Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study.

BACKGROUND: Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality. METHODS: A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality. RESULTS: Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality. CONCLUSION: Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Frequency and Predictors of Trauma Transfer Futility to a Rural Level I Trauma Center.

INTRODUCTION: Transfer of trauma patients whose injuries are deemed unsurvivable, often results in early death or transition to comfort care and could be considered misuse of health care resources. This is particularly true where tertiary care resources are limited. Identifying riskfactors for and predicting futile transfers could reduce this impact and help to optimize triage and management. METHODS: A retrospective study of interfacility trauma transfers to a single rural Level I rauma center from 2014 to 2019. Futility was defined as death, hospice, or declaration of comfort measures within 48 h of transfer without procedural or radiographic intervention at the accepting center. Multiple logistic regressions identified independent predictors of futile transfers. The predictive power of Mechanism,Glasgow coma scale, Age, and Arterial pressure (MGAP), an injury severity score based on Mechanism, Glasgow coma scale, Age, and systolic blood Pressure, were evaluated. RESULTS: Of the 3368 trauma transfers, 37 (1.1%) met criteria as futile. Futile transfers occurred among patients who were significantly older with falls as the most common mechanism. Age, Glasgow coma scale, systolic blood Pressure and Injury Severity Score were significant (P < 0.05) independent predictors of futile transfer. MGAP had a high predictive power area under the receiver operating characteristic (AUROC 0.864, 95% confidence interval 0.803-0.925) for futility. CONCLUSIONS: A small proportion (1.1%) of transfers to a rural Level I trauma center met criteria for futility. Predictive tools, such as MGAP scoring, can provide objective criteria for evaluation of transfer necessity and prompt care pathways that involve pre-transfer communications, telemedicine, and/or patient centered goals of care discussions. Such tools could be used in conjunction with a more granular assessment regarding potential operational barriers to reduce futile transfers and to enhance optimization of resource utilization in low-resource service areas.

Geographic Coverage and Verification of Trauma Centers in a Rural State: Highlighting the Utility of Location Allocationfor Trauma System Planning.

BACKGROUND: Care at verified trauma centers has improved survival and functional outcomes, yet determining the appropriate location of potential trauma centers is often driven by factors other than optimizing system-level patient care. Given the importance of transport time in trauma, we analyzed trauma transport patterns in a rural state lacking an organized trauma system and implemented a geographic information system to inform potential future trauma center locations. STUDY DESIGN: Data were collected on trauma ground transport during a 3-year period (2014 through 2016) from the Statewide Incident Reporting Network database. Geographic information system mapping and location-allocation modeling of the best-fit facility for trauma center verification was computed using trauma transport patterns, population density, road network layout, and 60-minute emergency medical services transport time based on current transport protocols. RESULTS: Location-allocation modeling identified 2 regional facilities positioned to become the next verified trauma centers. The proportion of the Vermont population without access to trauma center care within 60 minutes would be reduced from the current 29.68% to 5.81% if the identified facilities become verified centers. CONCLUSIONS: Through geospatial mapping and location-allocation modeling, we were able to identify gaps and suggest optimal trauma center locations to maximize population coverage in a rural state lacking a formal, organized trauma system. These findings could inform future decision-making for targeted capacity improvement and system design that emphasizes more equitable access to trauma center care in Vermont.

Population-Based Analysis of Firearm Injuries among Young Children in the United States, 2010-2015.

Firearm violence in the United States knows no age limit. This study compares the survival of children younger than five years to children and adolescents of age 5-19 years who presented to an ED for gunshot wounds (GSWs) in the United States to test the hypothesis of higher GSW mortality in very young children. A study of GSW patients aged 19 years and younger who survived to reach medical care was performed using the Nationwide ED Sample for 2010-2015. Hospital survival and incidence of fatal and nonfatal GSWs in the United States were the study outcomes. A multilevel logistic regression model estimated the strength of association among predictors of hospital mortality. The incidence of ED presentation for GSW is as high as 19 per 100,000 population per year. Children younger than five years were 2.7 times as likely to die compared with older children (15.3% vs 5.6%). Children younger than one year had the highest hospital mortality, 33.1 per cent. The mortality from GSW is highest among the youngest children compared with older children. This information may help policy makers and the public better understand the impact of gun violence on the youngest and most vulnerable Americans.

A trauma mortality prediction model based on the ICD-10-CM lexicon: TMPM-ICD10.

BACKGROUND: Outcome prediction models allow risk adjustment required for trauma research and the evaluation of outcomes. The advent of ICD-10-CM has rendered risk adjustment based on ICD-9-CM codes moot, but as yet no risk adjustment model based on ICD-10-CM codes has been described. METHODS: The National Trauma Data Bank provided data from 773,388 injured patients who presented to one of 747 trauma centers in 2016 with traumatic injuries ICD-10-CM codes and Injury Severity Score (ISS). We constructed an outcome prediction model using only ICD-10-CM acute injury codes and compared its performance with that of the ISS. RESULTS: Compared with ISS, the TMPM-ICD-10 discriminated survivors from non-survivors better (ROC TMPM-ICD-10 = 0.861 [0.860-0.872], ROC [reviever operating curve] ISS = 0.830 [0.823-0.836]), was better calibrated (HL [Hosmer-Lemeshow statistic] TMPM-ICD-10 = 49.01, HL ISS = 788.79), and had a lower Akaike information criteria (AIC TMPM-ICD10 = 30579.49; AIC ISS = 31802.18). CONCLUSIONS: Because TMPM-ICD10 provides better discrimination and calibration than the ISS and can be computed without recourse to Abbreviated Injury Scale coding, the TMPM-ICD10 should replace the ISS as the standard measure of overall injury severity for data coded in the ICD-10-CM lexicon. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, level II.

Surgeons and Surgical Trainees Underestimate the Total Charges and Reimbursements Associated With Commonly Performed General Surgery Procedures✰.

INTRODUCTION: Surgical care contributes significantly to the fiscal challenges facing the US health care system. Multiple studies have demonstrated surgeons' lack of awareness of the costs associated with individual portions of surgical care, namely operating room supplies. We sought to assess surgeon and trainee awareness of the comprehensive charges and reimbursements associated with procedures they perform. METHODS: We administered a voluntary anonymous survey to attending surgeons, general surgery residents, and fourth-year medical students who applied to general surgery residencies. We compared charge and reimbursement estimates for laparoscopic cholecystectomy and open inguinal hernia repair to the actual values. Additionally, we assessed the importance placed on the financial aspects of surgical care. RESULTS: We had an overall response rate of 94% (n = 45). A majority of attendings, residents, and medical students underestimated charges and reimbursements for open inguinal hernia repair and laparoscopic cholecystectomy. There was no significant difference in the accuracy of charge or reimbursement estimates between attendings, residents, and students for herniorrhaphy or cholecystectomy (Charge: hernia p = 0.08, cholecystectomy p = 0.30; Reimbursement: hernia p = 0.47, cholecystectomy p = 0.89). Years of training as an attending or resident did not predict accuracy of charge or reimbursement estimates for hernia repair or cholecystectomy (p > 0.3 for all regressions). The median (interquartile range) charge estimate for inguinal hernia repair was -$5914 (-$7914 to -$2914) from the actual charge, 45.8% of the true value, and the median reimbursement estimate was -$4519 (-$5369 to -$1218) from actual reimbursement, 27.3% of the true value. The median charge estimate for cholecystectomy was -$5734 (-$8733 to +$1266) from the actual charge, 58.3% of the true value, and the median reimbursement estimate was -$4847 (-$6847 to +$153) from actual reimbursement, 38.2% of the true value. CONCLUSIONS: Surgeons and their trainees underestimate the charges and reimbursements associated with commonly performed procedures.

Variation in readmission rates among hospitals following admission for traumatic injury.

INTRODUCTION: Readmission following hospital discharge is both common and costly. The Hospital Readmission Reduction Program (HRRP) financially penalizes hospitals for readmission following admission for some conditions, but this approach may not be appropriate for all conditions. We wished to determine if hospitals differed in their adjusted readmission rates following an index hospital admission for traumatic injury. PATIENTS AND METHODS: We extracted from the AHRQ National Readmission Dataset (NRD) all non-elderly adult patients hospitalized following traumatic injury in 2014. We estimated hierarchal logistic regression models to predicted readmission within 30 days. Models included either patient level predictors, hospital level predictors, or both. We quantified the extent of hospital variability in readmissions using the median odds ratio. Additionally, we computed hospital specific risk-adjusted rates of readmission and number of excess readmissions. RESULTS: Of the 177,322 patients admitted for traumatic injury 11,940 (6.7%) were readmitted within 30 days. Unadjusted hospital readmission rates for the 637 hospitals in our study varied from 0% to 20%. After controlling for sources of variability the range for hospital readmission rates was between 5.5% and 8.5%. Only 2% of hospitals had a random intercept coefficient significantly different from zero, suggesting that their readmission rates differed from the mean level of all hospitals. We also estimated that in 2014 only 11% of hospitals had more than 2 excess readmissions. Our multilevel model discriminated patients who were readmitted from those not readmitted at an acceptable level (C = 0.74). CONCLUSIONS: We found little evidence that hospitals differ in their readmission rates following an index admission for traumatic injury. There is little justification for penalizing hospitals based on readmissions after traumatic injury.

The role of preoperative high resolution manometry in predicting dysphagia after laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic fundoplication is an accepted surgical management of refractory gastro-esophageal reflux disease (GERD). The use of high resolution esophageal manometry (HRM) in preoperative evaluation is often applied to determine the degree of fundoplication to optimize reflux control while minimizing adverse sequela of postoperative dysphagia. OBJECTIVE: Assess the role of preoperative HRM in predicting surgical outcomes, specifically risk assessment of postoperative dysphagia and quality of life, among patients receiving laparoscopic Nissen fundoplication for GERD with immediate postoperative (< 4 weeks clinic), short-term (3-month clinic), and long-term (34 ± 10.4 months of telephone) follow-up. METHODS: Retrospective analysis of 146 patients over the age of 18 who received laparoscopic Nissen fundoplication at University of Vermont Medical Center from July 1, 2011 through December 31, 2014 was completed, of which 52 patients with preoperative HRM met inclusion criteria. Exclusion criteria included history of: (a) named esophageal motility disorder or aperistalsis; (b) esophageal cancer; (c) paraesophageal hernia noted intraoperatively. RESULTS: Elevated basal integrated relaxation pressure (IRP), which is the mean of 4 s of maximal lower esophageal sphincter (LES) relaxation within 10 s of swallowing, was significantly correlated with worsened severity of post-fundoplication dysphagia (r = 0.572, p < 0.0001 with sensitivity and NPV of 100%) and poorer quality of life (r = 0.348, p = 0.018) at up to 3-years follow-up. The presence of preoperative dysphagia was independently related to post-fundoplication dysphagia at short-term (r = 0.403, p = 0.018) and long-term follow-up (r = 0.415, p = 0.005). Also, both elevated mean wave amplitude (r=-0.397, p = 0.006) and distal contractile integral (DCI) (r = - 0.294, p = 0.047) were significantly, inversely correlated to post-Nissen dysphagia. No significant association was demonstrated between other preoperative HRM parameters and surgical outcomes. CONCLUSIONS: Inadequacy of lower esophageal sphincter (LES) relaxation with swallowing as delineated by elevated IRP is significantly predictive of worse long-term postoperative outcomes including dysphagia and quality of life scores. Further assessment of tailoring anti-reflux surgical approach with partial vs. total fundoplication to functionally resistant LES is required.

A novel approach to optimal placement of new trauma centers within an existing trauma system using geospatial mapping.

BACKGROUND: Trauma system expansion is a complex process often governed by financial and health care system imperatives. We sought to propose a new, informed approach to trauma system expansion through the use of geospatial mapping. We hypothesized that geospatial mapping set to specific parameters could effectively identify optimal placement of new trauma centers (TC) within an existing trauma system. METHODS: We used Pennsylvania Trauma Systems Foundation registry data of adult (age, ≥ 15 years) trauma for calendar years 2003 to 2015 (n = 408,432), hospital demographics, road networks, and US Census data files. We included TCs and zip codes outside of Pennsylvania to account for edge effects with trauma cases aggregated to the zip code centroid of residence. Our model assumptions included existing Pennsylvania Trauma Systems Foundation Level I and II TCs, a maximum travel time of 60 minutes to the TC, capacity based on mean statewide ratios of trauma cases per hospital bed size, Injury Severity Score, candidate hospitals with 200 or more licensed beds and 30 minutes or longer or 15 minutes or longer from an existing TC in nonurban/urban areas, respectively. We used the Network Analyst Location-Allocation function in ArcGIS Desktop to generate spatial models. RESULTS: Of the 130 candidate sites, only 14 met the bed size and travel time criteria from an existing TC. Approximately 70% of zip codes and 91% of cases were within 60 minutes of an existing TC. Adding one to six new optimally paced TCs increased to a maximum of 82% of zip codes and 96% of cases within 60 minutes of an existing TC. Changes to model assumptions had an impact on which candidate sites were selected. CONCLUSION: Intelligent trauma system design should include an objective process like geospatial to determine the optimum locations for new TCs within existing trauma networks. LEVEL OF EVIDENCE: Epidemiological study, level III.

Vena Cava Filter Use in Trauma and Rates of Pulmonary Embolism, 2003-2015.

IMPORTANCE: Vena cava filter (VCF) placement for pulmonary embolism (PE) prophylaxis in trauma is controversial. Limited research exists detailing trends in VCF use and occurrence of PE over time. OBJECTIVE: To analyze state and nationwide temporal trends in VCF placement and PE occurrence from 2003 to 2015 using available data sets. DESIGN, SETTING, AND PARTICIPANTS: A retrospective trauma cohort study was conducted using data from the Pennsylvania Trauma Outcome Study (PTOS) (461 974 patients from 2003 to 2015), the National Trauma Data Bank (NTDB) (5 755 095 patients from 2003 to 2014), and the National (Nationwide) Inpatient Sample (NIS) (24 449 476 patients from 2003 to 2013) databases. MAIN OUTCOMES AND MEASURES: Temporal trends in VCF placement and PE rates, filter type (prophylactic or therapeutic), and established predictors of PE (obesity, pregnancy, cancer, deep vein thrombosis, major procedure, spinal cord paralysis, venous injury, lower extremity fracture, pelvic fracture, central line, intracranial hemorrhage, and blood transfusion). Prophylactic filters were defined as VCFs placed before or without an existing PE, while therapeutic filters were defined as VCFs placed after a PE. RESULTS: Of the 461 974 patients in PTOS, the mean (SD) age was 47.2 (26.4) and 61.6% (284 621) were men; of the 5 755 095 patients in NTDB, the mean age (SD) was 42.0 (24.3) and 63.7% (3 666 504) were men; and of the 24 449 476 patients in NIS, the mean (SD) age was 58.0 (25.2) and 49.7% (12 160 231) were men. Of patients receiving a filter (11 405 in the PTOS, 71 029 in the NTDB, and 189 957 in the NIS), most were prophylactic VCFs (93.6% in the PTOS, 93.5% in the NTDB, and 93.3% in the NIS). Unadjusted and adjusted temporal trends for the PTOS and NTDB showed initial increases in filter placement followed by significant declines (unadjusted reductions in VCF placement rates, 76.8% in the PTOS and 53.3% in the NTDB). The NIS demonstrated a similar unadjusted trend, with a slight increase and modest decline (22.2%) in VCF placement rates over time; however, adjusted trends showed a slight but significant increase in filter rates. Adjusted PE rates for the PTOS and NTDB showed significant initial increases followed by slight decreases, with limited variation during the declining filter use periods. The NIS showed an initial increase in PE rates followed by a period of stagnation. CONCLUSIONS AND RELEVANCE: Despite a precipitous decline of VCF use in trauma, PE rates remained unchanged during this period. Taking this association into consideration, VCFs may have limited utility in influencing rates of PE. More judicious identification of at-risk patients is warranted to determine individuals who would most benefit from a VCF.

Implementation of the surgical safety checklist at a tertiary academic center: Impact on safety culture and patient outcomes.

BACKGROUND: The impact and efficacy of the World Health Organization Surgery Safety Checklist (SSC) is uncertain. We sought to determine if the SSC decreases complications and examined the attitudes of the surgical team members following implementation of the SSC. METHODS: A 28-question survey was developed to assess perspectives of surgical team members at the University of Vermont Medical Center (UVMC). The University Health System Consortium database was examined to compare the rates of nine complications before and after SSC implementation using Chi square analysis and Fisher's exact test. RESULTS: There was no significant decrease in any of the nine complications 2 years after SSC implementation. There was overall agreement that the SSC improved communication, safety, and prevented errors in the operating room. However, there was disagreement between nursing and surgeons over whether all three parts of the SSC were always completed. CONCLUSIONS: Implementation of the SSC did not result in a significant decrease in perioperative morbidity or mortality. However, it did improve the perception of safety culture by operating room staff.

Gunshot wounds resulting in hospitalization in the United States: 2004-2013.

INTRODUCTION: The United States (US) leads all high income countries in gunshot wound (GSW) deaths. However, as a result of two decades of reduced federal support, study of GSW has been largely neglected. In this paper we describe the current state of GSW hospitalizations in the US using population-based data. PATIENTS AND METHODS: We conducted an observational study of patients hospitalized for GSW in the National (Nationwide) Inpatient Sample (NIS) 2004 -2013. Our primary outcome is mortality after admission and we model its associations with gender, race, age, intent, severity of injury and weapon type, as well as providing temporal trends in hospital charges. RESULTS: Each year approximately 30,000 patients are hospitalized for GSW, and 2500 die in hospital. Men are 9 times as likely to be hospitalized for GSW as women, but are less likely to die. Twice as many blacks are hospitalized for GSW as non-Hispanic whites. In-hospital mortality for blacks and non-Hispanic whites was similar when controlled for other factors. Most GSW (63%) are the result of assaults which overwhelmingly involve blacks; accidents are also common (23%) and more commonly involve non-Hispanic whites. Although suicide is much less common (8.3%), it accounts for 32% of all deaths; most of which are older non-Hispanic white males. Handguns are the most common weapon reported, and have the highest mortality rate (8.4%). During the study period, the annual rate of hospitalizations for GSW remained stable at 80 per 100,000 hospital admissions; median inflation-adjusted hospital charges have steadily increased by approximately 20% annually from $30,000 to $56,000 per hospitalization. The adjusted odds for mortality decreased over the study period. Although extensively reported, GSW inflicted by police and terrorists represent few hospitalizations and very few deaths. CONCLUSIONS: The preponderance GSW hospitalizations resulting from assaults on young black males and suicides among older non-Hispanic white males have continued unabated over the last decade with escalating costs. As with other widespread threats to the public wellbeing, federally funded research is required if effective interventions are to be developed.

Primary Cleft Lip and Palate Repair in Assam, India: Does Preoperative Anthropometric Analysis Help Identify Patients With Increased Surgical Risk in a Clinically Prescreened Population?

OBJECTIVE: To compare anthropometric z-scores with incidence of post-operative complications for patients undergoing primary cleft lip or palate repair. DESIGN: This was a retrospective observational analysis of patients from a surgical center in Assam, India, and includes a cohort from a single surgical mission completed before the opening of the center. SETTING: Patients included in the study underwent surgery during an Operation Smile mission before the opening of Operation Smile's Guwahati Comprehensive Cleft Care Center in Guwahati, India. The remaining cohort received treatment at the center. All patients received preoperative assessment and screening; surgery; and postoperative care, education, and follow-up. PATIENTS, PARTICIPANTS: Our sample size included 1941 patients and consisted of all patients with complete information in the database who returned for follow-up after receiving primary cleft lip repair or primary cleft palate repair between January 2011 and April 2013. INTERVENTIONS: Preoperative anthropometric measurements. MAIN OUTCOME MEASURE(S): Postoperative complications. RESULTS: Anthropometric z-scores were not a significant predictor of adverse surgical outcomes in the group analyzed. Palate surgery had increased risk of complication versus lip repair, with an overall odds ratio of 5.66 (P < .001) for all patients aged 3 to 228 months. CONCLUSIONS: Anthropometric z-scores were not correlated with increased risk of surgical complications, possibly because patients were well screened for malnutrition before surgery at this center. Primary palate repair is associated with an approximate fivefold increased risk of developing postoperative complication(s) compared with primary lip repair.

Does Initial Imaging Modality Affect Breast Biopsy Upgrade Rates? A Single Institution Review.

INTRODUCTION: Image-guided core needle biopsy (CNB) is the standard for diagnostic breast biopsy. However, the upgrade rate to a higher order lesion defined as identification of malignancy on final pathology from surgical excision remains problematic. MATERIALS AND METHODS: A retrospective chart review of all core needle biopsies from 2008 to 2012 was performed. We identified lesions demonstrating atypia without associated malignancy on core needle biopsy and recorded multiple factors to evaluate predictors of upgrade. RESULTS: Of 151 independent core needle biopsies recorded, 26.5% were upgraded to a higher order lesion. Concurrent mammogram and ultrasound (US) were associated with higher sampling error than any individual imaging modality (P = .021). MRI had a trend toward lower rate of upgrade rate but did not reach statistical significance. DISCUSSION: Although MRI had a lower rate of upgrade rate due to sampling error, this did not reach significance possibly because of our small sample size.

The differential mortality of Glasgow Coma Score in patients with and without head injury.

IMPORTANCE: The GCS was created forty years ago as a measure of impaired consciousness following head injury and thus the association of GCS with mortality in patients with traumatic brain injury (TBI) is expected. The association of GCS with mortality in patients without TBI (non-TBI) has been assumed to be similar. However, if this assumption is incorrect mortality prediction models incorporating GCS as a predictor will need to be revised. OBJECTIVE: To determine if the association of GCS with mortality is influenced by the presence of TBI. DESIGN/SETTING/PARTICIPANTS: Using the National Trauma Data Bank (2012; N=639,549) we categorized patients as isolated TBI (12.8%), isolated non-TBI (33%), both (4.8%), or neither (49.4%) based on the presence of AIS codes of severity 3 or greater. We compared the ability GCS to discriminate survivors from non-survivors in TBI and in non-TBI patients using logistic models. We also estimated the odds ratios of death for TBI and non-TBI patients at each value of GCS using linear combinations of coefficients. MAIN OUTCOME MEASURE: Death during hospital admission. RESULTS: As the sole predictor in a logistic model GCS discriminated survivors from non-survivors at an acceptable level (c-statistic=0.76), but discriminated better in the case of TBI patients (c-statistic=0.81) than non-TBI patients (c-statistic=0.70). In both unadjusted and covariate adjusted models TBI patients were about twice as likely to die as non-TBI patients with the same GCS for GCS values<8; for GCS values>8 TBI and non-TBI patients were at similar risk of dying. CONCLUSIONS: A depressed GCS predicts death better in TBI patients than non-TBI patients, likely because in non-TBI patients a depressed GCS may simply be the result of entirely reversible intoxication by alcohol or drugs; in TBI patients, by contrast, a depressed GCS is more ominous because it is likely due to a head injury with its attendant threat to survival. Accounting for this observation into trauma mortality datasets and models may improve the accuracy of outcome prediction.

Outcomes are Worse in US Patients Undergoing Surgery on Weekends Compared With Weekdays.

BACKGROUND: Increasing surgical access to previously underserved populations in the United States may require a major expansion of the use of operating rooms on weekends to take advantage of unused capacity. Although the so-called weekend effect for surgery has been described in other countries, it is unknown whether US patients undergoing moderate-to-high risk surgery on weekends are more likely to experience worse outcomes than patients undergoing surgery on weekdays. OBJECTIVE: The aim of this study was to determine whether patients undergoing surgery on weekends are more likely to die or experience a major complication compared with patients undergoing surgery on a weekday. RESEARCH DESIGN: Using all-payer data, we conducted a retrospective cohort study of 305,853 patients undergoing isolated coronary artery bypass graft surgery, colorectal surgery, open repair of abdominal aortic aneurysm, endovascular repair of abdominal aortic aneurysm, and lower extremity revascularization. We compared in-hospital mortality and major complications for weekday versus weekend surgery using multivariable logistic regression analysis. RESULTS: After controlling for patient risk and surgery type, weekend elective surgery [adjusted odds ratio (AOR)=3.18; 95% confidence interval (CI), 2.26-4.49; P<0.001] and weekend urgent surgery (AOR=2.11; 95% CI, 1.68-2.66; P<0.001) were associated with a higher risk of death compared with weekday surgery. Weekend elective (AOR=1.58; 95% CI, 1.29-1.93; P<0.001) and weekend urgent surgery (AOR=1.61; 95% CI, 1.42-1.82; P<0.001) were also associated with a higher risk of major complications compared with weekday surgery. CONCLUSIONS: Patients undergoing nonemergent major cardiac and noncardiac surgery on the weekends have a clinically significantly increased risk of death and major complications compared with patients undergoing surgery on weekdays. These findings should prompt decision makers to seek to better understand factors, such physician and nurse staffing, which may contribute to the weekend effect.

Nontrauma surgeons can safely take call at an academic, rural level I trauma center.

BACKGROUND: Care protocols can facilitate effective management of injured patients across a spectrum of providers. It is uncertain whether patient care is compromised when a full time trauma surgeon is not on call in the rural setting, where manpower may be a challenge. METHODS: A retrospective cohort study was performed at an academic medical center with a level I trauma center. Patients admitted to the trauma service from 2007 to 2012 were compared with respect to mortality, missed injuries, delay in diagnosis, and length of stay based on whether they were admitted to the trauma service when a full-time trauma surgeon was on call. RESULTS: A total of 2,571 injured patients were admitted during the study period; 1,621 directly to the trauma service. Of those, 1,415 patients were initially seen by a trauma surgeon (group A) and 206 by a nontrauma surgeon (group B). Demographics were similar except that the trauma attending patients were somewhat older (44.7 vs 39.4 years, P = .002). There was no difference in the mean injury severity score (17.0 vs 16.0, P = .13) or Glasgow Coma Scale (12.7 vs 12.3, P = .7) between the 2 groups. There were 128 deaths; mortality rate in group A was 7.9% versus 7.7% for group B (P = .54). There was no difference in the incidence of delayed diagnosis or missed injuries (3.0 vs 3.4%, P = .8; .4 vs .9%, P = .27, respectively). The mean length of stay was shorter (7.9 vs 6.3, P = .016) in group B. CONCLUSIONS: There was no increase in mortality, delayed diagnosis, or missed injuries when nontrauma surgeons took call. Systems of care and algorithms can be developed that provide staffing flexibility yet maintain safe and effective care to trauma patients in the rural setting.