Improving blood pressure screening and control at an academic health system.

The goal of the University of California Davis Health Blood Pressure (BP) Quality Improvement Initiative was to improve the diagnosis, management and control of high BP. Patients aged 18-85 years were included in the initiative. Lean A3 problem solving was used to implement the following evidence-based interventions based on stakeholder interviews, value stream mapping and the Centers for Disease Control and Prevention's Million Hearts Initiative: staff training on accurate BP measurement, visual cues and reminders for BP screening, virtual case-based videoconferences, standardised clinical management algorithm, academic detailing visits, clinical decision support tools, access to pharmacists for medication comanagement, clinician workflow modification, patient education and access to home BP monitors. Following implementation of interventions, accurate screening of BP increased from 14% to 87% and BP control increased from 62% to 75%. Strategies that contributed the most to improvements were using a team-based approach, adjusting clinic workflow and frequent communication of results to staff.

The Financial Impact of the Affordable Care Act on a Level-1 Orthopedic Trauma Service.

OBJECTIVES: To determine the impact of the Affordable Care Act (ACA) on professional fees and proportion of payer type for an orthopedic trauma service at a level-1 trauma center. METHODS: We analyzed professional fee data and payer mix for the 18 months before and after implementation of the ACA. Data were collected for inpatients (IP) and outpatients (OP). We corrected for changes in patient volume between the 2-time periods by calculating average values per patient. RESULTS: Post ACA, we treated a higher percentage of patients with Medicaid and had a reduction in the percentage of uninsured/county payers. Collections for IPs decreased $75.49/patient and OPs decreased $0.10/patient. Our collection rate decreased 6% for IPs and 5% for OPs. In particular, Medicaid collections decreased by $180/IP, and $4/OP, and Medicare decreased by $61/IP and increased $5/OP post ACA, whereas contract collections increased by $140/IP and $20/OP. The changes in our own institution's insurance were mixed with decreases of $514/IP for partial risk and $735/IP for full-risk insurance and increases of $1/OP for partial risk, and $35/OP for full-risk insurance. CONCLUSIONS: Post ACA, we saw less patients, primarily in the OP setting. This shift was accompanied by a significant decrease in our collection rate; specifically, a decrease in the amount we collected per Medicaid patient-the category of payer that increased post ACA. The ACA did allow more uninsured patients access to medical care but was associated with lower IP and OP reimbursements.

Approaches to Distal Upper-Extremity Trauma: A Comparison of Plastic, Orthopedic, and Hand Surgeons in Academic Practice.

BACKGROUND: Hand trauma call duties at university medical centers are traditionally split among plastic surgeons and orthopedic surgeons, frequently without additional fellowship training in hand and upper-extremity surgery. Differences in operative approach between these groups have never been specifically described. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual, billing and coding data from 90 academic medical centers in the United States and can be used to characterize the practice patterns of various academic surgical specialties. OBJECTIVE: To characterize and compare the clinical experience of academic plastic, orthopedic, and hand surgeons in addressing traumatic distal upper extremity injuries (using the Faculty Practice Solutions Center data set). METHODS: Annual data for CPT defined procedures related to traumatic injuries of the nail bed, finger, hand, wrist, and forearm performed by plastic, orthopedic, and hand surgeons during calendar years 2010 to 2013 were included in the study. RESULTS: From 2010 to 2013, the experience of fellowship-trained hand surgeons in treating traumatic distal upper extremity injuries was consistently greater than that of plastic surgeons and general orthopedic surgeons across all categories. Injuries of the nail bed were repaired more frequently by plastic surgeons than orthopedic surgeons (average 1.3 annual procedures per surgeon for plastic surgeons compared with 0.3 for orthopedic surgeons). Fractures and dislocations involving the phalanx and metacarpal were repaired equally by both groups, with plastic surgeons using predominantly percutaneous (38%) or open methods (45% of repairs), and orthopedic surgeons using mostly closed reduction (59% of repairs), splinting, and casting. Fractures and dislocations involving the carpal bones, radius, and ulna were more frequently repaired by orthopedic surgeons (average 23.2 procedures versus 2.6 for plastic surgeons), whereas tendon repairs in all segments were performed more frequently by plastic surgeons (average 13.7 procedures versus 2.5 for orthopedic surgeons). Replantation and repair of neurovascular injuries were exceedingly rare (less than 1 occurrence) in all groups for all years and are not specifically reported in Table 1. Similarly, incision and drainage procedures and decompressive fasciotomies of the distal upper extremity were uncommonly performed and also not included (Table 1 displays the mean annual procedures per surgeon by grouped CPT coded procedures, with overall averages displayed to the right. Figure 1 displays the proportions of intra-articular and extra-articular bony hand injuries treated by closed, open, and percutaneous methods by each specialty). CONCLUSIONS: A large degree of variation exists in the treatment of distal upper extremity injuries, based on specialty service. Hand surgeons, not surprisingly, have the most robust clinical experience, whereas plastic surgeons and orthopedic surgeons each display varying strengths and weaknesses, perhaps a consequence of their respective training.

Management of children with solid organ injuries after blunt torso trauma.

BACKGROUND: Management of children with intra-abdominal solid organ injuries has evolved markedly. We describe the current management of children with intra-abdominal solid organ injuries after blunt trauma in a large multicenter network. METHODS: We performed a planned secondary analysis of a prospective, multicenter observational study of children (<18 years) with blunt torso trauma. We included children with spleen, liver, or kidney injuries identified by computed tomography, laparotomy/laparoscopy, or autopsy. Outcomes included disposition and interventions (blood transfusion for intra-abdominal hemorrhage, angiography, laparotomy/laparoscopy). We performed subanalyses of children with isolated injuries. RESULTS: A total of 12,044 children were enrolled; 605 (5.0%) had intra-abdominal solid organ injuries. The mean (SD) age was 10.7 (5.1) years, and injured organs included spleen 299 (49.4%), liver 282 (46.6%), and kidney 147 (24.3%). Intraperitoneal fluid was identified on computed tomography in 461 (76%; 95% confidence interval [CI], 73-80%), and isolated solid organ injuries were present in 418 (69%; 95% CI, 65-73%). Treatment included therapeutic laparotomy in 17 (4.1%), angiographic embolization in 6 (1.4%), and blood transfusion in 46 (11%) patients. Laparotomy rates for isolated injury were 11 (5.4%) of 205 (95% CI, 2.7-9.4%) at non-freestanding children's hospitals and 6 (2.8%) of 213 (95% CI, 1.0-6.0%) at freestanding children's hospitals (difference, 2.6%; 95% CI, -7.1% to 12.2%). Dispositions of the 212 children with isolated Grade I or II organ injuries were home in 6 (3%), emergency department observation in 9 (4%), ward in 114 (54%), intensive care unit in 73 (34%), operating suite in 7 (3%), and transferred in 3 (1%) patients. Intensive care unit admission for isolated Grade I or II injuries varied by center from 9% to 73%. CONCLUSION: Most children with solid organ injuries are managed with observation. Blood transfusion, while uncommon, is the most frequent therapeutic intervention; angiographic embolization and laparotomy are uncommon. Emergency department disposition of children with isolated Grade I to II solid organ injuries is highly variable and often differs from published guidelines. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level IV.

Rise in microsurgical free-flap breast reconstruction in academic medical practices.

BACKGROUND: Previous studies have examined national trends in breast reconstruction, using various data sets demonstrating increases in implant-based reconstruction and decreases in autologous reconstruction. However, academic breast reconstruction practices have never been specifically characterized. The University Health Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual billing and coding data from 90 academic medical centers in the United States, and has been used to characterize practice patterns of various academic surgical specialties. OBJECTIVE: To describe breast reconstruction trends unique to academic surgical practices, using the Faculty Practice Solutions Center database. METHODS: Annual data for defined breast reconstruction procedures (current procedural terminology codes: 19340, 19342, 19357, 19361, 19364, 19366, 19367, 19369, and 19380) performed by university plastic surgeons during calendar years 2007 to 2013 were included in the study. RESULTS: From 2007 to 2013, a 2-fold increase in the number of breast reconstruction procedures was observed (from a mean of 45.3 to 94.2 procedures per surgeon). During this period, implant-based reconstructions and autologous reconstructions rose in tandem (28.9-44.6 and 11.4-19.3, respectively), with a preserved 2.5:1 ratio between the 2 categories each year. When compared to reconstructions overall, the proportion of both implant reconstruction and autologous reconstruction procedures declined, since revision and other types of reconstructions increased (11% of all reconstructions in 2007 vs 32% in 2013). With regard to autologous reconstruction, microsurgical free flaps (mostly comprised of deep inferior epigastric artery perforator flaps) have supplanted latissimus flaps as the favored modality and comprised 13% to 14% of breast reconstruction cases overall from 2011 to 2013. CONCLUSION: In contrast to national trends, university-based plastic surgeons are performing a growing number of microsurgical free flaps as the preferred method for autologous breast reconstruction. Whereas implant-based reconstructions still predominate in academic practices, the trend of increasing preference toward implant-based reconstructions has slowed in recent years and revision reconstructions are on the rise.

The modern acute care surgeon: characterization of an evolving surgical niche.

BACKGROUND: Trauma and emergency surgery continues to evolve as a surgical niche. The simple fact that The Journal of Trauma is now entitled The Journal of Trauma and Acute Care Surgery captures this reality. We sought to characterize the niche that trauma and emergency surgeons have occupied during the maturation of the acute care surgery model. METHODS: We analyzed the University Health System Consortium-Association of American Medical Colleges Faculty Practice Solutions Center database for the years 2007 to 2012 for specific current procedural terminology (CPT) codes. This database includes coding and billing data for more than 90 academic medical centers throughout the United States. We analyzed frequency counts and work relative value units (wRVUs) generated for specific codes to characterize the average trauma and emergency surgeon's work experience over time. RESULTS: We found that acute care surgeons generated 42.4% of wRVUs from procedural work and 57.6% from cognitive work. For cognitive work, critical care services generated the most wRVUs per year (25.2% of total), and subsequent hospital care was the most frequently performed activity (1,236.6 codes generated per year). For procedural work, laparoscopic cholecystectomies produced the most wRVUs per year (2.4% of total), and placement of a nontunneled catheter was the most frequently performed procedure (42.2 times per year). The average acute care surgeon performed the following numbers of procedures per year: 29.6 cholecystectomies and 20.0 appendectomies; 7.7 wound vacuum device changes; 5.9 implantation of mesh procedures; 4.9 splenectomies and 0.4 splenorrhaphies; 2.6 perirectal abscess drainage procedures; less than one component separation fascial hernia repair; and less than one video-assisted thoracic surgery. CONCLUSION: The modern acute care surgeon is a hybrid of critical care medicine physician and ever-evolving surgical interventionist. Acute care surgeons continue to do traditional trauma work while increasingly performing acute care surgeries. The work of acute care surgeons serves a growing role and fills a valuable niche in our health care system.

Association between the seat belt sign and intra-abdominal injuries in children with blunt torso trauma in motor vehicle collisions.

OBJECTIVES: The objective was to determine the association between the abdominal seat belt sign and intra-abdominal injuries (IAIs) in children presenting to emergency departments with blunt torso trauma after motor vehicle collisions (MVCs). METHODS: This was a planned subgroup analysis of prospective data from a multicenter cohort study of children with blunt torso trauma after MVCs. Patient history and physical examination findings were documented before abdominal computed tomography (CT) or laparotomy. Seat belt sign was defined as a continuous area of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat belt restraint. The relative risk (RR) of IAI with 95% confidence intervals (CIs) was calculated for children with seat belt signs compared to those without. The risk of IAI in those patients with seat belt sign who were without abdominal pain or tenderness, and with Glasgow Coma Scale (GCS) scores of 14 or 15, was also calculated. RESULTS: A total of 3,740 children with seat belt sign documentation after blunt torso trauma in MVCs were enrolled; 585 (16%) had seat belt signs. Among the 1,864 children undergoing definitive abdominal testing (CT, laparotomy/laparoscopy, or autopsy), IAIs were more common in patients with seat belt signs than those without (19% vs. 12%; RR = 1.6, 95% CI = 1.3 to 2.1). This difference was primarily due to a greater risk of gastrointestinal injuries (hollow viscous or associated mesentery) in those with seat belt signs (11% vs. 1%; RR = 9.4, 95% CI = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI = 2.9% to 9.9%) with seat belt signs who did not have initial complaints of abdominal pain or tenderness and had GCS scores of 14 or 15. CONCLUSIONS: Patients with seat belt signs after MVCs are at greater risk of IAI than those without seat belt signs, predominately due to gastrointestinal injuries. Although IAIs are less common in alert patients with seat belt signs who do not have initial complaints of abdominal pain or tenderness, the risk of IAI is sufficient that additional evaluation such as observation, laboratory studies, and potentially abdominal CT scanning is generally necessary.

Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma.

BACKGROUND: The aim of this study was to evaluate the variability of clinician-performed Focused Assessment with Sonography for Trauma (FAST) examinations and its impact on abdominal computed tomography (AbCT) use in hemodynamically stable children with blunt torso trauma (BTT). The FAST is used with variable frequency in children with BTT. METHODS: We performed a planned secondary analysis of children (<18 years) with BTT. Patients with a Glasgow Coma Scale (GCS) score of less than 9, those with hypotension, and those taken directly to the operating suite were excluded. Clinicians documented their suspicion for intra-abdominal injury (IAI) as very low, less than 1%; low, 1% to 5%; moderate, 6% to 10%; high, 11% to 50%; or very high, greater than 50%. We determined the relative risk (RR) for AbCT use based on undergoing a FAST examination in each of these clinical suspicion strata. RESULTS: Of 6,468 (median age, 11.8 years; interquartile range, 6.3-15.5 years) children who met eligibility, 887 (13.7%) underwent FAST examination before CT scan. A total of 3,015 (46.6%) underwent AbCT scanning, and 373 (5.8%) were diagnosed with IAI. Use of the FAST increased as clinician suspicion for IAI increased, 11.0% with less than 1% suspicion for IAI, 13.5% with 1% to 5% suspicion, 20.5% with 6% to 10% suspicion, 23.2% with 11% to 50% suspicion, and 30.7% with greater than 50% suspicion. The patients in whom the clinicians had a suspicion of IAI of 1% to 5% or 6% to 10% were significantly less likely to undergo a CT scan if a FAST examination was performed: RR, 0.83 (0.67-1.03); RR, 0.81 (0.72-0.91); RR, 0.85 (0.78-0.94); RR, 0.99 (0.94-1.05); and RR, 0.97 (0.91-1.05) for patients with clinician suspicion of IAI of less than 1%, 1% to 5%, 6% to 10%, 11% to 50%, and greater than 50%, respectively. CONCLUSION: The FAST examination is used in a relatively small percentage of children with BTT. Use increases as clinician suspicion for IAI increases. Patients with a low or moderate clinician suspicion of IAI are less likely to undergo AbCT if they receive a FAST examination. A randomized controlled trial is required to more precisely determine the benefits and drawbacks of the FAST examination in the evaluation of children with BTT. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, II.

Practice patterns of academic general thoracic and adult cardiac surgeons.

OBJECTIVE: We hypothesized that academic adult cardiac surgeons (CSs) and general thoracic surgeons (GTSs) would have distinct practice patterns of, not just case-mix, but also time devoted to outpatient care, involvement in critical care, and work relative value unit (wRVU) generation for the procedures they perform. METHODS: We queried the University Health System Consortium-Association of American Medical Colleges Faculty Practice Solution Center database for fiscal years 2007-2008, 2008-2009, and 2009-2010 for the frequency of inpatient and outpatient current procedural terminology coding and wRVU data of academic GTSs and CSs. The Faculty Practice Solution Center database is a compilation of productivity and payer data from 86 academic institutions. RESULTS: The greatest wRVU generating current procedural terminology codes for CSs were, in order, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. In contrast, open lobectomy, video-assisted thoracic surgery wedge, and video-assisted thoracic surgery lobectomy were greatest for GTSs. The 10 greatest wRVU-generating procedures for CSs generated more wRVUs than those for GTSs (P<.001). Although CSs generated significantly more hospital inpatient evaluation and management (E & M) wRVUs than did GTSs (P<.001), only 2.5% of the total wRVUs generated by CSs were from E & M codes versus 18.8% for GTSs. Critical care codes were 1.5% of total evaluation and management billing for both CSs and GTSs. CONCLUSIONS: Academic CSs and GTSs have distinct practice patterns. CSs receive greater reimbursement for services because of the greater wRVUs of the procedures performed compared with GTSs, and evaluation and management coding is a more important wRVU generator for GTSs. The results of our study could guide academic CS and GTS practice structure and time prioritization.

Extremity soft tissue tumor surgery by surgical specialty: a comparison of case volume among oncology and non-oncology-designated surgeons.

INTRODUCTION: We sought to characterize the extent of extremity soft tissue tumor (ESTT) resections among surgical specialties, hypothesizing that substantial variation exists in the number of ESTT resections performed by specialty. METHODS: We queried the UHC-AAMC database for data from 85 institutions for years 2007-2009. We abstracted data on total number of musculoskeletal (MSK) procedures, number of subcutaneous (SQ), deep, and malignant ESTT resections, and anatomic site of resection. Data were available for 4,682 practitioners including the following specialties: general surgery (GS, N = 2,195), plastic surgery (PS, N = 792), surgical oncology (SO, N = 533), general orthopedics (GO, N = 1,079), and orthopedic oncology (OO, N = 83). RESULTS: The mean number of all MSK procedures performed per year was 19.0 ± 2.3 GS, 179.6 ± 3.0 PS, 32.4 ± 6.2 SO, 798.6 ± 115.4 GO, and 482.9 ± 6.5 OO (P = 0.001). SQ ESTT resections per year were similar among specialties (1.7 ± 0.3 GS, 2.7 ± 0.3 PS, 2.4 ± 0.4 SO, 1.7 ± 0.5 GO, 4.7 ± 0.2 OO), while deep and malignant resections were more likely performed by OO (combined deep and malignant: 0.9 ± 0.1 GS, 2.0 ± 0.4 PS, 9.9 ± 0.6 SO, 5.8 ± 0.3 GO, and 63.6 ± 8.1 OO, P = 0.001). Adjusting for number of physicians in the database, of the total deep and malignant ESTT resections, 9.4% were performed by GS, 7.7% by PS, 26.0% by SO, 30.8% by GO, and 26.0% by OO. CONCLUSION: Nearly 50% of deep and malignant ESTT resections are performed by non-oncology-designated surgeons. Approximately 17% are performed by practitioners who complete an average of one to two of these procedures per year. These findings may have significant implications for quality of care in soft tissue tumor surgery.

A multicenter study of the risk of intra-abdominal injury in children after normal abdominal computed tomography scan results in the emergency department.

STUDY OBJECTIVE: We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in the emergency department (ED) after blunt torso trauma. METHODS: This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention. RESULTS: Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%). CONCLUSION: In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.

Identifying children at very low risk of clinically important blunt abdominal injuries.

STUDY OBJECTIVE: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

Flexion and extension radiographic evaluation for the clearance of potential cervical spine injures in trauma patients.

BACKGROUND: Flexion and extension radiographs are often used in the setting of trauma to clear a cervical spine injury. The utility of such tests, however, remains to be determined. We hypothesized that in patients who underwent a negative computed tomography (CT) cervical spine scan, flexion and extension radiographs did not yield useful additional information. METHODS: We conducted a retrospective chart review of all patients admitted to a Level I trauma center who had a negative CT scan of the cervical spine and a subsequent cervical flexion-extension study for evaluation of potential cervical spine injury. All flexion-extension films were independently reviewed to determine adequacy as defined by C7/T1 visualization and 30° of change in the angle from flexion to extension. The independent reviews were compared to formal radiology readings and the influence of the flexion-extension studies on clinical decision making was also reviewed. RESULTS: One thousand patients met inclusion criteria for the study. Review of the flexion-extension radiographs revealed that 80% of the films either did not adequately demonstrate the C7/T1 junction or had less than 30° range of motion. There was one missed injury that was also missed on magnetic resonance imaging. Results of the flexion-extension views had minimal effects on clinical decision making. CONCLUSION: Adequate flexion extension films are difficult to obtain and are minimally helpful for clearance of the cervical spine in awake and alert trauma patients.

Nomograms to predict risk of in-hospital and post-discharge venous thromboembolism after abdominal and thoracic surgery: an American College of Surgeons National Surgical Quality Improvement Program analysis.

BACKGROUND: Postoperative venous thromboembolism (VTE) is increasingly viewed as a quality of care metric, although risk-adjusted incident rates of postoperative VTE and VTE after hospital discharge (VTEDC) are not available. We sought to characterize the predictors of VTE and VTEDC to develop nomograms to estimate individual risk of VTE and VTEDC. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified 471,867 patients who underwent inpatient abdominal or thoracic operations between 2005 and 2010. We excluded primary vascular and spine operations. We built logistic regression models using stepwise model selection and constructed nomograms for VTE and VTEDC with statistically significant covariates. RESULTS: The overall, unadjusted, 30-d incidence of VTE and VTEDC was 1.5% and 0.5%, respectively. Annual incidence rates remained unchanged over the study period. On multivariate analysis, age, body mass index, presence of preoperative infection, operation for cancer, procedure type (spleen highest), multivisceral resection, and non-bariatric laparoscopic surgery were significant predictors for VTE and VTEDC. Other significant predictors for VTE, but not VTEDC, included a history of chronic obstructive pulmonary disease, disseminated cancer, and emergent operation. We constructed and validated nomograms by bootstrapping. The concordance indices for VTE and VTEDC were 0.77 and 0.67, respectively. CONCLUSIONS: Substantial variation exists in the incidence of VTE and VTEDC, depending on patient and procedural factors. We constructed nomograms to predict individual risk of 30-d VTE and VTEDC. These may allow more targeted quality improvement interventions to reduce VTE and VTEDC in high-risk general and thoracic surgery patients.

Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity.

OBJECTIVE: To determine if patient race/ethnicity is independently associated with cranial computed tomography (CT) use among children with minor blunt head trauma. DESIGN: Secondary analysis of a prospective cohort study. SETTING: Pediatric research network of 25 North American emergency departments. PATIENTS: In total, 42 412 children younger than 18 years were seen within 24 hours of minor blunt head trauma. Of these, 39 717 were of documented white non-Hispanic, black non-Hispanic, or Hispanic race/ethnicity. Using a previously validated clinical prediction rule, we classified each child's risk for clinically important traumatic brain injury to describe injury severity. Because no meaningful differences in cranial CT rates were observed between children of black non-Hispanic race/ethnicity vs Hispanic race/ethnicity, we combined these 2 groups. MAIN OUTCOME MEASURE: Cranial CT use in the emergency department, stratified by race/ethnicity. RESULTS: In total, 13 793 children (34.7%) underwent cranial CT. The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not differ by race/ethnicity. In adjusted analyses, children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.86; 95% CI, 0.78-0.96) or lowest risk (odds ratio, 0.72; 95% CI, 0.65-0.80) for clinically important traumatic brain injury. Regardless of risk for clinically important traumatic brain injury, parental anxiety and request was commonly cited by physicians as an important influence for ordering cranial CT in children of white non-Hispanic race/ethnicity. CONCLUSIONS: Disparities may arise from the overuse of cranial CT among patients of nonminority races/ethnicities. Further studies should focus on explaining how medically irrelevant factors, such as patient race/ethnicity, can affect physician decision making, resulting in exposure of children to unnecessary health care risks.

Indications and performance of pelvic radiography in patients with blunt trauma.

OBJECTIVES: The objectives of this study are to validate a set of clinical variables to identify patients with pelvic fractures and to determine the sensitivity of anteroposterior (AP) pelvic radiographs in patients with pelvic fractures. METHODS: We conducted a prospective observational cohort study of adults (>18 years) with blunt torso trauma evaluated with abdominal/pelvic computed tomography. Physicians providing care in the emergency department documented history and physical examination findings after initial evaluation. High-risk variables included any of the following: hypotension (systolic blood pressure <90 mm Hg), Glasgow Coma Scale score less than 14, pelvic bone tenderness, or instability. Pelvic fractures were present if the orthopedic faculty documented a fracture to the pubis, ilium, ischium, or sacrum. RESULTS: We enrolled 4737 patients, including 289 (6.1%; 95% confidence interval [CI], 5.4%-6.8%) with pelvic fractures. Of the 289 patients, 256 (88.6%; 95% CI, 84.3%-92.0%) had at least one of the high-risk variables identified. Initial plain AP radiographs identified 234 (81.0%; 95% CI, 76.0%-85.3%) of 289 patients with pelvic fractures. The high-risk variables identified all 87 patients (100%; 95% CI, 96.6%-100%) undergoing surgery, whereas plain AP pelvic radiography identified a fracture in 83 patients (95.4%; 95% CI, 88.6%-98.7%) undergoing surgery. CONCLUSION: Previously identified high-risk variables for pelvic fracture identify most but not all patients with pelvic fractures. However, these high-risk variables identify all patients undergoing surgery and may be implemented as screening criteria for pelvic radiography. Anteroposterior pelvic radiographs fail to demonstrate a fracture in a substantial number of patients with pelvic fracture including patients who undergo surgery.

Who performs complex noncardiac thoracic surgery in United States academic medical centers?

BACKGROUND: We hypothesized that general thoracic surgeons (GTS) predominantly perform complex noncardiac thoracic surgery in academic hospitals compared with cardiac surgeons (CS), general surgeons, and surgical oncologists. METHODS: Fiscal year 2007-2008 to 2009-2010 coding and work relative value unit data from the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solutions Center database, which includes 86 academic institutions, was analyzed. Procedural groups for pneumonectomy, other pulmonary resection (including lobectomy, bilobectomy, segmentectomy, sleeve lobectomy, and video-assisted thoracoscopic surgery lobectomy-segmentectomy), and esophagectomy were evaluated. RESULTS: Of the 1,989,055.3 total work relative value units generated for complex noncardiac thoracic surgical procedures during the study period, 77.5% were generated by GTS, compared with 9.9% by CS, 8.9% by general surgeons, and 3.7% by surgical oncologists (p<0.001). General thoracic surgeons averaged 2.1 pneumonectomies, 51.1 other pulmonary resections, and 12.2 esophagectomies per year compared with 2.1 pneumonectomies, 9.4 other pulmonary resections, and less than 1 esophagectomy per year for CS. General surgeons and surgical oncologists averaged no more than 1.6 cases per year for all categories (all p<0.001, except for pneumonectomy, in which GTS versus CS was not significantly different). To determine the use of parenchymal-sparing operations, we looked at the ratio of sleeve lobectomy to pneumonectomy and found higher usage of parenchymal-sparing techniques by GTS, relative to pneumonectomy, compared with all other groups (p<0.001). General thoracic surgeons averaged 16.0 video-assisted thoracoscopic surgery lobectomies per year compared with approximately 1 per year for all other groups (p<0.001). General thoracic surgeons had a 47.1% increase in video-assisted thoracoscopic surgery lobectomies per year compared with 27.4% for CS. CONCLUSIONS: In academic hospitals, noncardiac thoracic surgery is performed mostly by GTS, supporting academic GTS as a distinct specialty. These results may help determine hospital referral and credentialing policies, and plan general and cardiothoracic surgery residency curriculum.

Presentations and outcomes of children with intraventricular hemorrhages after blunt head trauma.

OBJECTIVE: To describe the clinical presentations and outcomes of children with intraventricular hemorrhages (IVHs) after blunt head trauma (BHT). DESIGN: Subanalysis of a large, prospective, observational cohort study performed from June 1, 2004, through September 31, 2006. SETTING: Twenty-five emergency departments participating in the Pediatric Emergency Care Applied Research Network. Patients Children presenting with IVH after BHT. Exposure Blunt head trauma. MAIN OUTCOME MEASURES: Clinical presentations and outcomes, including the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scores at hospital discharge. RESULTS: Of 15 907 patients evaluated with computed tomography, 1156 (7.3%) had intracranial injuries. Forty-three of the 1156 (3.7%; 95% CI, 2.7%-5.0%) had nonisolated IVHs (ie, with intracranial injuries on computed tomography), and 10 of 1156 (0.9%; 95% CI, 0.4%-1.6%) had isolated IVHs. Only 4 of 43 (9.3%) of those with nonisolated IVHs had Glasgow Coma Scale (GCS) scores of 14 to 15, and all 10 (100.0%) with isolated IVHs had GCS scores of 15. No patients with isolated IVHs required neurosurgery or died. One patient had moderate overall disability (by the POPC score), and no patient had moderate or severe disability at discharge (by the PCPC score). Of the 43 patients with nonisolated IVHs, however, 16 (37.2%) died and 18 (41.9%) required neurosurgery. In 27 patients (62.8%), injuries ranged from moderate overall disability to brain death by the POPC score. CONCLUSIONS: Children with nonisolated IVHs after BHT typically present with GCS scores of less than 14, frequently require neurosurgery, and have high mortality rates. In contrast, those with isolated IVHs typically present with normal mental status and are at low risk for acute adverse events and poor outcomes.

Does this adult patient have a blunt intra-abdominal injury?

CONTEXT: Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma. OBJECTIVE: To systematically assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injuries in patients with blunt abdominal trauma. DATA SOURCES: We conducted a structured search of MEDLINE (1950-January 2012) and EMBASE (1980-January 2012) to identify English-language studies examining the identification of intra-abdominal injuries. A separate, structured search was conducted for studies evaluating bedside ultrasonography. STUDY SELECTION: We included studies of diagnostic accuracy for intra-abdominal injury that compared at least 1 finding with a reference standard of abdominal computed tomography, diagnostic peritoneal lavage, laparotomy, autopsy, and/or clinical course for intra-abdominal injury. Twelve studies on clinical findings and 22 studies on bedside ultrasonography met inclusion criteria for data extraction. DATA EXTRACTION: Critical appraisal and data extraction were independently performed by 2 authors. DATA SYNTHESIS: The prevalence of intra-abdominal injury in adult emergency department patients with blunt abdominal trauma among all evidence level 1 and 2 studies was 13% (95% CI, 10%-17%), with 4.7% (95% CI, 2.5%-8.6%) requiring therapeutic surgery or angiographic embolization of injuries. The presence of a seat belt sign (likelihood ratio [LR] range, 5.6-9.9), rebound tenderness (LR, 6.5; 95% CI, 1.8-24), hypotension (LR, 5.2; 95% CI, 3.5-7.5), abdominal distention (LR, 3.8; 95% CI, 1.9-7.6), or guarding (LR, 3.7; 95% CI, 2.3-5.9) suggest an intra-abdominal injury. The absence of abdominal tenderness to palpation does not rule out an intra-abdominal injury (summary LR, 0.61; 95% CI, 0.46-0.80). The presence of intraperitoneal fluid or organ injury on bedside ultrasound assessment is more accurate than any history and physical examination findings (adjusted summary LR, 30; 95% CI, 20-46); conversely, a normal ultrasound result decreases the chance of injury detection (adjusted summary LR, 0.26; 95% CI, 0.19-0.34). Test results increasing the likelihood of intra-abdominal injury include a base deficit less than -6 mEq/L (LR, 18; 95% CI, 11-30), elevated liver transaminases (LR range, 2.5-5.2), hematuria (LR range, 3.7-4.1), anemia (LR range, 2.2-3.3), and abnormal chest radiograph (LR range, 2.5-3.8). Symptoms and signs may be most useful in combination, particularly in identification of patients who do not need further diagnostic workup. CONCLUSIONS: Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.