Hemodynamic Deterioration of Trauma Patients Undergoing Interhospital Transfer.

INTRODUCTION: Organized trauma systems reduce morbidity and mortality after serious injury. Rapid transport to high-level trauma centers is ideal, but not always feasible. Thus, interhospital transfers are an important component of trauma systems. However, transferring a seriously injured patient carries the risk of worsening condition before reaching definitive care. In this study, we evaluated characteristics and outcomes of patients whose hemodynamic status worsened during the transfer process. METHODS: We conducted a retrospective cohort study using data from the Pennsylvania Trauma Outcomes Study database from 2011 to 2018. Patients were included if they had a heart rate ≤ 100 and systolic blood pressure ≥ 100 at presentation to the referring hospital and were transferred within 24 h. We defined hemodynamic deterioration (HDD) as admitting heart rate > 100 or systolic blood pressure < 100 at the receiving center. We compared demographics, mechanism of injury, injury severity, management, and outcomes between patients with and without HDD using descriptive statistics and multivariable regression analysis. RESULTS: Of 52,919 included patients, 5331 (10.1%) had HDD. HDD patients were more often moderately-severely injured (injury severity score 9-15; 40.4% versus 39.4%, P < 0.001) and injured via motor vehicle collision (23.2% versus 16.6%, P < 0.001) or gunshot wound (2.1% versus 1.3%, P < 0.001). HDD patients more often had extremity or torso injuries and after transfer were more likely to be transferred to the intensive care unit (35% versus 28.5%, P < 0.001), go directly to surgery (8.4% versus 5.9%, P < 0.001), or interventional radiology (0.8% versus 0.3%, P < 0.001). Overall mortality in the HDD group was 4.9% versus 2.1% in the group who remained stable. These results were confirmed using multivariable analysis. CONCLUSIONS: Interhospital transfers are essential in trauma, but one in 10 transferred patients deteriorated hemodynamically in that process. This high-risk component of the trauma system requires close attention to the important aspects of transfer such as patient selection, pretransfer management/stabilization, and communication between facilities.

Patient Experiences of Acute and Postacute Care After Trauma.

INTRODUCTION: Traumatic injury can transform a healthy, independent individual into a patient with complex health needs. Little is known about how injured patients understand their health and healthcare needs during postacute recovery, limiting our ability to optimize care. This multiple-methods study explored injured patients' experiences of care up to 30 days after discharge. METHODS: Injured adults admitted to an urban, Level I trauma center August 1, 2019-November 30, 2020 were sampled purposively to balance blunt and penetrating injuries. Patient experience and health status were assessed at baseline and 30 days postdischarge using the Quality of Trauma Care Patient-Reported Experience Measure. Fifteen qualitative interviews were conducted with a purposive subset and analyzed using qualitative content analysis. RESULTS: Of 67 participants (76% male, 73% Black, 51% penetrating, median age 34 years), 37 completed follow-up surveys. Quality of acute care was rated 9-10/10 by 81% of the sample for acute and 65% for postacute care (P = 0.09). Thirty percent described fair or poor mental health, but only mental health concerns were addressed for only 2/3. Pain control was inadequate in 31% at baseline and for 46% at follow-up (P = 0.09). Qualitative analysis revealed general satisfaction with acute care but challenges in recovery with unmet needs for communication and care coordination. CONCLUSIONS: Trauma patients appreciated the quality of their acute care experiences but identified opportunities for improvement in prognostic communication, pain management, and mental health support. Unmet mental and physical care needs persist at least 1 month after hospital discharge and reinforce the need for interventions that optimize postacute trauma care.

Economic influences on population health in the United States: Toward policymaking driven by data and evidence.

Atheendar S. Venkataramani and colleagues discuss economic factors and population health in the United States.

Access to Guideline Concordant Care for Node-Positive Non-Small Cell Lung Cancer in the United States.

BACKGROUND: This study sought to determine whether seeking care at multiple Commission on Cancer (CoC) hospitals is associated with different rates of receiving guideline-concordant care (GCC) among patients with non-small cell lung cancer (NSCLC). METHODS: The National Cancer Database was queried for the years 2004 to 2018 for patients with margin-negative pT1 to pT3 N1 to N2 M0 noncarcinoid NSCLC without neoadjuvant therapy. GCC was defined as chemotherapy for pN1 disease and as chemotherapy with or without radiation for pN2 disease. Patients who received care at >1 facility were examined separately. Factors previously associated with barriers to care were compared between groups. Kaplan-Meier analysis with log-rank tests analyzed 5-year overall survival (OS). Propensity score matching was performed to compare the effect sizes of race, insurance status, and income. RESULTS: In total 44,531 patients met inclusion criteria, 11,980 (26.9%) of whom sought care at >1 CoC institution. Among patients with pN1 disease, 5565 (76.7%) received GCC if they visited >1 facility vs 13,995 (68.5%) patients who sought care at 1 facility (P < .001). For patients with pN2 disease, 3991 (84.4%) received GCC if they visited >1 facility vs9369 (77.4%) patients receiving care at 1 facility (P < .001). Visiting >1 facility was associated with higher OS at 5 years (4784 [54.35%] vs 10,215 [45.62%]; P < .001). CONCLUSIONS: Visiting >1 CoC institution is associated with higher rates of GCC for individuals with pN1 to pN2 lung cancer. Patients who received care at >1 facility had higher OS at 5 years. Further study is warranted to identify factors associated with the ability of patients to seek care at multiple facilities.

Wedge Resection Outcomes: A Comparison of Video-Assisted and Robot-Assisted Wedge Resections.

BACKGROUND: Quality of oncologic resection for early-stage non-small cell lung cancer (NSCLC) may differ by surgical approach. Minimally invasive surgery has become the standard for surgical treatment of NSCLC. Our study compares quality of wedge resection by video-assisted thoracoscopic surgery (VATS) vs robotic video-assisted thoracoscopic surgery (RVATS). We hypothesized that RVATS would result in higher quality resections and improved patient outcomes. METHODS: A retrospective cohort analysis was completed using the National Cancer Database for patients with clinical stage 1 NSCLC with tumor size ≤2 cm who underwent a minimally invasive surgery wedge resection from 2010 to 2019. Wedge resections approached with RVATS were compared with VATS. A 1:1 propensity score matched analysis was performed. RESULTS: The cohort included 16,559 patients; 80.4% (13,406) received VATS and 18.9% (3153) received RVATS. Compared with RVATS, a VATS approach was associated with a lower likelihood of lymph nodes being examined (59.0% vs 75.2%; P < .001), fewer nodes dissected (median, 4 vs 5; P < .001), and less adjuvant systemic therapy administered (1.3% vs 2.2%; P < .001). Propensity score matching resulted in 2590 balanced pairs. Statistical significance was maintained for likelihood of lymph nodes examined, number of nodes dissected, and adjuvant systemic therapy administered. There was no significant difference in nodal upstaging after propensity score matching (3.7% vs 4.3%; P = .37). CONCLUSIONS: Compared with the VATS approach, wedge resections by RVATS for early-stage NSCLC were more likely to be associated with increased lymph nodes resected. These data may support increased use of RVATS for wedge resections.

Factors Associated With Margin Positivity After Lung Resection Surgery.

INTRODUCTION: The purpose of this study is to utilize a representative national sample to investigate the factors associated with margin positivity after attempted surgical resection. Given the changes in surgical approaches to lung cancer for the last 10 years, margin positivity and outcomes between robotic, video assisted thoracoscopic surgery (VATS) and open surgical resections may vary. METHODS: This retrospective cohort study utilized the National Cancer Database. Patients with non-small-cell lung cancer, 18 or older and who had a surgical lung resection between 2010 and 2019 were included. Demographic data, along with patient-level clinical variables were extracted. Patient-level outcome variables including 30-day, 90-day mortality and readmission rates were analyzed. Univariable and multivariable logistic regression was utilized to assess factors associated with margin positivity. RESULTS: A total of 226,884 patients were identified. Of the total cohort, 9229 had positive margins (4.2%). Patients with positive margins had statistically significant increased 30-day, 90-day mortality, as well as increased readmission rate. Older age, male sex, patients undergoing an open resection, patients who underwent a wedge resection, higher clinical stage, larger tumor size, squamous and adenosquamous histologies, and higher Charlson-Deyo Comorbidity Index were all associated with having a positive margin after resection. CONCLUSION: In conclusion, there was no difference in margin positivity when comparing robotic and VATS resection, however, open resection had increased rates of margin positivity. Increasing tumor size, clinical stage, squamous and adenosquamous histologies, male sex, and patients undergoing a wedge resection were all associated with increased rates of margin positivity.

Impact of stereotactic body radiation therapy volume on surgical patient selection, short-term survival, and long-term survival in early-stage non-small cell lung cancer.

OBJECTIVES: Stereotactic body radiation therapy (SBRT) is increasingly used to treat non-small cell lung cancer. The purpose of this study is to analyze relationships between facility SBRT utilization and surgical patient selection and survival after surgery. METHODS: Data on patients with TI/T2N0M0 lesions and treatment facility characteristics were abstracted from the National Cancer Database, 2008 to 2017. Facilities were stratified using an SBRT/surgery ratio previously associated with short-term survival benefit for patients treated surgically, and by a previously identified surgical volume threshold. Multiple regression analyses, Cox proportional-hazard regressions, and Kaplan-Meier log rank test were employed. RESULTS: In total, 182,610 patients were included. Proportion of high SBRT:surgery ratio (≥17%) facilities increased from 118 (11.5%) to 558 (48.4%) over the study period. Patients undergoing surgery at high-SBRT facilities had comparable comorbidity scores and tumor sizes to those at low-SBRT facilities, and nonclinically significant differences in age, race, and insurance status. Among low-volume surgical facilities, treatment at a high SBRT-using facility was associated with decreased 30-day mortality (1.8% vs 1.4%, P < .001) and 90-day mortality (3.3% vs 2.6%, P < .001). At high-volume surgical facilities, no difference was observed. At 5 years, a survival advantage was identified for patients undergoing resection at facilities with high surgical volumes (hazard ratio, 0.91; confidence interval, 0.90-0.93 P < .001) but not at high SBRT-utilizing facilities. CONCLUSIONS: Differences in short-term survival following resection at facilities with high-SBRT utilization may be attributable to low surgical volume facilities. Patients treated at high volume surgical facilities do not demonstrate differences in short-term or long-term survival based on facility SBRT utilization.

Intraoperative Versus Preoperative Diagnosis of Lung Cancer: Differences in Treatments and Patient Outcomes.

OBJECTIVES: Non-small cell lung cancer (NSCLC) is frequently diagnosed during surgical resection. It remains unclear if lack of preoperative tissue diagnosis influences likelihood of receipt of guideline-concordant care or postoperative outcomes. METHODS: A retrospective cohort analysis was completed utilizing the National Cancer Database for patients undergoing lung resection with clinical stage 1 NSCLC from 2004 to 2018. Diagnosis during resection was defined as zero days between diagnosis and definitive lung resection. Patients receiving neoadjuvant therapy were excluded. Subgroup analyses were completed by resection type, including wedge resection. RESULTS: The cohort included 91,328 patients, 33,517 diagnosed during definitive resection and 57,811 diagnosed preoperatively. For patients diagnosed preoperatively, median time from diagnosis to surgery was 42 days (interquartile range 28-63 days). Patients diagnosed intraoperatively had smaller median tumor size (1.7 cm vs. 2.5 cm, P < .01) and were more likely to undergo wedge resection (10,668 [31.8%] vs. 7,617 [13.2%], P < .01). Intraoperative diagnosis resulted in lower likelihood of nodal sampling (27,356 [81.9%] vs. 53,183 [92.4%], P < .01) and nodal upstaging (2,482 [9.7%] vs. 7701 [15.5%], P < .01). Amongst patients with intraoperative diagnoses, those treated via wedge resection were less likely to undergo lymph node sampling (5,515 [52.0%] vs. 5,606 [61.1%], P < .01). Amongst patients with positive lymph nodes, patients diagnosed intraoperatively were less likely to receive adjuvant therapy (1,677 [5.0%] vs. 5,669 [9.8%], P < .01). CONCLUSIONS: Preoperative tissue diagnosis of NSCLC is associated with more frequent lymph node harvest, increased rates of upstaging and receipt of adjuvant therapy. Preoperative workup may contribute to increased rates of guideline-concordant lung cancer care.

Hospital Utilization of Stereotactic Body Radiation Therapy and Rates of Surgical Refusal.

BACKGROUND: Increasingly, stereotactic body radiation therapy (SBRT) is used for patients unfit for or unwilling to undergo operation for early-stage non-small cell lung cancer. It remains unclear how SBRT utilization has influenced patient refusal of surgical resection. METHODS: A retrospective cohort analysis was completed using the National Cancer Database for patients with T1/T2 N0 M0 lesions from 2008 to 2017. Facilities were categorized into tertiles by SBRT/surgery ratio for each year of analysis. Propensity score matching was used to compare rates of surgical refusal and rates of postrefusal receipt of SBRT. Multivariable regression analysis was performed to evaluate effect size. RESULTS: The study included 129 901 patients; 63 048 were treated at low-tertile SBRT/surgery facilities, 41 674 at middle-tertile SBRT/surgery facilities, and 25 179 at high-tertile SBRT/surgery facilities. Patients refusing surgery at high SBRT/surgery facilities had fewer comorbid conditions and smaller tumors. Rates of SBRT after surgical refusal differed (low SBRT/surgery facilities, 17.2%; high SBRT/surgery facilities, 55.9%; P < .001). In a matched cohort of 76 636, surgical refusal differed (low SBRT/surgery facilities, 4.2%; high SBRT/surgery facilities, 6.0%; P < .001). On multivariable regression, treatment at a top-tertile SBRT/surgery facility was the largest risk factor for surgical refusal (odds ratio, 3.82 [3.53-4.13]; P < .001) and was most strongly associated with postrefusal receipt of SBRT (odds ratio, 6.11 [5.09-7.34]; P < .001). CONCLUSIONS: Patients treated at high SBRT-using facilities are more likely to refuse surgical resection and more likely to receive radiation therapy after surgical refusal. Further analysis is needed to better understand patient refusal of surgery in the setting of early-stage non-small cell lung cancer.

Defining risk factors for mortality after emergent hiatal hernia repair in the era of minimally invasive surgery.

BACKGROUND: Risk factors for mortality following emergent hiatal hernia (HH) repair in the era of minimally invasive surgery remain poorly defined. METHODS: Data was obtained from the National Inpatient Sample (NIS), National Readmissions Database, and National Emergency Department Sample for patients undergoing HH repair between 2010 and 2018. Univariate and multivariate logistic regression analyses reported with odds ratio (OR) and 95% confidence intervals (CI) were performed to identify factors associated mortality. RESULTS: Via the NIS, mortality rate was 2.2% (147 patients). Via the NEDS, the mortality rate was 3.6% (303 patients). On multivariate analysis, predictors of mortality included age (OR 1.05, CI: 1.04,1.07), male sex (OR 1.49, CI: 1.06,2.11), frailty (OR 2.49, CI: 1.65,3.75), open repair (OR 3.59, CI: 2.50,5.17), and congestive heart failure (OR 2.71, CI: 1.81,4.06). CONCLUSIONS: There are multiple risk factors for mortality after hiatal hernia repair. There is merit to a laparoscopic approach even in emergent settings.

Is wedge a dirty word? Demographic and facility-level variables associated with high-quality wedge resection.

Objectives: Although sublobar resections have gained traction, wedge resections vary widely in quality. We seek to characterize the demographic and facility-level variables associated with high-quality wedge resections. Methods: The National Cancer Database was queried from 2010 to 2018. Patients with T1/T2 N0 M0 non-small cell lung cancer 2 cm or less who underwent wedge resection without neoadjuvant therapy were included. A wedge resection with no nodes sampled or with positive margins was categorized as a low-quality wedge. A wedge resection with 4 or more nodes sampled and negative margins was categorized as a high-quality wedge. Facility-specific variables were investigated via quartile analysis based on the overall volume and proportion of high-quality wedge or low-quality wedge resections performed. Results: A total of 21,742 patients met inclusion criteria, 6390 (29.4%) of whom received a high-quality wedge resection. Factors associated with high-quality wedge resection included treatment at an academic center (3005 [47.0%] vs low-quality wedge 6279 [40.9%]; P < .001). The 30- and 90-day survivals were similar, but patients who received a high-quality wedge resection had improved 5-year survival (4902 [76.7%] vs 10,548 [68.7%]; P < .001). Facilities in the top quartile by volume of high-quality wedge resections performed 69% (4409) of all high-quality wedge resections, and facilities in the top quartile for low-quality wedge resections performed 67.6% (10,378) of all low-quality wedge resections. A total of 113 facilities were in the top quartile by volume for both high-quality wedge and low-quality wedge resections. Conclusions: High-quality wedge resections are associated with improved 5-year survival when compared with low-quality wedge resections. By volume, high-quality wedge and low-quality wedge resections cluster to a minority of facilities, many of which overlap. There is discordance between best practice guidelines and current practice patterns that warrants additional study.

Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury.

Purpose of Review: Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care. Recent Findings: Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential. Summary: A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.

The impact of COVID-19 infection on outcomes after injury in a state trauma system.

BACKGROUND: The COVID-19 pandemic reshaped the health care system in 2020. COVID-19 infection has been associated with poor outcomes after orthopedic surgery and elective, general surgery, but the impact of COVID-19 on outcomes after trauma is unknown. METHODS: We conducted a retrospective cohort study of patients admitted to Pennsylvania trauma centers from March 21 to July 31, 2020. The exposure of interest was COVID-19 (COV+) and the primary outcome was inpatient mortality. Secondary outcomes were length of stay and complications. We compared demographic and injury characteristics between positive, negative, and not-tested patients. We used multivariable regression with coarsened exact matching to estimate the impact of COV+ on outcomes. RESULTS: Of 15,550 included patients, 8,170 (52.5%) were tested for COVID-19 and 219 (2.7%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in terms of age and sex, but were less often white (53.5% vs. 74.7%, p < 0.0001), and more often uninsured (10.1 vs. 5.6%, p = 0.002). Injury severity was similar, but firearm injuries accounted for 11.9% of COV+ patients versus 5.1% of COV- patients (p < 0.001). Unadjusted mortality for COV+ was double that of COV- patients (9.1% vs. 4.7%, p < 0.0001) and length of stay was longer (median, 5 vs. 4 days; p < 0.001). Using coarsened exact matching, COV+ patients had an increased risk of death (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.29-15.99), any complication (OR, 1.85; 95% CI, 1.08-3.16), and pulmonary complications (OR, 5.79; 95% CI, 2.02-16.54) compared with COV- patients. CONCLUSION: Patients with concomitant traumatic injury and COVID-19 infection have elevated risks of morbidity and mortality. Trauma centers must incorporate an understanding of these risks into patient and family counseling and resource allocation during this pandemic. LEVEL OF EVIDENCE: Level II, Prognostic Study.