Brice Lionel Batomen Kuimi

Performance of International Classification of Diseases-based injury severity measures used to predict in-hospital mortality: A systematic review and meta-analysis.

BACKGROUND The International Classification of Diseases (ICD) is the main classification system used for population-based injury surveillance activities but does not contain information on injury severity. ICD-based injury severity measures can be empirically derived or mapped, but no single approach has been formally recommended. This study aimed to compare the performance of ICD-based injury severity measures to predict in-hospital mortality among injury-related admissions. METHODS A systematic review and a meta-analysis were conducted. MEDLINE, EMBASE, and Global Health databases were searched from their inception through September 2014. Observational studies that assessed the performance of ICD-based injury severity measures to predict in-hospital mortality and reported discriminative ability using the area under a receiver operating characteristic curve (AUC) were included. Metrics of model performance were extracted. Pooled AUC were estimated under random-effects models. RESULTS Twenty-two eligible studies reported 72 assessments of discrimination on ICD-based injury severity measures. Reported AUC ranged from 0.681 to 0.958. Of the 72 assessments, 46 showed excellent (0.80 ⩽ AUC < 0.90) and 6 outstanding (AUC ≥ 0.90) discriminative ability. Pooled AUC for ICD-based Injury Severity Score (ICISS) based on the product of traditional survival proportions was significantly higher than measures based on ICD mapped to Abbreviated Injury Scale (AIS) scores (0.863 vs. 0.825 for ICDMAP-ISS [p = 0.005] and ICDMAP-NISS [p = 0.016]). Similar results were observed when studies were stratified by the type of data used (trauma registry or hospital discharge) or the provenance of survival proportions (internally or externally derived). However, among studies published after 2003 the Trauma Mortality Prediction Model based on ICD-9 codes (TMPM-9) demonstrated superior discriminative ability than ICISS using the product of traditional survival proportions (0.850 vs. 0.802, p = 0.002). Models generally showed poor calibration. CONCLUSION ICISS using the product of traditional survival proportions and TMPM-9 predict mortality more accurately than those mapped to AIS codes and should be preferred for describing injury severity when ICD is used to record injury diagnoses. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.

Access to a Canadian provincial integrated trauma system: A population-based cohort study

BACKGROUND Access to specialised trauma care is an important measure of trauma system efficiency. However, few data are available on access to integrated trauma systems. We aimed to describe access to trauma centres (TCs) in an integrated Canadian trauma system and identify its determinants. METHODS We conducted a population-based cohort study including all injured adults admitted to acute care hospitals in the province of Québec between 2006 and 2011. Proportions of injured patients transported directly or transferred to TCs were assessed. Determinants of access were identified through a modified Poisson regression model and a relative importance analysis was used to determine the contribution of each independent variable to predicting access. RESULTS Of the 135,653 injury admissions selected, 75% were treated within the trauma system. Among 25,522 patients with major injuries [International Classification of diseases Injury Severity Score (ICISS<0.85)], 90% had access to TCs. Access was higher for patients aged under 65, men and among patients living in more remote areas (p-value <0.001). The region of residence followed by injury mechanism, number of trauma diagnoses, injury severity and age were the most important determinants of access to trauma care. CONCLUSIONS In an integrated, mature trauma system, we observed high access to TCs. However, problems in access were observed for the elderly, women and in urban areas where there are many non-designated hospitals. Access to trauma care should be monitored as part of quality of care improvement activities and pre-hospital guidelines for trauma patients should be applied uniformly throughout the province.

Performance of International Classification of Diseases–based injury severity measures used to predict in-hospital mortality and intensive care admission among traumatic brain-injured patients

BACKGROUND The International Classification of Diseases (ICD) is the main classification system used for population-based traumatic brain injury (TBI) surveillance activities but does not contain direct information on injury severity. International Classification of Diseases–based injury severity measures can be empirically derived or mapped to the Abbreviated Injury Scale, but no single approach has been formally recommended for TBI. OBJECTIVE The aim of this study was to compare the accuracy of different ICD-based injury severity measures for predicting in-hospital mortality and intensive care unit (ICU) admission in TBI patients. METHODS We conducted a population-based retrospective cohort study. We identified all patients 16 years or older with a TBI diagnosis who received acute care between April 1, 2006, and March 31, 2013, from the Quebec Hospital Discharge Database. The accuracy of five ICD-based injury severity measures for predicting mortality and ICU admission was compared using measures of discrimination (area under the receiver operating characteristic curve [AUC]) and calibration (calibration plot and the Hosmer-Lemeshow goodness-of-fit statistic). RESULTS Of 31,087 traumatic brain-injured patients in the study population, 9.0% died in hospital, and 34.4% were admitted to the ICU. Among ICD-based severity measures that were assessed, the multiplied derivative of ICD-based Injury Severity Score (ICISS-Multiplicative) demonstrated the best discriminative ability for predicting in-hospital mortality (AUC, 0.858; 95% confidence interval, 0.852–0.864) and ICU admissions (AUC, 0.813; 95% confidence interval, 0.808–0.818). Calibration assessments showed good agreement between observed and predicted in-hospital mortality for ICISS measures. All severity measures presented high agreement between observed and expected probabilities of ICU admission for all deciles of risk. CONCLUSIONS The ICD-based injury severity measures can be used to accurately predict in-hospital mortality and ICU admission in TBI patients. The ICISS-Multiplicative generally outperformed other ICD-based injury severity measures and should be preferred to control for differences in baseline characteristics between TBI patients in surveillance activities or injury research when only ICD codes are available. LEVEL OF EVIDENCE Prognostic study, level III.

Impact of socio–economic status on unplanned readmission following injury: A multicenter cohort study

BACKGROUND Unplanned readmissions cost the US economy approximately

Influence of access to an integrated trauma system on in-hospital mortality and length of stay

17 billion in 2009 with a 30-day incidence of 19.6%. Despite the recognised impact of socio-economic status (SES) on readmission in diagnostic populations such as cardiovascular patients, its impact in trauma patients is unclear. We examined the effect of SES on unplanned readmission following injury in a setting with universal health insurance. We also evaluated whether additional adjustment for SES influenced risk-adjusted readmission rates, used as a quality indicator (QI). STUDY DESIGN We conducted a multicenter cohort study in an integrated Canadian trauma system involving 56 adult trauma centres using trauma registry and hospital discharge data collected between 2005 and 2010. The main outcome was unplanned 30-day readmission; all cause, due to complications of injury and due to subsequent injury. SES was determined using ecological indices of material and social deprivation. Odds ratios of readmission and 95% confidence intervals adjusted for covariates were generated using multivariable logistic regression with a correction for hospital clusters. We then compared a readmission QI validated previously (original QI) to a QI with additional adjustment for SES (SES-adjusted QI) using the mean absolute difference. RESULTS The cohort consisted of 52,122 trauma admissions of which 6.5% were rehospitalised within 30 days of discharge. Compared to patients in the lowest quintile of social deprivation, those in the highest quintile had a 20% increase in the odds of all-cause unplanned readmission (95% CI=1.06-1.36) and a 27% increase in the odds of readmission due to complications of injury (95% CI=1.04-1.54). No association was observed for material deprivation or for readmissions due to subsequent injuries. We observed a strong agreement between the original and SES-adjusted readmission (mean absolute difference= 0.04%). CONCLUSIONS Patients admitted for traumatic injury who suffer from social deprivation have an increased risk of unplanned rehospitalisation due to complications of injury in the 30 days following discharge. Better discharge planning or follow up for such patients may improve patient outcome and resource use for trauma admissions. Despite observed associations, results suggest that the trauma QI based on unplanned readmission does not require additional adjustment for SES.

Hospital length of stay following admission for traumatic brain injury in a Canadian integrated trauma system: A retrospective multicenter cohort study

BACKGROUND Few data are available on population-based access to specialised trauma care and its influence on patient outcomes in an integrated trauma system. We aimed to evaluate the influence of access to an integrate trauma system on in-hospital mortality and length of stay (LOS). METHODS All adults admitted to acute care hospitals for major trauma [International Classification of Diseases Injury Severity Score (ICISS<0.85)] in a Canadian province with an integrated trauma system between 2006 and 2011 were included using an administrative hospital discharge database. The influence of access to an integrated trauma system on in-hospital mortality and LOS was assessed globally and for critically injured patients (ICISS<0.75), according to the type of injury [traumatic brain injury (TBI), abdominal/thoracic, spine, orthopaedic] using logistic and linear multivariable regression models. RESULTS We identified 22,749 injury admissions. In-hospital mortality was 7% and median LOS was 9 days for all injuries. Overall, 92% of patients were treated within the trauma system. Globally, patients who did not have access had similar mortality and LOS compared to patients who had access. However, we observed a 62% reduction in mortality for critical abdominal/thoracic injuries (odds ratio=0.38; 95% CI, 0.16-0.92) and an 8% increase in LOS for TBI patients (geometric mean ratio=1.08; 95% CI, 1.02-1.14) treated within the trauma system. CONCLUSIONS Results provides evidence that in a health system with an integrated mature trauma system, access to specialised trauma care is high and the small proportion of patients treated outside the system, have similar mortality and LOS compared to patients treated within the system. This study suggests that the Québec trauma system performs well in its mandate to offer appropriate treatment to victims of injury that require specialised care.

Impact of wearing a helmet on the risk of hospitalization and intracranial haemorrhage after a sports injury

BACKGROUND Traumatic brain injury (TBI) is the leading cause of disability in children and young adults and costs CAD

Erratum to: Frail older adults with minor fractures show lower health-related quality of life (SF-12) scores up to six months following emergency department discharge

3 billion annually in Canada. Stakeholders have expressed the urgent need to obtain information on resource use for TBI to improve the quality and efficiency of acute care in this patient population. We aimed to assess the components and determinants of hospital and ICU LOS for TBI admissions. METHODS We performed a retrospective multicenter cohort study on 11,199 adults admitted for TBI between 2007 and 2012 in an inclusive Canadian trauma system. Our primary outcome measure was index hospital LOS (admission to the hospital with the highest designation level). Index LOS was compared to total LOS (all consecutive admissions related to the injury). Expected LOS was calculated by matching TBI admissions to all-diagnosis hospital admissions by age, gender, and year of admission. LOS determinants were identified using multilevel linear regression. RESULTS Geometric mean total LOS was 1day longer than geometric mean index LOS (12.6 versus 11.7 days). Observed index and ICU LOS were respectively 4.2days and 2.5days longer than that expected according to all-diagnosis admissions. The six most important determinants of LOS were discharge destination, severity of concomitant injuries, extracranial complications, GCS, TBI severity, and mechanical ventilation, accounting for 80% of explained variation. CONCLUSIONS Results of this multicenter retrospective cohort study suggest that hospital and ICU LOS for TBI admissions are 56% and 119% longer than expected according to all-diagnosis admissions, respectively. In addition, hospital LOS is underestimated when only the index visit is considered and is largely influenced by discharge destination and extracranial complications, suggesting that improvements could be achieved with better discharge planning and interventions targeting prevention of in-hospital complications. This study highlights the importance of considering TBI patients as a distinct population when allocating resources or planning quality improvement interventions.

Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study

ABSTRACT Background: Despite their reported protective effect against the occurrence of head injuries, helmets are still used inconsistently in sports in which they are optional. We aimed to assess the impact of helmet use on the risk of hospitalization and intracranial haemorrhage for trauma occurring during sport activities. Methods: Retrospective cohort of all patients who presented themselves, over an 18-month period, at the emergency department of a tertiary trauma centre for an injury sustained in a sport or leisure activity where the use of a helmet is optional. Impact of helmet use was assessed using multivariable regression analyses (relative risks, RR). Results: Among the 1,022 patients included in the study, half were cyclists and 40% were skiers or snowboarders. A total of 40 % of patients wore a helmet at the time of injury, 18% had a head injury, 16% were hospitalized and 13% of patients with a head injury had an intracranial haemorrhage. Among all patients, no association was observed between hospital admission and helmet use. However, helmet use in patients with a head injury was associated with significant reductions in the risks of hospitalization (RR 0.41 [95% CI: 0.22–0.76]) and intracranial haemorrhage (RR 0.28 [95% CI: 0.11–0.71]). Conclusions: Results suggest that, in recreational athletes who sustain a head injury, helmet use is associated with a reduced risk of hospitalization (all sports) and intracranial haemorrhage (cyclists).