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1.
Artigo em Inglês | MEDLINE | ID: mdl-34739000

RESUMO

BACKGROUND: Social determinants of health (SDOH) impact patient outcomes in trauma. Census data are often used to account for SDOH; however, there is no consensus on which variables are most important. Social vulnerability indices offer the advantage of combining multiple constructs into a single variable. Our objective was to determine if incorporation of SDOH in patient-level risk-adjusted outcome modeling improved predictive performance. METHODS: We evaluated two social vulnerability indices at the zip code level: Distressed Community Index (DCI) and National Risk Index (NRI). Individual variable combinations from AHRQ's SDOH Dataset were used for comparison. Patients were obtained from the Pennsylvania Trauma Outcomes Study 2000-2020. These measures were added to a validated base mortality prediction model with comparison of area under the curve (AUC) and Bayesian information criterion (BIC). We performed center benchmarking using risk-standardized mortality ratios to evaluate change in rank and outlier status based on SDOH. Geospatial analysis identified geographic variation and autocorrelation. RESULTS: 449,541 patients were included. The DCI and NRI were associated with an increase in mortality (aOR 1.02; 95%CI 1.01-1.03 per 10% percentile rank increase, p < 0.01, respectively). The DCI, NRI, and 7 AHRQ variable also improved base model fit but discrimination was similar. Two-thirds of centers changed mortality ranking when accounting for SDOH compared to the base model alone. Outlier status changed in 7% of center, most representing an improvement from worse-than-expected to non-outlier or non-outlier to better-than-expected. There was significant geographic variation and autocorrelation of the DCI and NRI (DCI; Moran's I 0.62, p = 0.01; NRI; Moran's I 0.34, p = 0.01). CONCLUSIONS: SDOH are associated with an individual patient's risk of mortality after injury. Accounting for SDOH may be important in risk-adjustment for trauma center benchmarking. LEVEL OF EVIDENCE: Epidemiological, IV.

2.
Artigo em Inglês | MEDLINE | ID: mdl-34629458

RESUMO

BACKGROUND: Rapid platelet function testing is frequently used to determine platelet function in patients with traumatic intracranial hemorrhage (tICH). Accuracy and clinical significance of decreased platelet response detected by these tests is not well understood. We sought to determine whether VerifyNow and Whole Blood Aggregometry (WBA) can detect poor platelet response and to elucidate its clinical significance for tICH patients. METHODS: We prospectively enrolled patients with isolated tICH between 2018 and 2020. Demographics, medical history, injury characteristics and patient outcomes were recorded. Platelet function was determined by VerifyNow and WBA testing at the time of arrival to the trauma bay and 6 hours later. RESULTS: A total of 221 patients were enrolled, including 111 patients on no antiplatelet medication, 78 on aspirin, 6 on clopidogrel and 26 on aspirin and clopidogrel. In the trauma bay, 29.7% and 67.7% of patients on no antiplatelet medication had poor platelet response on VerifyNow and WBA, respectively. Among patients on aspirin, 72.2% and 82.2% had platelet dysfunction on VerifyNow and WBA. Among patients on clopidogrel, 67.9% and 88.9% had platelet dysfunction on VerifyNow and WBA. Patients with non-responsive platelets had similar in-hospital mortality (3 [3.0%] vs. 6 [6.3%], p = 0.324), tICH progression (26 [27.1%] vs 24 [26.1%], p = 0.877), ICU admission rates (34 [34.3%] vs 38 [40.0%), p = 0.415) and length of stay (3 [IQR 2-8] vs 3.2 [IQR 2-7], p = 0.818) to those with responsive platelets. Platelet transfusion did not improve platelet response or patient outcomes. CONCLUSIONS: Rapid platelet function testing detects a highly prevalent poor platelet response among patients with tICH, irrespective of antiplatelet medication use. VerifyNow correlated fairly with whole blood aggregometry among patients with tICH and platelet responsiveness detectable by these tests did not correlate with clinical outcomes. Additionally, our results suggest that platelet transfusion may not improve clinical outcomes in patients with tICH. LEVEL OF EVIDENCE: level I, Diagnostic Tests.

3.
J Surg Oncol ; 124(3): 324-333, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33939838

RESUMO

BACKGROUND: Medicaid expansion under the Affordable Care Act has improved access to screening and treatment for certain cancers. It is unclear how this policy has affected the diagnosis and management of pancreatic cancer. METHODS: Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during two time periods: pre-expansion (2011-2012) and postexpansion (2015-2016). We investigated changes in cancer staging, treatment decisions, and surgical outcomes. RESULTS: In this national cohort, pancreatic cancer patients in expansion states had increased Medicaid coverage relative to those in nonexpansion states (DID = 17.49, p < 0.01). Medicaid expansion also led to an increase in early-stage diagnoses (Stage I/II, DID = 4.71, p = 0.03), higher comorbidity scores among surgical patients (Charlson/Deyo score 0: DID = -13.69, p = 0.02), a trend toward more neoadjuvant radiation (DID = 6.15, p = 0.06), and more positive margins (DID = 11.69, p = 0.02). There were no differences in rates of surgery, postoperative outcomes, or overall survival. CONCLUSION: Medicaid expansion was associated with improved insurance coverage and earlier stage diagnoses for Medicaid and uninsured pancreatic cancer patients, but similar surgical outcomes and overall survival. These findings highlight both the benefits of Medicaid expansion and the potential limitations of policy change to improve outcomes for such an aggressive malignancy.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Neoplasias Pancreáticas/economia , Neoplasias Pancreáticas/mortalidade , Adulto , Idoso , Estudos de Coortes , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/cirurgia , Patient Protection and Affordable Care Act , Sistema de Registros , Estudos Retrospectivos , Estados Unidos/epidemiologia
4.
J Trauma Acute Care Surg ; 90(6): 967-972, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34016920

RESUMO

BACKGROUND: The National Field Triage Guidelines were created to inform triage decisions by emergency medical services (EMS) providers and include eight anatomic injuries that prompt transportation to a Level I/II trauma center. It is unclear how accurately EMS providers recognize these injuries. Our objective was to compare EMS-identified anatomic triage criteria with International Classification of Diseases-10th revision (ICD-10) coding of these criteria, as well as their association with trauma center need (TCN). METHODS: Scene patients 16 years and older in the NTDB during 2017 were included. National Field Triage Guidelines anatomic criteria were classified based on EMS documentation and ICD-10 diagnosis codes. The primary outcome was TCN, a composite of Injury Severity Score greater than 15, intensive care unit admission, urgent surgery, or emergency department death. Prevalence of anatomic criteria and their association with TCN was compared in EMS-identified versus ICD-10-coded criteria. Diagnostic performance to predict TCN was compared. RESULTS: There were 669,795 patients analyzed. The ICD-10 coding demonstrated a greater prevalence of injury detection. Emergency medical service-identified versus ICD-10-coded anatomic criteria were less sensitive (31% vs. 59%), but more specific (91% vs. 73%) and accurate (71% vs. 68%) for predicting TCN. Emergency medical service providers demonstrated a marked reduction in false positives (9% vs. 27%) but higher rates of false negatives (69% vs. 42%) in predicting TCN from anatomic criteria. Odds of TCN were significantly greater for EMS-identified criteria (adjusted odds ratio, 4.5; 95% confidence interval, 4.46-4.58) versus ICD-10 coding (adjusted odds ratio 3.7; 95% confidence interval, 3.71-3.79). Of EMS-identified injuries, penetrating injury, flail chest, and two or more proximal long bone fractures were associated with greater TCN than ICD-10 coding. CONCLUSION: When evaluating the anatomic criteria, EMS demonstrate greater specificity and accuracy in predicting TCN, as well as reduced false positives compared with ICD-10 coding. Emergency medical services identification is less sensitive for anatomic criteria; however, EMS identify the most clinically significant injuries. Further study is warranted to identify the most clinically important anatomic triage criteria to improve our triage protocols. LEVEL OF EVIDENCE: Care management, Level IV; Prognostic, Level III.


Assuntos
Codificação Clínica/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Triagem/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico , Adulto , Idoso , Codificação Clínica/normas , Serviços Médicos de Emergência/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Valor Preditivo dos Testes , Estudos Retrospectivos , Centros de Traumatologia/normas , Índices de Gravidade do Trauma , Triagem/normas
5.
J Trauma Acute Care Surg ; 91(2): 399-405, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33852559

RESUMO

BACKGROUND: Social vulnerability indices were created to measure resiliency to environmental disasters based on socioeconomic and population characteristics of discrete geographic regions. They are composed of multiple validated constructs that can also potentially identify geographically vulnerable populations after injury. Our objective was to determine if these indices correlate with injury fatality rates in the US. METHODS: We evaluated three social vulnerability indices: The Hazards & Vulnerability Research Institute's Social Vulnerability Index (SoVI), the Center for Disease Control's Social Vulnerability Index (SVI), and the Economic Innovation Group's Distressed Community Index (DCI). We analyzed SVI subindices and common individual census variables as indicators of socioeconomic status. Outcomes included age-adjusted county-level overall, firearm, and motor vehicle collision deaths per 100,000 population. Linear regression determined the association of injury fatality rates with the SoVI, SVI, and DCI. Bivariate choropleth mapping identified geographic variation and spatial autocorrelation of overall fatality, SoVI, and DCI. RESULTS: A total of 3,137 US counties were included. Only 24.6% of counties fell into the same vulnerability quintile for all three indices. Despite this, all indices were associated with increasing fatality rates for overall, firearm, and motor vehicle collision fatality. The DCI performed best by model fit, explanation of variance, and diagnostic performance on overall injury fatality. There is significant geographic variation in SoVI, DCI, and injury fatality rates at the county level across the United States, with moderate spatial autocorrelation of SoVI (Moran's I, 0.35; p < 0.01) and high autocorrelation of injury fatality rates (Moran's I, 0.77; p < 0.01) and DCI (Moran's I, 0.53; p < 0.01). CONCLUSION: While the indices contribute unique information, higher social vulnerability is associated with higher injury fatality across all indices. These indices may be useful in the epidemiologic and geographic assessment of injury-related fatality rates. Further study is warranted to determine if these indices outperform traditional measures of socioeconomic status and related constructs used in trauma research. LEVEL OF EVIDENCE: Epidemiological, level IV.


Assuntos
Acidentes de Trânsito/mortalidade , Classe Social , Populações Vulneráveis , Ferimentos e Lesões/mortalidade , Ferimentos por Arma de Fogo/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Mapeamento Geográfico , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Espacial , Estados Unidos/epidemiologia
6.
J Trauma Acute Care Surg ; 91(1): 178-185, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33605701

RESUMO

BACKGROUND: Despite evidence of benefit after injury, helicopter emergency medical services (HEMS) overtriage remains high. Scene and transfer overtriage are distinct processes. Our objectives were to identify geographic variation in overtriage and patient-level predictors, and determine if overtriage impacts population-level outcomes. METHODS: Patients 16 years or older undergoing scene or interfacility HEMS in the Pennsylvania Trauma Outcomes Study were included. Overtriage was defined as discharge within 24 hours of arrival. Patients were mapped to zip code, and rates of overtriage were calculated. Hot spot analysis identified regions of high and low overtriage. Mixed-effects logistic regression determined patient predictors of overtriage. High and low overtriage regions were compared for population-level injury fatality rates. Analyses were performed for scene and transfer patients separately. RESULTS: A total of 85,572 patients were included (37.4% transfers). Overtriage was 5.5% among scene and 11.8% among transfer HEMS (p < 0.01). Hot spot analysis demonstrated geographic variation in high and low overtriage for scene and transfer patients. For scene patients, overtriage was associated with distance (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.06 per 10 miles; p = 0.04), neck injury (OR, 1.27; 95% CI, 1.01-1.60; p = 0.04), and single-system injury (OR, 1.37; 95% CI, 1.15-1.64; p < 0.01). For transfer patients, overtriage was associated with rurality (OR, 1.64; 95% CI, 1.22-2.21; p < 0.01), facial injury (OR, 1.22; 95% CI, 1.03-1.44; p = 0.02), and single-system injury (OR, 1.35; 95% CI, 1.18-2.19; p < 0.01). For scene patients, high overtriage was associated with higher injury fatality rate (coefficient, 1.72; 95% CI, 1.68-1.76; p < 0.01); low overtriage was associated with lower injury fatality rate (coefficient, -0.73; 95% CI, -0.78 to -0.68; p < 0.01). For transfer patients, high overtriage was not associated with injury fatality rate (p = 0.53); low overtriage was associated with lower injury fatality rate (coefficient, -2.87; 95% CI, -4.59 to -1.16; p < 0.01). CONCLUSION: Geographic overtriage rates vary significantly for scene and transfer HEMS, and are associated with population-level outcomes. These findings can help guide targeted performance improvement initiatives to reduce HEMS overtriage. LEVEL OF EVIDENCE: Therapeutic, level IV.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Serviços Médicos de Emergência/organização & administração , Triagem/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adulto , Idoso , Aeronaves , Feminino , Mapeamento Geográfico , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estudos Retrospectivos , Fatores de Tempo , Centros de Traumatologia
7.
J Surg Res ; 261: 385-393, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33493891

RESUMO

BACKGROUND: Trauma field triage matches injured patients to the appropriate level of care. Prior work suggests the Glasgow Coma Scale motor (GCSm) is as accurate as the total GCS (GCSt) and easier to use. However, older patients present with higher GCS for a given injury, and as such, it is unclear if this substitution is advisable. Our objective was to compare the GCS deficit patterns between geriatric and adult patients presenting with severe traumatic brain injury (TBI), as well as the diagnostic performance of the GCSm versus GCSt within the field triage criteria in these populations. MATERIALS AND METHODS: We conducted a retrospective, observational cohort study of patients ≥16 y in the National Trauma Data Bank 2007-2015. GCS deficit patterns were compared between adults (16-65) and geriatric patients (>65). Measures of diagnostic performance of GCSt≤13 versus GCSm≤5 criteria to predict trauma center need (TCN) were compared. RESULTS: In total, 4,480,185 patients were analyzed (28% geriatric). Geriatric patients more frequently presented with non-motor-only deficits than adults (16.4% versus 12.4%, P < 0.001), and these patients demonstrated higher severe TBI (40.3% versus 36.7%, P < 0.001) and craniotomy (5.8% versus 5.1%, P < 0.001) rates. GCSt was more sensitive and accurate in predicting TCN for geriatric patients and had lower rates of undertriage as compared to GCSm. CONCLUSIONS: Geriatric patients more frequently present with non-motor-only deficits after injury, and this is associated with severe head injury. Substitution of GCSm for GCSt would exacerbate undertriage in geriatric patients and, thus, the total GCS should be maintained for field triage in geriatric patients.


Assuntos
Lesões Encefálicas Traumáticas , Escala de Resultado de Glasgow , Atividade Motora , Triagem/métodos , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Avaliação Geriátrica , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
8.
J Am Coll Surg ; 232(2): 146-156.e1, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33242599

RESUMO

BACKGROUND: The Affordable Care Act facilitated improved insurance coverage for states that expanded Medicaid coverage, but the impact on cancer outcomes is unclear. This study compared changes in the diagnosis and management of colon cancer in states that did and did not participate in Medicaid expansion. STUDY DESIGN: Using a quasi-experimental difference-in-differences (DID) approach, we analyzed Medicaid and uninsured patients in the National Cancer Data Base during 2 time periods: pre (2011-2012) and post expansion (2015-2016). Patients in non-expansion states were compared with those in January 2014 expansion states with regard to changes in patient and facility characteristics, cancer staging, treatment decisions, and surgical outcomes. RESULTS: Along with increased Medicaid coverage (DID = 20.27; p < 0.001), patients in expansion states had an increase in stage I diagnoses (DID = 2.97; p = 0.035), distance traveled (miles, DID = 6.67; p = 0.005), and treatment at integrated network programs (DID = 2.67; p = 0.045). More early-stage patients were treated within 30 days (DID = 7.24; p = 0.035) and more stage IV patients received palliative care (DID = 5.01; p = 0.048). Among surgical patients, Medicaid expansion correlated with fewer urgent cases (< 7 days, DID = -5.88; p = 0.008) and more minimally invasive surgery (DID = 5.00; p = 0.022). There were no observed differences in postoperative outcomes or adjuvant chemotherapy. CONCLUSIONS: Medicaid expansion correlated with earlier diagnosis, enhanced access, and improved surgical care for colon cancer patients. These findings highlight the importance of improving health insurance coverage and can help guide future policy efforts.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Neoplasias do Colo/diagnóstico , Neoplasias do Colo/cirurgia , Medicaid/organização & administração , Adulto , Quimioterapia Adjuvante , Neoplasias do Colo/patologia , Detecção Precoce de Câncer , Feminino , Política de Saúde , Acesso aos Serviços de Saúde , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Metástase Neoplásica , Estadiamento de Neoplasias , Cuidados Paliativos , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos
9.
Ann Surg ; 2020 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-32773624

RESUMO

OBJECTIVE: The aim of the study was to quantify the risk of incarceration of incisional hernias. BACKGROUND: Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown. METHODS: A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration. RESULTS: Among 30,998 patients with an incisional hernia (mean age 58.1 ±â€Š15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively. CONCLUSIONS: Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.

10.
J Trauma Acute Care Surg ; 89(1): 246-253, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32195996

RESUMO

BACKGROUND: There are well-known disparities for patients injured in rural setting versus urban setting. Many cite access to care; however, the mechanisms are not defined. One potential factor is differences in field triage. Our objective was to evaluate differences in prehospital undertriage (UT) in rural setting versus urban settings. METHODS: Adult patients in the Pennsylvania Trauma Outcomes Study (PTOS) registry 2000 to 2017 were included. Rural/urban setting was defined by county according to the Pennsylvania Trauma Systems Foundation. Rural/urban classification was performed for patients and centers. Undertriage was defined as patients meeting physiologic or anatomic triage criteria from the National Field Triage Guidelines who were not initially transported to a Level I or Level II trauma center. Logistic regression determined the association between UT and rural/urban setting, adjusting for transport distance and prehospital time. Models were expanded to evaluate the effect of individual triage criteria, trauma center setting, and transport mode on UT. RESULTS: There were 453,112 patients included (26% rural). Undertriage was higher in rural patients (8.6% vs. 3.4%, p < 0.01). Rural setting was associated with UT after adjusting for distance and prehospital time (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.82-6.78; p < 0.01). Different triage criteria were associated with UT in rural/urban settings. Rural setting was associated with UT for patients transferred to an urban center (OR, 3.32; 95% CI, 1.75-6.25; p < 0.01), but not a rural center (OR, 0.68; 95% CI, 0.08-5.53; p = 0.72). Rural setting was associated with UT for ground (OR, 5.01; 95% CI, 2.65-9.46; p < 0.01) but not air transport (OR, 1.18; 95% CI, 0.54-2.55; p = 0.68). CONCLUSION: Undertriage is more common in rural settings. Specific triage criteria are associated with UT in rural settings. Lack of a rural trauma center requiring transfer to an urban center is a risk factor for UT of rural patients. Air medical transport mitigated the risk of UT in rural patients. Provider and system interventions may help reduce UT in rural settings. LEVEL OF EVIDENCE: Care Management, Level IV.


Assuntos
Disparidades em Assistência à Saúde , Triagem/normas , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Saúde da População Rural , Centros de Traumatologia , Saúde da População Urbana
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