Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 79
Filtrar
1.
Artigo em Inglês | MEDLINE | ID: mdl-35293375

RESUMO

BACKGROUND: A growing body of literature suggests the persistence of a counterproductive triage-pattern wherein uninsured adults with major-injuries presenting to NTCs are more likely than insured adults to be transferred. Geographic differences are frequently blamed. The objective of this study was to explore geography's influence on variations in insurance transfer-patterns, asking whether differences in distance and travel-time by road from non-trauma centers (NTCs) to the nearest level 1 or 2 trauma center alter the effect. As a secondary objective, differences in neighborhood socioeconomic disadvantage were also assessed. METHODS: Adults (16-64 years) with major-injuries (ISS >15) presenting to NTC EDs were abstracted from 2007-2014 state inpatient/ED claims. Differences in the risk-adjusted odds of admission-vs-transfer were compared using mixed-effect hierarchical logistic-regression and spatial-analysis. RESULTS: A total of 48,283 adults presenting to 492 NTC EDs were included. Among them, risk-adjusted admission differences based on insurance-status exist (e.g. private-vs-uninsured OR[95%CI]: 1.60[1.45-1.76]). Spatial-analysis revealed significant geographic-variation (p-value<0.001). However, in contrast to expectations, the largest insurance-based discrepancies were seen in less disadvantaged NTCs located closer to larger trauma centers. Stratified analyses comparing the closest-vs-furthest distance, shortest-vs-longest travel-time, and least-vs-most deprived populations agreed, as did sensitivity analyses restricting uninsured transfer patients to those who remained uninsured-vs-subsequently became insured. CONCLUSION: Adults with major-injuries presenting to NTCs were less likely to be transferred if insured. The trend persisted after accounting for differences in access-to-care, revealing that while significant geographic-variation in the phenomenon exists, geography alone does not explain the issue. Taken together, the findings suggest that additional and potentially subjective elements to insurance-based triage disparities at NTCs are likely to exist. LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level III.

2.
J Surg Res ; 273: 192-200, 2022 05.
Artigo em Inglês | MEDLINE | ID: mdl-35092878

RESUMO

INTRODUCTION: Alcohol use remains a significant contributing factor in traumatic injuries in the United States, resulting in substantial patient morbidity and societal cost. Because of this, the American College of Surgeons Verification, Review, and Consultation Program requires the screening of 80% of trauma admissions. Multiple studies suggest that patients who use alcohol are subject to stigma by health care providers and may ultimately face legal and financial ramifications of a positive alcohol screening test. There is also evidence that sociodemographic factors may dictate drug and alcohol screening patterns among patients. Because this screening target is often not uniformly achieved among all patients presenting with injury, we sought to investigate whether there are any discrepancies in screening across sociodemographic groups. METHODS: We investigated the Trauma Quality Program Participant User File for all trauma cases admitted during 2017 and compared the rates of the serum alcohol screening test across different demographic factors, including race and ethnicity. We then performed an adjusted multivariable logistic regression to determine the odds ratio (OR) for receiving a test based on these demographic factors adjusted for hospital and clinical factors. RESULTS: There were 729,174 traumas included in the study. Of this group, 345,315 (47.4%) were screened with a serum alcohol test. Screening rates varied by injury mechanism and were highest among motorcycle crashes (66.0% of patients screened) and lowest among falls (32.8% of patients screened). Overall, Asian and Pacific Islander (52.5% screened), Black (57.7% screened), and other race (58.4% screened) had higher rates of alcohol screening than White patients (43.7% screened, P < 0.001). Similarly, Hispanic patients were screened at higher rates than non-Hispanic patients (56.4% screening versus 46.2% screening, P < 0.001). These differences persisted across nearly all injury categories. In multivariable logistic regression, Asian and Pacific Islanders were associated with the highest odds of being screened (OR 1.34, P < 0.001) followed by other race (OR 1.25, P < 0.001) in comparison to White patients. CONCLUSIONS: There are consistent and significant differences in alcohol screening rates across race and ethnicity, despite accounting for injury mechanism and comorbidities.


Assuntos
Hospitalização , Humanos , Estados Unidos
4.
Surgery ; 171(2): 305-311, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34332782

RESUMO

BACKGROUND: Laparoscopy is superior to open surgery for elective colectomy, but its role in emergency colectomy remains unclear. Previous studies were small and limited by confounding because surgeons may have selected lower-risk patients for laparoscopy. We therefore studied the effect of attempting laparoscopy for emergency colectomies while adjusting for confounding using multiple techniques in a large, nationwide registry. METHODS: Using National Surgical Quality Improvement Program data, we identified emergency colectomy cases from 2014 to 2018. We first compared outcomes between patients who underwent laparoscopic versus open surgery, while adjusting for baseline variables using both propensity scores and regression. Next, we performed a negative control exposure analysis. By assuming that the group that converted to open did not benefit from the attempt at laparoscopy, we used the observed benefit to bound the effect of unmeasured confounding. RESULTS: Of 21,453 patients meeting criteria, 3,867 underwent laparoscopy, of which 1,375 converted to open. In both inverse probability of treatment weighting and regression analyses, attempting laparoscopy was associated with improved 30-day mortality, overall morbidity, anastomotic leak, surgical site infection, postoperative septic shock, and length of hospital stay compared with open surgery. These effects were consistent with the lower bounds computed from the converted group. CONCLUSION: Laparoscopic surgery for colorectal emergencies appears to improve outcomes compared with open surgery. The benefit is observed even after adjusting for both measured and unmeasured confounding using multiple statistical approaches, thus suggesting a benefit not attributable to patient selection.


Assuntos
Colectomia/métodos , Laparoscopia/métodos , Adulto , Idoso , Colectomia/efeitos adversos , Fatores de Confusão Epidemiológicos , Emergências , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Pontuação de Propensão , Análise de Regressão , Estudos Retrospectivos , Resultado do Tratamento
5.
J Trauma Acute Care Surg ; 92(4): 664-674, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-34936593

RESUMO

BACKGROUND: Grading systems for acute cholecystitis are essential to compare outcomes, improve quality, and advance research. The American Association for the Surgery of Trauma (AAST) grading system for acute cholecystitis was only moderately discriminant when predicting multiple outcomes and underperformed the Tokyo guidelines and Parkland grade. We hypothesized that through additional expert consensus, the predictive capacity of the AAST anatomic grading system could be improved. METHODS: A modified Delphi approach was used to revise the AAST grading system. Changes were made to improve distribution of patients across grades, and additional key clinical variables were introduced. The revised version was assessed using prospectively collected data from an AAST multicenter study. Patient distribution across grades was assessed, and the revised grading system was evaluated based on predictive capacity using area under receiver operating characteristic curves for conversion from laparoscopic to an open procedure, use of a surgical "bail-out" procedure, bile leak, major complications, and discharge home. A preoperative AAST grade was defined based on preoperative, clinical, and radiologic data, and the Parkland grade was also substituted for the operative component of the AAST grade. RESULTS: Using prospectively collected data on 861 patients with acute cholecystitis the revised version of the AAST grade has an improved distribution across all grades, both the overall grade and across each subscale. A higher AAST grade predicted each of the outcomes assessed (all p ≤ 0.01). The revised AAST grade outperformed the original AAST grade for predicting operative outcomes and discharge disposition. Despite this improvement, the AAST grade did not outperform the Parkland grade or the Emergency Surgery Score. CONCLUSION: The revised AAST grade and the preoperative AAST grade demonstrated improved discrimination; however, a purely anatomic grade based on chart review is unlikely to predict outcomes without addition of physiologic variables. Follow-up validation will be necessary. LEVEL OF EVIDENCE: Diagnostic Test or Criteria, Level IV.


Assuntos
Colecistite Aguda , Laparoscopia , Colecistite Aguda/diagnóstico , Colecistite Aguda/cirurgia , Humanos , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos
6.
J Surg Res ; 268: 712-719, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34487964

RESUMO

BACKGROUND: We aimed to examine the clinical value of serial MRSA surveillance cultures to rule out a MRSA diagnosis on subsequent cultures during a patient's surgical intensive care unit (SICU) admission. MATERIAL AND METHODS: We performed a retrospective cohort study to evaluate patients who received a MRSA surveillance culture at admission to the SICU (n = 6,915) and collected and assessed all patient cultures for MRSA positivity during their admission. The primary objective was to evaluate the transition from a MRSA negative surveillance on admission to MRSA positive on any subsequent culture during a patient's SICU stay. Percent of MRSA positive cultures by type following MRSA negative surveillance cultures was further analyzed. MEASUREMENTS AND MAIN RESULTS: 6,303 patients received MRSA nasal surveillance cultures at admission with 21,597 clinical cultures and 7,269 MRSA surveillance cultures. Of the 6,163 patients with an initial negative, 53 patients (0.87%) transitioned to MRSA positive. Of the 139 patients with an initial positive, 30 (21.6%) had subsequent MRSA positive cultures. Individuals who had an initial MRSA surveillance positive status on admission predicted MRSA positivity rates for cultures in qualitative lower respiratory cultures (64.3% versus. 3.1%), superficial wound (60.0% versus 1.6%), deep wound (39.0% versus 0.8%), tissue culture (26.3% versus 0.6%), and body fluid (20.8% versus 0.7%) cultures when compared to MRSA negative patients on admission. CONCLUSION: Following MRSA negative nasal surveillance cultures patients showed low likelihood of MRSA infection suggesting empiric anti-MRSA treatment is unnecessary for specific patient populations. SICU patient's MRSA status at admission should guide empiric anti-MRSA therapy.


Assuntos
Infecção Hospitalar , Staphylococcus aureus Resistente à Meticilina , Infecções Estafilocócicas , Cuidados Críticos , Infecção Hospitalar/tratamento farmacológico , Humanos , Unidades de Terapia Intensiva , Estudos Retrospectivos , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/epidemiologia
9.
J Trauma Acute Care Surg ; 91(5): 790-797, 2021 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-33951027

RESUMO

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being increasingly adopted to manage noncompressible torso hemorrhage, but a recent analysis of the 2015 to 2016 Trauma Quality Improvement Project (TQIP) data set showed that placement of REBOA was associated with higher rates of death, lower extremity amputation, and acute kidney injury (AKI). We expand this analysis by including the 2017 data set, quantifying the potential role of residual confounding, and distinguishing between traumatic and ischemic lower extremity amputation. METHODS: This retrospective study used the 2015 to 2017 TQIP database and included patients older than 18 years, with signs of life on arrival, who had no aortic injury and were not transferred. Resuscitative endovascular balloon occlusions of the aorta placed after 2 hours were excluded. We adjusted for baseline variables using propensity scores with inverse probability of treatment weighting. A sensitivity analysis was then conducted to determine the strength of an unmeasured confounder (e.g., unmeasured shock severity/response to resuscitation) that could explain the effect on mortality. Finally, lower extremity injury patterns of patients undergoing REBOA were inspected to distinguish amputation indicated for traumatic injury from complications of REBOA placement. RESULTS: Of 1,392,482 patients meeting the inclusion criteria, 187 underwent REBOA. After inverse probability of treatment weighting, all covariates were balanced. The risk difference for mortality was 0.21 (0.14-0.29) and for AKI was 0.041 (-0.007 to 0.089). For the mortality effect to be explained by an unmeasured confounder, it would need to be stronger than any observed in terms of its relationship with mortality and with REBOA placement. Eleven REBOA patients underwent lower extremity amputation; however, they all suffered severe traumatic injury to the lower extremity. CONCLUSION: There is no evidence in the TQIP data set to suggest that REBOA causes amputation, and the evidence for its effect on AKI is considerably weaker than previously reported. The increased mortality effect of REBOA is confirmed and could only be nullified by a potent confounder. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.


Assuntos
Oclusão com Balão/mortalidade , Procedimentos Endovasculares/mortalidade , Hemorragia/mortalidade , Ressuscitação/mortalidade , Traumatismos Torácicos/mortalidade , Adulto , Idoso , Aorta , Oclusão com Balão/métodos , Fatores de Confusão Epidemiológicos , Bases de Dados Factuais , Procedimentos Endovasculares/métodos , Feminino , Hemorragia/etiologia , Hemorragia/cirurgia , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Ressuscitação/métodos , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/cirurgia , Adulto Jovem
10.
J Surg Res ; 266: 1-5, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33975026

RESUMO

INTRODUCTION: Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients. RESULTS: A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.


Assuntos
Traumatismos Abdominais/mortalidade , Anticoagulantes/efeitos adversos , Hemorragia/etiologia , Baço/lesões , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/mortalidade , Hemorragia/terapia , Humanos , Escala de Gravidade do Ferimento , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
11.
JAMA Surg ; 156(5): 472-478, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33688932

RESUMO

Importance: Previous studies comparing emergency surgery outcomes with surgeon experience have been small or used administrative databases without controlling for patient physiology or operative complexity. Objective: To evaluate the association of acute care surgeon experience with patient morbidity and mortality after emergency surgical procedures. Design, Setting, and Participants: This cohort study evaluated the association of surgeon experience with emergency surgery outcomes at 5 US academic level 1 trauma centers where the same surgeons provided emergency general surgical care. A total of 772 patients who presented with a traumatic injury and required an emergency surgical procedure or who presented with or developed a condition requiring an emergency general surgical intervention were operated on by 1 of 56 acute care surgeons. Surgeon groups were divided by experience of less than 6 years (early career), 6 to 10 years (early midcareer), 11 to 30 years (late midcareer), and 30 years or more (late career) from the end of training. Surgeons with less than 3 years of experience were also compared with the entire cohort. Hierarchical logistic regression models were constructed controlling for Emergency Surgery Score, case complexity, preoperative transfusion, and trauma or emergency general surgery. Data were collected from May 2015 to July 2017 and analyzed from February to May 2020. Main Outcomes and Measures: Mortality, complications, length of stay, blood loss, and unplanned return to the operating room. Results: Of 772 included patients, 469 (60.8%) were male, and the mean (SD) age was 50.1 (20.0) years. Of 772 operations, 618 were by surgeons with less than 10 years of experience. Early- and late-midcareer surgeons generally operated on older patients and patients with more septic shock, acute kidney failure, and higher Emergency Surgery Scores. Patient mortality, complications, postoperative transfusion, organ-space surgical site infection, and length of stay were similar between surgeon groups. Patients operated on by early-career surgeons had higher rates of unplanned return to the operating room compared with those operated on by early-midcareer surgeons (odds ratio [OR], 0.66; 95% CI, 0.40-1.09), late-midcareer surgeons (OR, 0.34; 95% CI, 0.13-0.90), and late-career surgeons (OR, 1.11; 95% CI, 0.45-2.75). Patients operated on by surgeons with less than 3 years of experience had similar mortality compared with the rest of the cohort (OR, 1.97; 95% CI, 0.85-4.57) but higher rates of complications (OR, 2.07; 95% CI, 1.05-4.07). Conclusions and Relevance: In this study, experienced surgeons generally operated on older patients with more septic shock and kidney failure without affecting risk-adjusted mortality. Increased complications and unplanned return to the operating room may improve with experience. Early-career surgeons' outcomes may be improved if they are supported while experience is garnered.


Assuntos
Competência Clínica , Hemorragia Pós-Operatória/etiologia , Cirurgiões/normas , Ferimentos e Lesões/cirurgia , Injúria Renal Aguda/complicações , Adulto , Idoso , Transfusão de Sangue , Emergências , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Reoperação/estatística & dados numéricos , Fatores de Risco , Choque Séptico/complicações , Infecção da Ferida Cirúrgica/etiologia , Taxa de Sobrevida , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento , Estados Unidos , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade , Adulto Jovem
12.
J Surg Res ; 260: 369-376, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33388533

RESUMO

BACKGROUND: Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). MATERIALS AND METHODS: This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. RESULTS: Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001). CONCLUSIONS: Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.


Assuntos
Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea/uso terapêutico , Coagulantes/uso terapêutico , Hemorragia Intracraniana Traumática/terapia , Plasma , Padrões de Prática Médica/tendências , Varfarina/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Fatores de Coagulação Sanguínea/economia , Coagulantes/economia , Connecticut , Feminino , Seguimentos , Custos Hospitalares/estatística & dados numéricos , Humanos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/economia , Hemorragia Intracraniana Traumática/mortalidade , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Padrões de Prática Médica/economia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Centros de Traumatologia/economia , Resultado do Tratamento
13.
J Trauma Acute Care Surg ; 90(1): 87-96, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33332782

RESUMO

BACKGROUND: The American Association for the Surgery of Trauma (AAST) patient assessment committee has created grading systems for emergency general surgery diseases to assist with clinical decision making and risk adjustment during research. Single-institution studies have validated the cholecystitis grading system as associated with patient outcomes. Our aim was to validate the grading system in a multi-institutional fashion and compare it with the Parkland grade and Tokyo Guidelines for acute cholecystitis. METHODS: Patients presenting with acute cholecystitis to 1 of 8 institutions were enrolled. Discrete data to assign the AAST grade were collected. The Parkland grade was collected prospectively from the operative surgeon from four institutions. Parkland grade, Tokyo Guidelines, AAST grade, and the AAST preoperative grade (clinical and imaging subscales) were compared using linear and logistic regression to the need for surgical "bailout" (subtotal or fenestrated cholecystectomy, or cholecystostomy), conversion to open, surgical complications (bile leak, surgical site infection, bile duct injury), all complications, and operative time. RESULTS: Of 861 patients, 781 underwent cholecystectomy. Mean (SD) age was 51.1 (18.6), and 62.7% were female. There were six deaths. Median AAST grade was 2 (interquartile range [IQR], 1-2), and median Parkland grade was 3 (interquartile range [IQR], 2-4). Median AAST clinical and imaging grades were 2 (IQR, 2-2) and 1 (IQR, 0-1), respectively. Higher grades were associated with longer operative times, and worse outcomes although few were significant. The Parkland grade outperformed the AAST grade based on area under the receiver operating characteristic curve. CONCLUSION: The AAST cholecystitis grading schema has modest discriminatory power similar to the Tokyo Guidelines, but generally lower than the Parkland grade, and should be modified before widespread use. LEVEL OF EVIDENCE: Diagnostic study, level IV.


Assuntos
Colecistite Aguda/diagnóstico , Índice de Gravidade de Doença , Idoso , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia , Colecistite Aguda/patologia , Colecistite Aguda/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Medição de Risco , Resultado do Tratamento , Estados Unidos
14.
Ann Surg ; 272(4): 548-553, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32932304

RESUMO

OBJECTIVE: Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition. METHODS: Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types. RESULTS: A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09-1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63-9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19-12.29). CONCLUSIONS: Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Cobertura do Seguro , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Humanos , Medicaid , Estados Unidos
15.
Ann Surg ; 272(2): 288-303, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675542

RESUMO

OBJECTIVE: This study aimed to answer 2 questions: first, to what degree does hospital operative volume affect mortality for adult patients undergoing 1 of 10 common emergency general surgery (EGS) operations? Second, at what hospital operative volume threshold will nearly all patients undergoing an emergency operation realize the average mortality risk? BACKGROUND: Nontrauma surgical emergencies are an underappreciated public health crisis in the United States; redefining where such emergencies are managed may improve outcomes. The field of trauma surgery established regionalized systems of care in part because studies demonstrated a clear relationship between hospital volume and survival for traumatic emergencies. Such a relationship has not been well-studied for nontrauma surgical emergencies. METHODS: Retrospective cohort study of all acute care hospitals in California performing nontrauma surgical emergencies. We employed a novel use of an ecological analysis with beta regression to investigate the relationship between hospital operative volume and mortality. RESULTS: A total of 425 acute care hospitals in California performed 165,123 EGS operations. Risk-adjusted mortality significantly decreased as volume increased for all 10 EGS operations (P < 0.001 for each); the relative magnitude of this inverse relationship differed substantially by procedure. Hospital operative volume thresholds were defined and varied by operation: from 75 cases over 2 years for cholecystectomy to 7 cases for umbilical hernia repair. CONCLUSIONS: Survival rates for nontrauma surgical emergencies were improved when operations were performed at higher-volume hospitals. The use of ecological analysis is widely applicable to the field of surgical outcomes research.

16.
J Trauma Acute Care Surg ; 89(5): 947-954, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32467465

RESUMO

BACKGROUND: Geriatric patients with rib fractures are at risk for developing complications and are often admitted to a higher level of care (intensive care units [ICUs]) based on existing guidelines. Forced vital capacity (FVC) has been shown to correlate with outcomes in patients with rib fractures. Complete spirometry may quantify pulmonary capacity, predict outcome, and potentially assist with admission triage decisions. METHODS: We prospectively enrolled 86 patients, 60 years or older with three or more isolated rib fractures presenting after injury. After informed consent, patients were assessed with respect to pain (visual analog scale), grip strength, FVC, forced expiratory volume 1 second (FEV1), and negative inspiratory force on hospital days 1, 2, and 3. Outcomes included discharge disposition, length of stay (LOS), pneumonia, intubation, and unplanned ICU admission. RESULTS: Mean age was 77.4 (SD, 10.2) and 43 (50.0%) were female. Forty-five patients (55.6%) were discharged home, median LOS was 4 days (interquartile range, 3-7). Pneumonias (2), unplanned ICU admissions (3), and intubation (1) were infrequent. Spirometry measures including FVC, FEV1, and grip strength predicted discharge to home and FEV1, and pain level on day 1 moderately correlated with the LOS. Within each subject, FVC, FEV1, and negative inspiratory force did not change for 3 days despite pain at rest and pain after spirometry improving from day 1 to 3 (p = 0.002, p < 0.001 respectively). Change in pain also did not predict outcomes and pain level was not associated with respiratory volumes on any of the 3 days. After adjustment for confounders, FEV1 remained a significant predictor of discharge home (odds ratio, 1.03; 95% confidence interval, 1.01-1.06) and LOS (p = 0.001). CONCLUSION: Spirometry measurements early in the hospital stay predict ultimate discharge home, and this may allow immediate or early discharge. The impact of pain control on pulmonary function requires further study. LEVEL OF EVIDENCE: Diagnostic test, level IV.


Assuntos
Medição da Dor/estatística & dados numéricos , Dor/diagnóstico , Fraturas das Costelas/terapia , Espirometria/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Força da Mão , Hospitais de Reabilitação/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Dor/etiologia , Manejo da Dor/métodos , Alta do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Valor Preditivo dos Testes , Estudos Prospectivos , Fraturas das Costelas/complicações , Fraturas das Costelas/mortalidade , Centros de Traumatologia/estatística & dados numéricos , Resultado do Tratamento
18.
Trauma Surg Acute Care Open ; 5(1): e000371, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32154373

RESUMO

BACKGROUND: Transfusion of red blood cells (RBC) increases morbidity and mortality, and emergency general surgery (EGS) cases have increased risk for transfusion and complication given case complexity and patient acuity. Transfusion reduction strategies and blood-conservation technology have been developed to decrease transfusions. This study explores whether transfusion rates in EGS have decreased as these new strategies have been implemented. METHODS: This is a retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) data from three academic medical centers. Operations performed by general surgeons on adults (aged ≥18 years) were selected. Data were analyzed from two periods: 2011-2013 and 2014-2016. Cases were grouped by the first four digits of the primary procedure Current Procedural Terminology code. Transfusion was defined as any RBC transfusion during or within 72 hours following the operation. Composite morbidity was defined as any NSQIP complication within 30 days following the operation. RESULTS: Overall general surgery transfusion rates decreased from 6.4% to 4.8% from period 1 to period 2 (emergent: 16.6%-11.5%; non-emergent 4.9%-3.7%; Fisher's exact p values <0.001). Among patients transfused, the number of units received decreased slightly (median 2 U (IQR 2-3) to median 2 U (IQR 1-3), Mann-Whitney U test p=0.005). Morbidity decreased (overall: 13.8%-12.3%, p=0.001; emergent: 26.3%-20.6%, p<0.001) while mortality did not change. DISCUSSION: Rates of RBC transfusion decreased in both emergent and non-emergent cases. Efforts to reduce transfusion may have been successful in the EGS population. Morbidity improved over the time periods while mortality was unchanged. LEVEL OF EVIDENCE: Level III.

19.
J Am Coll Surg ; 230(6): 966-973.e10, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32032720

RESUMO

BACKGROUND: The American College of Surgeons maintains that surgical care in the US has not reached optimal safety and quality. This can be driven partially by higher-risk, emergency operations in geriatric patients. We therefore sought to answer 2 questions: First, to what degree does standardized postoperative mortality vary in hospitals performing nonelective operations in geriatric patients? Second, can the differences in hospital-based mortality be explained by patient-, operative-, and hospital-level characteristics among outlier institutions? STUDY DESIGN: Patients 65 years and older who underwent 1 of 8 common emergency general surgery operations were identified using the California State Inpatient Database (2010 to 2011). Expected mortality was obtained from hierarchical, Bayesian mixed-effects logistic regression models. A risk-adjusted hospital-level standardized mortality ratio (SMR) was calculated from observed-to-expected in-hospital deaths. "Outlier" hospitals had an SMR 80% CI that did not cross the mean SMR of 1.0. High-mortality (SMR >1.0) and low-mortality (SMR <1.0) outliers were compared. RESULTS: We included 24,207 patients from 107 hospitals. SMRs varied widely, from 2.3 (highest) to 0.3 (lowest). Eleven hospitals (10.3%) were poor-performing high-SMR outliers, and 10 hospitals (9.3%) were exceptional-performing low-SMR outliers. SMR was 3 times worse in the high-SMR compared with the low-SMR group (1.7 vs 0.6; p < 0.001). Patient-, operation-, and hospital-level characteristics were equivalent among outlier-hospitals. CONCLUSIONS: Significant hospital variation exists in standardized mortality after common general surgery operations done emergently in older patients. More than 10% of institutions have substantial excess mortality. These findings confirm that the safety of emergency operation in geriatric patients can be significantly improved by decreasing the wide variability in mortality outcomes.


Assuntos
Serviço Hospitalar de Emergência , Cirurgia Geral , Serviços de Saúde para Idosos , Complicações Pós-Operatórias/epidemiologia , Qualidade da Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , California , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Masculino , Estudos Retrospectivos
20.
J Trauma Acute Care Surg ; 88(3): 366-371, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31804419

RESUMO

BACKGROUND: It has been theorized that a tiered, regionalized system of care for emergency general surgery (EGS) patients-akin to regional trauma systems-would translate into significant survival benefits. Yet data to support this supposition are lacking. The aim of this study was to determine the potential number of lives that could be saved by regionalizing EGS care to higher-volume, lower-mortality EGS institutions. METHODS: Adult patients who underwent one of 10 common EGS operations were identified in the California Inpatient Database (2010-2011). An algorithm was constructed that "closed" lower-volume, higher-mortality hospitals and referred those patients to higher-volume, lower-mortality institutions ("closure" based on hospital EGS volume-threshold that optimized to 95% probability of survival). Primary outcome was the number of lives saved. Fifty thousand regionalization simulations were completed (5,000 for each operation) employing a bootstrap resampling method to proportionally redistribute patients. Estimates of expected deaths at the higher-volume hospitals were recalculated for every bootstrapped sample. RESULTS: Of the 165,123 patients who underwent EGS operations over the 2-year period, 17,655 (10.7%) were regionalized to a higher-volume hospital. On average, 128 (48.8%) of lower-volume hospitals were "closed," ranging from 68 (22.0%) hospital closures for appendectomy to 205 (73.2%) for small bowel resection. The simulations demonstrated that EGS regionalization would prevent 9.7% of risk-adjusted EGS deaths, significantly saving lives for every EGS operation: from 30.8 (6.5%) deaths prevented for appendectomy to 122.8 (7.9%) for colectomy. Regionalization prevented 4.6 deaths per 100 EGS patient-transfers, ranging from 1.3 for appendectomy to 8.0 for umbilical hernia repair. CONCLUSION: This simulation study provides important new insight into the concept of EGS regionalization, suggesting that 1 in 10 risk-adjusted deaths could be prevented by a structured system of EGS care. Future work should expand upon these findings using more complex discrete-event simulation models. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Planejamento Hospitalar/organização & administração , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Modelos Logísticos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adulto , Algoritmos , California , Serviço Hospitalar de Emergência/estatística & dados numéricos , Fechamento de Instituições de Saúde , Mortalidade Hospitalar , Planejamento Hospitalar/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos , Humanos , Encaminhamento e Consulta
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...