increase was in patients older than 84 years, who experienced a 3-fold increase from 3.18 to 9.77 hospitalizations per 10,000 individuals per year (P < 0.0001). From 2000 to 2010, the rate of halo vest placement decreased from 25.2% to 10.4% (P < 0.0001), whereas the rate of surgical intervention increased from 13.1% to 16.5% (P = 0.029). For nonoperatively treated patients, the mean hospitalization charge per patient increased from $39,346 in 2000 to $63,222 in 2010, and for surgically treated patients, it increased from $70,784 in 2000 to $133,064 in 2010 (P < 0.0001). During the decade, the estimated charges for annual inpatient care for patients with C2 fracture in the United States increased 4.7-fold from $334,138,919 to $1,577,254,958 (P < 0.0001). CONCLUSION: The incidence of C2 fracture hospitalizations increased dramatically from 2000 to 2010, with the most rapid increase in the elderly represented by a greater than 3-fold increase for patients older than 84 years. The inpatient charges for treating C2 fractures have risen faster than the increased incidence, with a 4.7-fold increase in hospital charges resulting in estimated annual charges of more than $1.5 billion in 2010. LEVEL OF EVIDENCE: 3.

A population-based survival assessment of categorizing level III and IV rural hospitals as trauma centers.

CONTEXT: Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse. PURPOSE: To determine if there is improved survival among injured patients hospitalized in states that categorize rural hospitals as trauma centers. METHODS: We analyzed a retrospective cohort of injured patients included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 1997 to 1999. We used generalized estimating equations to compare survival among injured patients hospitalized in states that categorize rural hospitals as Level III and IV trauma centers versus those that do not. Multivariable models adjusted for important confounders, including patient demographics, co-morbid conditions, injury severity, and hospital-level factors. FINDINGS: There were 257,044 admitted patients from 7 states with a primary injury diagnosis, of whom 64,190 (25%) had a "serious" index injury, 32,763 (13%) were seriously injured (by ICD-9 codes), and 12,435 (5%) were very seriously injured (by ICD-9 codes). There was no survival benefit associated with rural hospital categorization among all patients with a primary injury diagnosis or for those with specific index injuries. However, seriously injured patients (by ICD-9 codes) had improved survival when hospitalized in a categorizing state (OR for mortality 0.72, 95% confidence interval [CI] 0.53-0.97; OR for very seriously injured 0.68, 95% CI 0.52-0.90). CONCLUSIONS: There was no survival benefit to categorizing rural hospitals among a broad, heterogeneous group of hospitalized patients with a primary injury diagnosis; however the most seriously injured patients did have increased survival in such states.

Early neurosurgical procedures enhance survival in blunt head injury: propensity score analysis.

BACKGROUND: Studies of trauma systems have identified traumatic brain injury as a frequent cause of death or disability. Due to the heterogeneity of patient presentations, practice variations, and potential for secondary brain injury, the importance of early neurosurgical procedures upon survival remains controversial. Traditional observational outcome studies have been biased because injury severity and clinical prognosis are associated with use of such interventions. OBJECTIVE: We used propensity analysis to investigate the clinical efficacy of early neurosurgical procedures in patients with traumatic brain injury. METHODS: We analyzed a retrospectively identified cohort of 518 consecutive patients (ages 18-65 years) with blunt, traumatic brain injury (head Abbreviated Injury Scale score of >or= 3) presenting to the emergency department of a Level-1 trauma center. The propensity for a neurosurgical procedure (i.e., craniotomy or ventriculostomy) in the first 24 h was determined (based upon demographic, clinical presentation, head computed tomography scan findings, intracranial pressure monitor use, and injury severity). Multivariate logistic regression models for survival were developed using both the propensity for a neurosurgical procedure and actual performance of the procedure. RESULTS: The odds of in-hospital death were substantially less in those patients who received an early neurosurgical procedure (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.05-0.41). The mortality benefit of early neurosurgical intervention persisted after exclusion of patients who died within the first 24 h (OR 0.13; 95% CI 0.04-0.48). CONCLUSIONS: Analysis of observational data after adjustment using the propensity score for a neurosurgical procedure in the first 24 h supports the association of early neurosurgical intervention and patient survival in the setting of significant blunt, traumatic brain injury. Transfer of at-risk head-injured patients to facilities with high-level neurosurgical capabilities seems warranted.

Proportion of seriously injured patients admitted to hospitals in the US with a high annual injured patient volume: a metric of regionalized trauma care.

BACKGROUND: Multiple regional trauma systems have been implemented over the past 3 decades to achieve the goal of regionalized care for injured patients. The American College of Surgeons Committee on Trauma (ACS-COT) advocates that seriously injured patients should be treated in designated Level I trauma centers that meet criteria including admitting more than 1,200 injured patients annually. Reliable measures are needed to evaluate the implementation of regionalized care nationally. The goal of this study was to measure the proportion of seriously injured patients treated at high injury-volume hospitals. STUDY DESIGN: We performed a retrospective observational study of injured patients hospitalized in the US during the years 1995 to 2003, drawn from the Nationwide Inpatient Sample. Hospitals were ranked in order of annual volume of injured patient admissions. A patient's severity of injury was calculated using ICD-9-based Injury Severity Score (ICISS). The principal measure was the proportion of seriously injured patients (ICISS

Racial disparities in mortality among adults hospitalized after injury.

BACKGROUND: Injury is a major cause of death in adults. Although racial disparities in healthcare access and health outcomes are well documented for medical conditions, the influence of race on access to emergent care after injury has received little scrutiny. OBJECTIVES: We sought to determine whether race was associated with risk of in-hospital death after injury. RESEARCH DESIGN: Data from the Healthcare Cost and Utilization Project (1998-2002) were used to estimate multivariate models of in-hospital mortality, controlling for age, race, gender, comorbid conditions, injury severity, primary payer, median income of zip code of residence, and hospital type. Additional multivariate models were estimated among stratified subsets of patients, including injury severity and hospital type. SUBJECTS: Patients age 18-64 with a primary diagnosis of injury. RESULTS: Relative to injured white patients, black and Asian patients had a higher risk of death [1.5% vs. 2.1% and 2.0%, multivariate odds ratios (OR) = 1.14 and 1.39]. Other racial/ethnic groups showed no significant mortality difference from white patients. In stratified analyses, we found large black-white mortality disparities among mild to moderately injured patients (OR = 1.40, 95% confidence interval: 1.18-1.66), whereas Asian-white disparities were concentrated among more severely injured patients (OR = 1.37, 95% confidence interval: 1.03-1.80). CONCLUSIONS: Black and Asian patients have a higher risk of death after injury than white patients. These data raise important questions about access to quality trauma care for racial minority patients.

Variability in rates of arthrodesis for patients with thoracolumbar spine fractures with and without associated neurologic injury.

STUDY DESIGN: Retrospective cohort study using a large clinical database. OBJECTIVE: Assess hospital-based rates of thoracolumbar spine arthrodesis within the United States for patients with a thoracolumbar spine fracture. SUMMARY OF BACKGROUND DATA: Substantial variation has been documented in per capita rates of elective lumbar spinal arthrodesis. Similar data regarding rates of arthrodesis for traumatic thoracolumbar injuries have not been reported. METHODS: Data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2002 was used. ICD-9-CM codes were used to identify patients with thoracolumbar vertebral fractures with and without associated neurologic injury. Hospitals were grouped by teaching status and volume of thoracolumbar fracture patients and compared for rates of arthrodesis. Arthrodesis rates for the 25 highest fracture volume hospitals in the database were compared individually. RESULTS: A total of 24,098 patients with thoracolumbar fracture were identified: 91.7% had a thoracolumbar fracture without neurologic injury, while 8.3% had a thoracolumbar fracture with neurologic injury. Overall, 9.1% of thoracolumbar fracture patients without neurologic injury underwent arthrodesis, while 61.4% of thoracolumbar fracture patients with neurologic injury underwent arthrodesis. For all patients, rates of arthrodesis at high-volume hospitals were significantly greater than arthrodesis rates at lower-volume hospitals. Similarly, urban teaching hospitals had higher rates of arthrodesis than those at urban nonteaching hospitals. Among the 25 highest-volume hospitals in our sample, spinal arthrodesis rates for patients without associated neurologic injury ranged from 4% to 23%, a 5.8-fold variation. Among fracture patients with neurologic injury, arthrodesis rates ranged from 50% to 91%, a 1.8-fold variation. CONCLUSION: Hospital teaching status and spine fracture volume affected rates of spine arthrodesis in thoracolumbar fracture patients with and without neurologic injury. Variability in fusion rate for thoracolumbar spine trauma appears to be lower than that reported for elective spine procedures, especially in the presence of a neurologic injury.

Variability in rates of arthrodesis procedures for patients with cervical spine injuries with and without associated spinal cord injury.

BACKGROUND: Cervical spine injury, with or without spinal cord injury, is an important cause of morbidity and mortality in the United States. While substantial regional variation has been shown in per capita rates of elective cervical spine surgery, similar data regarding arthrodesis rates for traumatic cervical injury have not been reported, to our knowledge. We assessed the rates of cervical spinal arthrodesis for patients who had a cervical spine injury with or without an associated spinal cord injury. METHODS: The data for the present study came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2002. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients with a cervical vertebral fracture or dislocation with or without an associated spinal cord injury. Hospitals were grouped according to their teaching status, location (urban or rural), and volume of cervical spine injury patients. The rates of spinal arthrodesis and halo/tong placement were compared for patients within each diagnostic category. RESULTS: Twenty-eight thousand, five hundred and eighteen patients with a cervical spine injury were analyzed. Spinal arthrodesis was performed for 16.5% of patients who had a cervical fracture without an associated spinal cord injury, for 50.4% of patients who had a cervical spine fracture with an associated spinal cord injury, and for 44.1% of patients who had a cervical dislocation. With the numbers available, the rates of arthrodesis for patients who had a fracture without a spinal cord injury and for patients who had a cervical dislocation were not significantly different between high and low-volume centers, although the rate for patients who had a cervical fracture with a spinal cord injury was significantly higher at high-volume hospitals. The rates of arthrodesis did not vary significantly between urban teaching and nonteaching hospitals, with the numbers available, for patients in any of the three diagnostic categories. Individual hospitals had a threefold to fivefold variation in the arthrodesis rate for patients with a cervical spine injury, depending on the diagnostic category. CONCLUSIONS: The present study demonstrated substantial differences in the rate of arthrodesis for patients with cervical spine trauma, depending on the diagnostic category. The variations in the rates of arthrodesis within diagnostic categories appear to be lower than the previously reported variation in the rates of elective cervical spine procedures.

Regional differences in outcomes for hospitalized injured patients.

BACKGROUND: Our goal was to use a hospital population-based data set that was a sample of all injured patients admitted to a hospital in the United States to develop universal measures of outcome and processes of care. METHODS: Patients with a primary discharge diagnosis of injury (ICD-9 800 to 959) in the HCUP/Nationwide Inpatient Sample for the years 1995 to 2000 were used to estimate the annual number of hospitalized injured patients. Using census data, we calculated age- and sex- adjusted average annual incidence rates for four census regions in the United States: Northeast, Midwest, South and West. Outcomes measured were annual rates per million populations of hospitalization rate, death rate, and potentially ineffective care (PIC) rate defined as >28 days of hospitalization ending in death. Length of stay (LOS) was calculated as total number of days annually hospitalized for injury for census regions per million populations. RESULTS: Incidence rates per million populations and 95% confidence intervals for rate of hospitalizations for injury were: Northeast, 5596 (5338-5853); Midwest, 5516 (5316-5716); South, 5639 (5410-5869); West, 5307 (5071-5543). Incidence rates per million populations and 95% confidence intervals for rate of in-hospital deaths were: Northeast, 129 (119-139); Midwest, 131 (122-139); South, 141 (129-152); West, 114 (106-123). Incidence rates per million populations and 95% confidence intervals for rate of PIC were: Northeast, 11 (10-13); Midwest, 5 (4-5); South, 6 (5-7); West, 4 (3-4). Incidence rates per million populations and 95% confidence intervals for hospital days were: Northeast, 34 (32-36); Midwest, 30 (28-31); South, 30 (29-32); West, 26 (24-27). CONCLUSION: Regional differences in outcomes and processes of care for hospitalized injured patients exist and may be influenced by hospital characteristics and region of the country. Research to identify the factors that cause these hospital and regional variations is needed. These observations suggest that to develop a uniform standard for quality of care, it will be essential to have valid and robust hospital population-based measures.

The incidence and burden of ladder, structure, and scaffolding falls.

OBJECTIVES: The national morbidity and mortality associated with falls from a height is incompletely described. The authors estimated the rates of injury, hospitalization, and mortality due to these falls for subgroups of the U.S. population. METHODS: Administrative databases (1995-2000) provided national samples of patients treated for injuries following a fall from a height (ICD-9-CM E-codes E881.0, E881.1, or E882). Inpatient data are from the Nationwide Inpatient Sample, and emergency department data are from the National Hospital Ambulatory Medical Care Survey. RESULTS: A total of 347,484 (95% confidence interval = 308,417 to 386,551) emergency department presentations occur annually for injuries following a fall. Hospitalized patients older than 75 years of age had a 3.3% case fatality, and 42% were discharged to a skilled nursing facility. For patients older than 55 years of age, 86% of falls were not work related. CONCLUSIONS: Ladder and structure falls by elders are a substantial emergency department problem warranting thorough clinical evaluation and injury prevention efforts.

Mortality benefit of transfer to level I versus level II trauma centers for head-injured patients.

OBJECTIVE: To determine whether head-injured patients transferred to level I trauma centers have reduced mortality relative to transfers to level II trauma centers. DATA SOURCE/STUDY SETTING: Retrospective cohort study of 542 patients with head injury who initially presented to 1 of 31 rural trauma centers in Oregon and Washington, and were transferred from the emergency department to 1 of 15 level I or level II trauma centers, between 1991 and 1994. STUDY DESIGN: A bivariate probit, instrumental variables model was used to estimate the effect of transfer to level I versus level II trauma centers on 30-day postdischarge mortality. Independent variables included age, gender, Injury Severity Scale (ISS), other indicators of injury severity, and a dichotomous variable indicating transfer to a level I trauma center. The differential distance between the nearest level I and level II trauma centers was used as an instrument. PRINCIPAL FINDINGS: Patients transferred to level I trauma centers differ in unmeasured ways from patients transferred to level II trauma centers, biasing estimates based on standard statistical methods. Transfer to a level I trauma center reduced absolute mortality risk by 10.1% (95% confidence interval 0.3%, 22.2%) compared with transfer to level II trauma centers. CONCLUSIONS: Patients with severe head injuries transferred from rural trauma centers to level I centers are likely to have improved survival relative to transfer to level II centers.

Hospital factors associated with splenectomy for splenic injury: a national perspective.

BACKGROUND: The management of patients with splenic injury has shifted from routine splenectomy to attempts at splenic salvage. Using the Healthcare Cost and Utilization Project's National Inpatient Sample (HCUP-NIS), we assessed the patterns of care for splenic trauma. We hypothesized that the processes of care in urban and rural hospitals would differ. METHODS: Generalized estimating equations were used to identify predictor variables associated with laparotomy and splenectomy from a national, population-based sample of inpatients (HCUP-NIS). Fourteen thousand nine hundred one patients with an International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis code of 865 were selected from the 1998 to 2000 HCUP-NIS data. Exclusion criteria included age greater than 80 years. Analyses were compared using all patients and excluding patients who died during the first 2 hospital days. RESULTS: Eight thousand five hundred fifty-three patients were treated in urban teaching hospitals. Forty percent underwent a laparotomy and 28% underwent a splenectomy at that time. Another 4,461 patients were cared for in urban nonteaching hospitals. Of these, 46% had a laparotomy and 35% underwent a splenectomy. The remaining 1,887 patients were seen in rural hospitals. Forty-six percent had a laparotomy and 36% had a splenectomy. Patients in urban teaching hospitals had lower risk-adjusted odds of splenectomy in multivariate models controlling for confounders including overall injury severity. Overall splenic salvage increased from 1998 to 2000, primarily because of increased salvage rates among urban teaching hospitals. CONCLUSION: The management of patients with splenic injury differs among urban teaching, urban nonteaching, and rural hospitals. Surgeons at urban teaching hospitals appear more willing to attempt splenic salvage by means of nonoperative management.

Advanced statistics: the propensity score--a method for estimating treatment effect in observational research.

Observational studies assessing the effect of a particular treatment or exposure may be subject to bias, which can be difficult to eliminate using standard analytic techniques. Multivariable models are commonly used in observational research to assess the relationship between a certain exposure or treatment and an outcome, while adjusting for important variables necessary to ensure comparability between the groups. Large differences in the observed covariates between two study groups may exist in observational studies in which the investigator has no control over who was allocated to each treatment group, and these differences may lead to biased estimates of treatment effect. When there are large differences in important prognostic characteristics between the treatment groups, adjusting for these differences with conventional multivariable techniques may not adequately balance the groups, and the remaining bias may limit valid causal inference. Use of a propensity score, described as a conditional probability that a subject will be "treated" based on an observed group of covariates, may better adjust covariates between the groups and reduce bias. The purpose of this article is to describe the use of propensity scores to adjust for bias when estimating treatment effects in observational research and to compare use of this technique with conventional multivariable regression. The authors present three methods for integrating propensity scores into observational analyses using a database collected on head-injured trauma patients. The article details the methods for creating a propensity score, analyzing data with the score, and explores differences between propensity score methods and conventional multivariable methods, including potential benefits and limitations. Graphical representations of the analyses are provided as well.

Variations in injury patterns, treatment, and outcome for spinal fracture and paralysis in adult versus geriatric patients.

STUDY DESIGN: Retrospective cohort analysis of hospital discharge and mortality data for spinal fracture and spinal cord injury patients in a single state from 1990 to 1995. OBJECTIVES: Population-based review of preinjury patient factors, injury and treatment patterns, and in-hospital versus 60-day mortality in adult and geriatric spinal injury patients. SUMMARY OF BACKGROUND DATA: While population-based analyses of hospitalized injured patients indicate that geriatric patients are at higher risk for adverse outcome, less is known about the specific subset of patients with spinal fracture and spinal cord injury. A specific knowledge gap exists regarding factors that influence survival after hospital discharge of spine-injured patients. METHODS: Patients with cervical, thoracic, or lumbar spinal fracture were identified by ICD-9-CM discharge diagnosis codes. Age, gender, preexisting conditions, and injury severity were determined, and patients were divided into adult (ages 16-64 years; n = 6,029) and geriatric (ages >or=65 years; n = 3,973) groups. In-hospital and 60-day mortality rates and odds ratios of 60-day mortality were calculated relative to patient and injury characteristics, level of treating hospital, and surgical treatment. RESULTS: Increased 60-day mortality was associated with preexisting medical conditions, increased injury severity, and paralysis but reduced with surgical treatment. Geriatric patients had fewer cervical injures, lower force injuries, less severe overall injuries, decreased paralysis, increased preexisting conditions, decreased treatment at level 1 and 2 treatment centers, and decreased odds of surgical treatment. Geriatric patients also had increased 60-day versus in-hospital mortality and increased mortality associated with cervical spine injury. DISCUSSION: Differences exist in preinjury patient factors, injury and treatment patterns, and mortality between adult and geriatric patients following spinal injuries. The increased 60-day versus in-hospital mortality for the geriatric population suggests that 60-day mortality may be a better measure of outcome for these patients. While the possibility of selection bias exists, both geriatricand adult patients had reduced 60-day mortality associated with surgical intervention.

Explaining racial differences in receipt of coronary angiography: the role of physician referral and physician specialty.

The authors examine three hypotheses regarding race differences in utilization of coronary angiography (CA): (1) patients with a cardiology consultation are more likely to obtain a referral for CA, (2) African American patients are less likely to have a cardiology consultation, and (3) among patients referred for CA, there is no difference by race in receipt of the procedure. To determine if they obtained a referral for or received CA, 2.623 candidates for CA were followed. Multivariate models were estimated using logistic regression. Cardiology consultation was associated with referral for CA (OR = 5.1, p < .001). White patients had higher odds of cardiology consultation (OR = 2.2, p < .001). The racial disparity was reduced among patients who received a referral (OR = 1.4, p < .05). Researchers must eliminate racial differences in access to specialty care and variation in referral patterns by physician specialty, and efforts must be targeted to those specialties where greater disparities exist.

Rib fracture pain and disability: can we do better?

OBJECTIVE: The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series. METHODS: Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0-10). Disability at 30 days was assessed using the SF-36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university-based Level I trauma center. RESULTS: Forty patients with a mean of 2.7 +/- 1.6 rib fractures were enrolled. Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 +/- 2.1 at 30 days and 1.0 +/- 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p < 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p < 0.001). The total mean days lost from work/usual activity was 70 +/- 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 +/- 39 days compared with 91 +/- 33 days in patients with associated extrathoracic injuries (p < 0.01). CONCLUSION: Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.

The cardiac access longitudinal study. A study of access to invasive cardiology among African American and white patients.

OBJECTIVES: We sought to identify factors contributing to racial disparity in the receipt of coronary angiography (CA). BACKGROUND: Numerous studies have demonstrated that African American patients are less likely to receive needed diagnostic and therapeutic coronary procedures than white patients. This report summarizes the methods and findings of a study linking medical records with patient and physician interviews to address racial disparities in the utilization of CA. METHODS: This is a retrospective, cross-sectional study conducted in three urban hospitals in Maryland. A total of 9,275 medical records were reviewed, representing all 7,058 cardiac patients admitted in a two-year period. We identified 2,623 patients who, according to American College of Cardiology guidelines, were candidates for receiving CA. A total of 1,669 patients (721 African Americans and 948 whites) and 74% of their physicians were successfully interviewed. Multivariate and hierarchical multivariate logistic regression were used to construct a model of receipt of CA within one year of the hospitalization. RESULTS: The unadjusted odds of white patients receiving CA was three times greater than the odds for African American patients (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.4 to 3.7). Adjusting for patients' clinical and social characteristics resulted in a 13% reduction in the OR for race. Adjusting for physician and health care system characteristics reduced the OR by 43%, to 1.7 (95% CI 1.3 to 2.4). CONCLUSIONS: Racial disparity in the utilization of CA is a function of differences in the health care system "context" in which African American and white patients obtain care, combined with differences in the specific clinical characteristics of patients.

Physician referral patterns and race differences in receipt of coronary angiography.

OBJECTIVE: This study addresses the following research questions: (1) Is race a predictor of obtaining a referral for coronary angiography (CA) among patients who are appropriate candidates for the procedure? (2) Is there a race disparity in obtaining CA among patients who obtain a referral for the procedure? STUDY SETTING: Three community hospitals in Baltimore, Maryland. STUDY DESIGN: We abstracted hospital records of 7,927 patients from three hospitals to identify 2,653 patients who were candidates for CA. Patients were contacted by telephone to determine if they received a referral for CA. Logistic regression was used to assess whether racial differences in obtaining a referral were affected by adjustment for several potential confounders. A second set of analyses examined race differences in use of the procedure among a subsample of patients that obtained a referral. PRINCIPAL FINDINGS: After controlling for having been hospitalized at a hospital with in-house catheterization facilities, ACC/AHA (American College of Cardiology/American Heart Association) classification, sex, age, and health insurance status, race remained a significant determinant of referral (OR = 3.0, p < .05). Additionally, we found no significant race differences in receipt of the procedure among patients who obtained a referral. CONCLUSIONS: Our results demonstrate that race differences in utilization of CA tend to occur during the process of determining the course of treatment. Once a referral is obtained, African American patients are not less likely than white patients to follow through with the procedure. Thus, future research should seek to better understand the process by which the decision is made to refer or not refer patients.

Injury mortality following the loss of air medical support for rural interhospital transport.

OBJECTIVES: This study evaluated variation in mortality among interfacility transfers three years before and after discontinuation of a rotor-wing transport service. METHODS: A retrospective cohort assessment was conducted among severely injured patients transferred from four rural hospitals to a single tertiary center in regions with continued versus discontinued rotor-wing service. Thirty-day mortality following discharge from the receiving tertiary facility served as the primary outcome measure. RESULTS: Discontinuation of rotor-wing transport decreased interfacility transfers and increased transfer time. Transferred patients were four times more likely to die after (compared with before) rotor-wing service was discontinued (p = 0.05). No difference was noted in the region with continued rotor-wing service [odds ratio (OR) = 0.53, p = 0.47]. CONCLUSIONS: Injury mortality increased with loss of air transport for interfacility transfer in a rural area.

Survival of seriously injured patients first treated in rural hospitals.

BACKGROUND: Patients injured in rural counties are hypothesized to have improved survival if local hospitals are categorized as Level III, Level IV, and Level V trauma centers. METHODS: Data were abstracted on patients with brain, liver, or spleen injuries who were first treated in 16 rural hospitals in Oregon (with categorized trauma centers) and 16 hospitals in Washington (without categorized trauma centers). Logistic regression models evaluated survival up to 30 days after hospital discharge. RESULTS: Among Oregon's 642 study patients, 63% were transferred to another hospital. Among Washington's 624 patients, a higher proportion, 70%, were transferred. Risk-adjusted odds of death for Washington patients (reference odds, 1) were the same as for Oregon patients (odds ratio, 0.82; 95% confidence interval, 0.53-1.28). Most patients died after transfer to another hospital. CONCLUSION: In states with a prevailing practice of promptly transferring brain-injured patients, survival of these patients may not be enhanced by categorization of hospitals as rural trauma centers. To further improve the outcome of these patients, policy makers should adjust statewide trauma system guidelines to enhance integration and to perfect coordination among sequential decision makers.