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1.
J Trauma Acute Care Surg ; 92(4): 691-700, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-34991125

RESUMO

BACKGROUND: Socioeconomic disadvantage is associated with worse outcomes after elective surgery, but the effect on emergency general surgery (EGS) remains unclear. We examined the association of socioeconomic disadvantage and outcomes after EGS procedures and investigated whether admission to hospitals with comprehensive clinical and social resources mitigated this effect. METHODS: Adults undergoing 1 of the 10 most burdensome high- and low-risk EGS procedures were identified in six 2014 State Inpatient Databases. Socioeconomic disadvantage was assessed using Area Deprivation Index (ADI) of patient residence. Multivariable logistic regression models adjusting for patient and hospital factors were used to evaluate the association between ADI quartile (high >75 percentile vs. low <25 percentile), and 30-day readmission, in-hospital mortality, and discharge disposition. Effect modification between ADI and (a) level 1 trauma center and (b) safety-net hospital status was tested. RESULTS: A total of 103,749 patients were analyzed: 72,711 low-risk (70.1%) and 31,038 high-risk procedures (29.9%). Patients from neighborhoods with high socioeconomic disadvantage had a higher proportion with ≥3 comorbidities (41.9% vs. 32.0%), minority race/ethnicity (66.3% vs. 42.4%), and Medicaid (28.8% vs. 14.7%) and were less likely to be treated at level 1 trauma centers (18.3% vs. 27.7%; p < 0.001 for all). Adjusting for competing factors, high socioeconomic disadvantage was associated with increased in-hospital mortality after high-risk procedures (odd ratio, 1.30; 95% confidence interval, 1.01-1.66; p = 0.04) and higher odds of non-home discharge (odd ratio, 1.15; 95% confidence interval, 1.02-1.30; p = 0.03) for low-risk procedures. Socioeconomic disadvantage was not associated with 30-day readmission for either procedure group. Level 1 trauma status and safety-net hospital did not meaningfully mitigate effect of ADI for any outcome. CONCLUSION: Socioeconomic disadvantage is associated with increased mortality after high-risk procedures and higher odds of non-home discharge after low-risk procedures. This effect was not mitigated by either level 1 trauma or safety-net hospitals. Interventions that specifically address the needs of socially vulnerable communities will be required to significantly improve EGS outcomes for this population. LEVEL OF EVIDENCE: Prognostic and Epidemiologic, level III.


Assuntos
Readmissão do Paciente , Provedores de Redes de Segurança , Adulto , Mortalidade Hospitalar , Humanos , Fatores Socioeconômicos , Centros de Traumatologia , Estados Unidos/epidemiologia
3.
J Surg Res ; 267: 109-116, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34147000

RESUMO

BACKGROUND: The insurance status of pediatric trauma patients is associated with access to post-discharge resources, including inpatient rehabilitation. Our goal was to understand the impact of changes in insurance coverage on access to post-acute care resources for pediatric trauma patients. MATERIALS AND METHODS: We utilized the National Trauma Data Bank from 2012 to 2016 for all pediatric trauma patients with a highest body region abbreviated injury score >2. Our primary outcome was hospital discharge disposition location. We used multivariable regression to adjust for salient patient and trauma center characteristics. Additionally, we performed a sensitivity analysis including only high-volume hospitals to examine the relationship between the magnitude of facility level expansion in coverage and changes in patient disposition. RESULTS: We identified 195,649 pediatric trauma patients meeting inclusion criteria. From 2012 to 2016 the proportion of patients with Medicaid (35% versus 39%, P < 0.001) and private insurance (39% versus 45%, P < 0.001) increased. Increased discharges with home health (HH) (+0.6% adjusted risk difference 2012 to 2016, P < 0.001) and decreased discharges to inpatient rehabilitation and skilled nursing facilities (-0.6% adjusted risk difference 2012 to 2016, P = 0.01) were associated with changes in insurance coverage. After stratifying high volume facilities by magnitude of increase in Medicaid and private insurance, we found that, for all groups, discharge to inpatient rehabilitation and skilled nursing facilities decreased (P < 0.01). CONCLUSIONS: Expanded insurance coverage for children was paradoxically associated with decreased discharge to inpatient rehabilitation and skilled nursing facilities after severe traumatic injury. These findings suggest that additional barriers may drive limitations in access to pediatric post-discharge services.


Assuntos
Assistência ao Convalescente , Alta do Paciente , Criança , Estudos de Coortes , Humanos , Cobertura do Seguro , Medicaid , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem , Estados Unidos
4.
J Surg Res ; 266: 292-299, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34038851

RESUMO

BACKGROUND: Moral distress is common among healthcare providers, leading to staff burnout and attrition. This study aimed to identify root causes of and potential solutions to moral distress experienced by surgical intensive care unit (SICU) providers. MATERIALS AND METHODS: This is a mixed methods study of physicians and nurses from a single, academic SICU. We obtained quantitative data from the Measures of Moral Distress for Healthcare Professionals (MMD-HP) survey and qualitative data from semi-structured interviews. The MMD-HP is a 27 question, validated survey on triggers of moral distress. Survey and interview data were analyzed to identify drivers of moral distress using a convergent design. RESULTS: 21 nurses and 25 physicians were surveyed and 17 providers interviewed. MMD-HP data demonstrated high levels of moral distress for nurses (mean total MMD-HP 132 ± 63.5) and physicians (121.7 ± 64.7), P = 0.68. The most frequent root cause of moral distress for all providers was participating in the delivery of aggressive care perceived to be futile. Nurses also reported caring for patients with unclear goals of care as a key driver of moral distress. Interview data supported these findings. Providers recommended improving access to palliative care to increase early communication on patient goals of care and end-of-life as a solution. Culture in the SICU often promotes supporting aggressive care however, acting as a potential barrier to increasing palliative resources. CONCLUSIONS: Providing aggressive care that is perceived as futile was the primary driver of moral distress in the SICU. Interventions to improve early communication and access to end-of-life care should be prioritized to decrease moral distress in staff.


Assuntos
Cuidados Críticos/psicologia , Princípios Morais , Enfermeiras e Enfermeiros/psicologia , Médicos/psicologia , Angústia Psicológica , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros/estatística & dados numéricos , Médicos/estatística & dados numéricos , Inquéritos e Questionários , Adulto Jovem
5.
J Trauma Acute Care Surg ; 91(2): 265-271, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33938510

RESUMO

BACKGROUND: Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers. METHODS: Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence. RESULTS: Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16). CONCLUSION: In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury. LEVEL OF EVIDENCE: Therapeutic, level IV; Epidemiologic, level III.


Assuntos
Analgésicos Opioides/administração & dosagem , Anestesia por Condução/métodos , Delírio/prevenção & controle , Manejo da Dor/métodos , Fraturas das Costelas/complicações , Escala Resumida de Ferimentos , Idoso , Delírio/epidemiologia , Feminino , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Traumatismo Múltiplo , Análise Multivariada , Medição da Dor , Estudos Retrospectivos , Centros de Traumatologia
6.
J Trauma Acute Care Surg ; 90(5): 853-860, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33797498

RESUMO

BACKGROUND: Emergency general surgery (EGS) encompasses a spectrum of time-sensitive and resource-intensive conditions, which require adequate and timely access to surgical care. Developing metrics to accurately quantify spatial access to care is critical for this field. We sought to evaluate the ability of the spatial access ratio (SPAR), which incorporates travel time, hospital capacity, and population demand in its ability to measure spatial access to EGS care and delineate disparities. METHODS: We constructed a geographic information science platform for EGS-capable hospitals in California and mapped population location, race, and socioeconomic characteristics. We compared the SPAR to the shortest travel time model in its ability to identify disparities in spatial access overall and for vulnerable populations. Reduced spatial access was defined as >60 minutes travel time or lowest three classes of SPAR. RESULTS: A total of 283 EGS-capable hospitals were identified, of which 142 (50%) had advanced resources. Using shortest travel time, only 166,950 persons (0.4% of total population) experienced prolonged (>60 minutes) travel time to any EGS-capable hospital, which increased to 1.05 million (2.7%) for advanced-resource centers. Using SPAR, 11.5 million (29.5%) had reduced spatial access to any EGS hospital, and 13.9 million (35.7%) for advanced-resource centers. Rural residents had significantly decreased access for both overall and advanced EGS services when assessed by SPAR despite travel times within the 60-minute threshold. CONCLUSION: While travel time and SPAR showed similar overall geographic patterns of spatial access to EGS hospitals, SPAR identified a greater a greater proportion of the population as having limited access to care. Nearly one third of California residents experience reduced spatial access to EGS hospitals when assessed by SPAR. Metrics that incorporate measures of population demand and hospital capacity in addition to travel time may be useful when assessing spatial access to surgical services. LEVEL OF EVIDENCE: Cross-sectional study, level VI.


Assuntos
Cuidados Críticos/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Cirurgia Geral/organização & administração , Disparidades em Assistência à Saúde , Hospitais/estatística & dados numéricos , Doença Aguda , California , Cuidados Críticos/estatística & dados numéricos , Estudos Transversais , Demografia , Emergências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Acesso aos Serviços de Saúde/organização & administração , Humanos , Modelos Organizacionais , Serviços de Saúde Rural/estatística & dados numéricos , Fatores Socioeconômicos , Análise Espacial , Inquéritos e Questionários
7.
J Urol ; 205(3): 841-847, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33021435

RESUMO

PURPOSE: The majority of high grade renal trauma can be managed conservatively. However, nephrectomy is still common for acute management. We hypothesized that when controlling for multiple injury severity measures, nephrectomy would be associated with increased mortality. MATERIALS AND METHODS: We identified high grade renal trauma patients from the National Trauma Data Bank® from 2007-2016. Exclusion criteria were age <18 years, severe head injury and death within 4 hours of admission. We performed conditional logistic regression analysis to determine if nephrectomy was independently associated with mortality, controlling for age, gender, race/ethnicity, mechanism of injury, shock, blood transfusion, Glasgow Coma Scale, Revised Trauma Score and Injury Severity Score. Interaction was measured for mechanism of injury and shock with mortality. RESULTS: We identified 42,898 patients with high grade renal trauma (grade III-V), of whom 3,204 (7.5%) underwent nephrectomy. Unadjusted mortality was 16.6% in nephrectomy vs 5.7% in nonnephrectomy patients. In multivariable logistic regression, nephrectomy was associated with 82% increased odds of death (OR 1.82, 95% CI 1.63-2.03, p <0.001). Other significant associations with death included age, nonWhite race, penetrating mechanism, hypotension, blood transfusion, lower Glasgow Coma Scale, lower Revised Trauma Score and higher Injury Severity Score. The association between nephrectomy and death did not differ by mechanism of injury. However, it was slightly attenuated in patients presenting in shock. CONCLUSIONS: In the National Trauma Data Bank, nephrectomy is independently associated with increased risk of mortality after adjusting for patient demographics, injury characteristics and multiple measures of overall injury severity. Nephrectomy may impact overall survival and must be avoided when possible.


Assuntos
Rim/lesões , Rim/cirurgia , Nefrectomia/mortalidade , Adulto , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índices de Gravidade do Trauma , Estados Unidos/epidemiologia
8.
BMC Health Serv Res ; 20(1): 1119, 2020 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-33272278

RESUMO

BACKGROUND: To increase bed capacity and resources, hospitals have postponed elective surgeries, although the financial impact of this decision is unknown. We sought to report elective surgical case distribution, associated gross hospital revenue and regional hospital and intensive care unit (ICU) bed capacity as elective surgical cases are cancelled and then resumed under simulated trends of COVID-19 incidence. METHODS: A retrospective, cohort analysis was performed using insurance claims from 161 million enrollees from the MarketScan database from January 1, 2008 to December 31, 2017. COVID-19 cases were calculated using Institute for Health Metrics and Evaluation models. Centers for Disease Control (CDC) reports on the number of hospitalized and intensive care patients by age estimated the number of cases seen in the ICU, the reduction in elective surgeries and the financial impact of this from historic claims data, using a denominator of all inpatient revenue and outpatient surgeries. RESULTS: Assuming 5% infection prevalence, cancelling all elective procedures decreases ICU overcapacity from 160 to 130%, but these elective surgical cases contribute 78% (IQR 74, 80) (1.1 trillion (T) US dollars) to inpatient hospital plus outpatient surgical gross revenue per year. Musculoskeletal, circulatory and digestive category elective surgical cases compose 33% ($447B) of total revenue. CONCLUSIONS: Procedures involving the musculoskeletal, cardiovascular and digestive system account for the largest loss of hospital gross revenue when elective surgery is postponed. As hospital bed capacity increases following the COVID-19 pandemic, restoring volume of these elective cases will help maintain revenue. In these estimates, adopting universal masking would help to avoid overcapacity in all states.


Assuntos
COVID-19/epidemiologia , Procedimentos Cirúrgicos Eletivos/economia , Número de Leitos em Hospital/estatística & dados numéricos , Pandemias , Economia Hospitalar , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva , Estudos Retrospectivos , Estados Unidos/epidemiologia
10.
JAMA Surg ; 155(9): 841-848, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32697290

RESUMO

Importance: Care fragmentation at time of readmission after emergency general surgery (EGS) is associated with high mortality; however, the factors underlying this finding remain unclear. Objective: To identify patient and hospital factors associated with increased mortality among patients after EGS readmitted within 30 days of discharge to a nonindex hospital. Design, Setting, and Participants: Retrospective cohort study using the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. Participants were all adult patients (18 years or older) who underwent 1 of the 15 most common EGS procedures in the United States from January 1 to November 30, 2014, and survived to discharge. The dates of analysis were October through December 2019. Exposures: Thirty-day readmission to a hospital other than that of the index surgical procedure. The study examined the association of interventions during readmission, change in hospital resource level, and severity of patient illness during readmission. Main Outcomes and Measures: Ninety-day inpatient mortality. Results: In total, 71 944 patients who underwent EGS (mean [SD] age, 59.0 [18.3] years; 53.5% [38 487 of 71 944] female) were readmitted within 30 days of discharge, of whom 10 495 (14.6%) were readmitted to a nonindex hospital. Compared with patients readmitted to index hospitals, patients readmitted to nonindex hospitals were more likely to be readmitted to hospitals with low annual EGS volume (33.5% vs 25.6%, P < .001) and be in the top half of illness severity profile (37.2% vs 31.2%, P < .001). Overall 90-day mortality was higher in the patients readmitted to nonindex hospitals (6.1% vs 4.3%, P < .001). When adjusted for baseline patient and hospital characteristics, care fragmentation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.36; 95% CI, 1.17-1.58; P < .001). After adjustment for interventions performed during readmission, change in EGS hospital volume level, and severity of patient illness, care fragmentation was no longer independently associated with mortality (aOR, 1.05; 95% CI, 0.88-1.26; P = .58). In this complete model, severity of illness was the strongest risk factor of mortality during readmission. Conclusions and Relevance: In this cohort study of adult patients who require rehospitalization after EGS, 14.6% are readmitted to a hospital other than where the index procedure was performed. Although the overall mortality rate is higher for this population, the excess mortality appears to be primarily associated with severity of patient illness at time of readmission. These data underscore the need to develop systems of care to rapidly triage patients to hospitals best equipped to manage their condition.


Assuntos
Continuidade da Assistência ao Paciente , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Idoso , Emergências , Serviço Hospitalar de Emergência , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/mortalidade , Adulto Jovem
11.
medRxiv ; 2020 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-32511614

RESUMO

BACKGROUND: To increase bed capacity and resources, hospitals have postponed elective surgeries, although the financial impact of this decision is unknown. We sought to report elective surgical case distribution, associated gross hospital earnings and regional hospital and intensive care unit (ICU) bed capacity as elective surgical cases are cancelled and then resumed under simulated trends of COVID-19 incidence. METHODS: A retrospective, cohort analysis was performed using insurance claims from 161 million enrollees from the MarketScan database from January 1, 2008 to December 31, 2017. COVID-19 cases were calculated using a generalized Richards model. Centers for Disease Control (CDC) reports on the number of hospitalized and intensive care patients by age were used to estimate the number of cases seen in the ICU, the reduction in elective surgeries and the financial impact of this from historic claims data, using a denominator of all inpatient revenue and outpatient surgeries. RESULTS: Assuming 5% infection prevalence, cancelling all elective procedures decreases ICU overcapacity from 340% to 270%, but these elective surgical cases contribute 78% (IQR 74, 80) (1.1 trillion (T) US dollars) to inpatient hospital plus outpatient surgical gross earnings per year. Musculoskeletal, circulatory and digestive category elective surgical cases compose 33% ($447B) of total revenue. CONCLUSIONS: Procedures involving the musculoskeletal, cardiovascular and digestive system account for the largest loss of hospital gross earnings when elective surgery is postponed. As hospital bed capacity increases following the COVID-19 pandemic, restoring volume of these elective cases will help maintain revenue.

13.
J Trauma Acute Care Surg ; 89(1): 118-124, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32176177

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. METHODS: This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. RESULTS: A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). CONCLUSION: This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. LEVEL OF EVIDENCE: Prognostic study, level III.


Assuntos
Emergências , Cirurgia Geral , Medição de Risco/métodos , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estudos Prospectivos , Ferimentos e Lesões/mortalidade
14.
J Trauma Acute Care Surg ; 88(2): 219-229, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31804415

RESUMO

BACKGROUND: We sought to examine patterns of readmission after nonoperative trauma, including rates of delayed operative intervention and mortality. METHODS: The Nationwide Readmissions Database (2013-2014) was queried for all adult trauma admissions and 30-day readmissions. Index admissions were classified as operative (OI) or nonoperative (NOI), and readmissions examined for major operative intervention (MOR). Multivariable regression modeling was used to evaluate risk for readmission requiring MOR and in-hospital mortality. RESULTS: Of 2,244,570 trauma admissions, there were 59,573 readmissions: 66% after NOI, and 35% after OI. Readmission rate was higher after NOI compared with OI (3.6% vs. 1.7% p < 0.001). Readmitted NOI patients were older, with a higher proportion of Injury Severity Score ≥15 and were readmitted earlier (NOI median 8 days vs. OI 11 days). Thirty-one percent of readmitted NOI patients required MOR and experienced higher overall mortality compared with OI patients with operative readmission (NOI 2.9% vs. OI 2%, p = 0.02). Intracranial hemorrhage was an independent risk factor for NOI readmission requiring MOR in both the overall (hazard ratio, 1.11; 95% confidence interval [CI], 1.01-1.22) and Injury Severity Score of 15 or greater cohorts (hazard ratio, 1.46; 95% CI, 1.24-1.7), with a predominance of nonspine neurosurgical procedures (20.3% and 55.1%, respectively). Operative readmission after NOI cost a median of $17,364 (interquartile range, US $11,481 to US $27,816) and carried a total annual cost of US $147 million (95% CI, US $141 million to $154 million). CONCLUSIONS: Nonoperative trauma patients have a higher readmission rate than operative index patients and nearly one third require operative intervention during readmission. Operative readmission carries a higher overall mortality rate in NOI patients and together accounts for nearly US $150 million in annual costs. LEVEL OF EVIDENCE: Epidemiological, level III.


Assuntos
Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Readmissão do Paciente/estatística & dados numéricos , Tempo para o Tratamento/economia , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Tempo , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos , Ferimentos e Lesões/economia , Ferimentos e Lesões/mortalidade , Adulto Jovem
15.
J Am Coll Surg ; 230(2): 228-236, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31654733

RESUMO

BACKGROUND: It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population. STUDY DESIGN: Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively. RESULTS: Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication. CONCLUSIONS: Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.


Assuntos
Assistência ao Convalescente/métodos , Tratamento de Emergência , Utilização de Instalações e Serviços/estatística & dados numéricos , Recursos em Saúde/estatística & dados numéricos , Segurança do Paciente , Procedimentos Cirúrgicos Operatórios , Telefone , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
16.
Am J Surg ; 217(6): 1010-1015, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31023549

RESUMO

BACKGROUND: Percutaneous Cholecystostomy Tubes (PCT) have become an accepted and common modality of treating acute cholecystitis in patients that are not appropriate surgical candidates. As percutaneous gallbladder drainage has rapidly increased newer research suggests that the technique may be overused, and patients may be burdened with them for extended periods. We examined our experience with PCT placement to identify independent predictors of interval cholecystectomy versus destination PCT. METHODS: All patients with cholecystitis initially treated with PCT from 2014 to 2017 were stratified by whether they underwent subsequent interval cholecystectomy. Demographic data, initial laboratory values, Tokyo Grade, Charlson Comorbidity Index, ASA Class, complications related to PCT, complications related to cholecystectomy, and mortality data were retrospectively collected. Descriptive statistics, univariable, and multivariable Poisson regression were performed. RESULTS: 165 patients received an initial cholecystostomy tube to treat cholecystitis. 61 (37%) patients went on to have an interval cholecystectomy. There were 4 complications reported after cholecystectomy. A total of 46 (27.9%) deaths were reported, only one of which was in the cholecystectomy group. Age, Tokyo Grade, liver function tests, ASA Class, and Charlson Comorbidity Index were significantly different between the interval cholecystectomy and no-cholecystectomy groups. Univariable regression was performed and variables with p < 0.2 were included in the multivariable model. Multivariable Poisson regression showed that increasing Tokyo Grade (IRR 0.454, p = 0.042, 95% CI 0.194-0.969); and increasing Charlson Comorbidity Score (IRR 0.890, p = 0.026, 95% CI 0.803-0.986) were associated with no-cholecystectomy. Higher Albumin (IRR 1.580, p = 0.011, 95% CI 1.111-2.244) was associated with having an interval cholecystectomy. CONCLUSION: Patients in the no-cholecystectomy group were older, had more comorbidities, higher Tokyo Grade, ASA Class, and initial liver function test values than those that had interval cholecystectomy. Since interval cholecystectomy was performed with a low rate of complications, we may be too conservative in performing cholecystectomy after drainage and condemning many patients to destination tubes.


Assuntos
Colecistectomia/estatística & dados numéricos , Colecistite Aguda/cirurgia , Colecistostomia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistostomia/instrumentação , Colecistostomia/métodos , Remoção de Dispositivo/estatística & dados numéricos , Drenagem/instrumentação , Drenagem/métodos , Drenagem/estatística & dados numéricos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do Tratamento , Utah
17.
Surgery ; 165(6): 1122-1127, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30871812

RESUMO

BACKGROUND: Women are underrepresented in trauma research, and aggregated results of clinical trials may mask effects that differ by sex. It is unclear whether women respond differently to severe hemorrhage compared with men. We sought to evaluate sex-based differences in outcomes after severe trauma with hemorrhage. METHODS: We performed a secondary analysis of the Pragmatic Randomized Optimal Platelet and Plasma Ratios trial. Trauma patients predicted to require massive transfusion were randomized to a 1:1:1 vs 1:1:2 plasma to platelet to red blood cell transfusion ratio. Analysis was performed according to sex, controlling for clinical characteristics and transfusion arm. RESULTS: A total of 134 women and 546 men were analyzed. In multivariable analysis, there was no difference in mortality at 24 hours (hazard ratio for women 0.64, 95% confidence interval 0.34-1.23, P = .18) or in time to hemostasis (hazard ratio 1.10, 95% confidence interval 0.84-1.42, P = .49) by sex. We observed no difference between sexes in volume of blood products transfused during active hemorrhage. However, after anatomic hemostasis, women received lower volumes of all products, with a 38% reduction in fresh frozen plasma (mean ratio 0.62 (95% confidence interval 0.43-0.89, P = .01), 49% reduction in platelets (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01) and 49% reduction in volume of red blood cells (mean ratio 0.51, 95% confidence interval 0.33-0.79, P < .01). CONCLUSION: Mortality and time to hemostasis of trauma patients with hemorrhage did not differ by sex. Although there was no difference in transfusion requirement during active hemorrhage, once hemostasis was achieved, women received fewer units of all blood products than men. Further research is required to determine whether women exhibit differences in coagulation during and after severe traumatic hemorrhage.


Assuntos
Transfusão de Eritrócitos/estatística & dados numéricos , Hemorragia/terapia , Transfusão de Plaquetas/estatística & dados numéricos , Ressuscitação/métodos , Ferimentos e Lesões/complicações , Adulto , Feminino , Hemorragia/etiologia , Hemorragia/mortalidade , Técnicas Hemostáticas/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Tempo para o Tratamento , Índices de Gravidade do Trauma , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia , Adulto Jovem
18.
Med Care ; 52(3): 235-42, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24509361

RESUMO

BACKGROUND: Hospitals show wide variation in outcomes and systems of care. It is unclear whether hospital complexity-the range of services and technologies provided-affects outcomes and in what direction. We sought to determine whether complexity was associated with inpatient surgical mortality. METHODS: Using national Medicare data, we identified all fee-for-service inpatients who underwent 1 of 5 common high-risk surgical procedures in 2008-2009 and measured complexity by the number of unique primary diagnoses admitted to each hospital over the 2-year period. We calculated 30-day postoperative mortality rates, adjusting for patient and hospital characteristics, and used multivariable Poisson regression models to test for an association between hospital complexity and mortality rates. We then used this model to generate predicted mortality rates for low-volume and high-volume hospitals across the spectrum of hospital complexity. RESULTS: A total of 2691 hospitals were analyzed, representing a total of 382,372 admissions. After adjusting for hospital characteristics, including hospital volume, increasing hospital complexity was associated with lower surgical mortality rates. Patients receiving care at the hospitals in the lowest quintile of unique diagnoses had a 27% higher risk of death than those at the highest quintile. The effect of complexity was largest for low-volume hospitals, which were capable of achieving mortality rates similar to high-volume hospitals when in the most complex quintile. CONCLUSIONS: Hospital complexity matters and is associated with lower surgical mortality rates, independent of hospital volume. The effect of complexity on outcomes for nonsurgical services warrants investigation.


Assuntos
Administração Hospitalar/estatística & dados numéricos , Mortalidade Hospitalar/tendências , Complicações Pós-Operatórias/mortalidade , Idoso , Feminino , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Fatores de Risco , Estados Unidos
19.
JAMA Intern Med ; 173(14): 1351-7, 2013 Jul 22.
Artigo em Inglês | MEDLINE | ID: mdl-23797306

RESUMO

IMPORTANCE: Federal efforts about public reporting and quality improvement programs for hospitals have focused primarily on a small number of medical conditions. Whether performance on these conditions accurately predicts the quality of broader hospital care is unknown. OBJECTIVE: To determine whether mortality rates for publicly reported medical conditions are correlated with hospitals' overall performance. METHODS: Using national Medicare data, we compared hospital performance at 2322 US acute care hospitals on 30-day risk-adjusted mortality, aggregated across the 3 publicly reported conditions (acute myocardial infarction, congestive heart failure, and pneumonia), with performance on a composite risk-adjusted mortality rate across 9 other common medical conditions, a composite mortality rate across 10 surgical conditions, and both composites combined. We also examined the relationship between alternative surrogates of quality (hospital size and teaching status) and performance on these composite outcomes. RESULTS: Our sample included 6,670,859 hospitalizations for Medicare fee-for-service beneficiaries from 2008 through 2009. Hospitals in the top quartile of performance on publicly reported conditions had a 3.6% lower absolute risk-adjusted mortality rate on the combined medical-surgical composite than those in the bottom quartile (9.4% vs 13.0%; P < .001). These top performers on publicly reported conditions had 5 times greater odds of being in the top quartile on the overall combined composite risk-adjusted mortality rate (odds ratio [OR], 5.3; 95% CI, 4.3-6.5). Mortality rates for the index condition were predictive of medical (OR, 8.4; 95% CI, 6.8-10.3) and surgical (2.7; 2.2-3.3) performance when these groups were considered separately. In comparison, large size (OR, 1.9; 95% CI, 1.5-2.4) and teaching status (2.4; 1.8-3.2) showed weaker relationships with overall hospital mortality rates. CONCLUSIONS AND RELEVANCE: Hospital performance on publicly reported conditions can potentially be used as a signal of overall hospital mortality rates.


Assuntos
Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde , Indicadores de Qualidade em Assistência à Saúde , Idoso , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Número de Leitos em Hospital , Hospitais/normas , Hospitais de Ensino , Humanos , Masculino , Medicare , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Pneumonia/mortalidade , Pneumonia/terapia , Risco Ajustado , Estados Unidos/epidemiologia
20.
Injury ; 44(9): 1241-5, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22658421

RESUMO

BACKGROUND: Injury sustained in rural areas has been shown to carry higher mortality rates than trauma in urban settings. This disparity is partially attributed to increased distance from definitive care and underscores the importance of proper primary trauma management prior to transfer to a trauma facility. The purpose of this study was to assess Advanced Trauma Life Support (ATLS) guideline adherence in the management of adult trauma patients transferred from rural hospitals to a level I facility. METHODS: We performed a retrospective analysis of all adult major trauma patients transferred ≥50km from an outlying hospital to a level I trauma centre from 2007 through 2009. Transfer practices were evaluated using ATLS guidelines. RESULTS: 646 patients were analyzed. Mean age was 40.5years and 94% sustained blunt injuries with a median Injury Severity Score (ISS) of 22. Median transport distance was 253km. Among all patients, there were notable deficiencies (<80% adherence) in 8 of 11 ATLS recommended interventions, including patient rewarming (8% adherence), chest tube insertion (53%), adequate IV access (53%), and motor/sensory exam (72%). Patients with higher ISS scores, and those transferred by air were more likely to receive ATLS recommended interventions. CONCLUSIONS: Key aspects of ATLS resuscitation guidelines are frequently missed during transfer of trauma patients from the periphery to level I trauma centres. Comprehensive quality improvement initiatives, including targeted education, telemedicine and trauma team training programmes could improve quality of care.


Assuntos
Cuidados de Suporte Avançado de Vida no Trauma/estatística & dados numéricos , Fidelidade a Diretrizes/normas , Transferência de Pacientes/estatística & dados numéricos , Ferimentos e Lesões , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Pessoal Técnico de Saúde/educação , Feminino , Hospitais Rurais , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , América do Norte/epidemiologia , Transferência de Pacientes/normas , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
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