Etienne E. Pracht

Evaluation of a mature trauma system.

Introduction:An effective trauma system should offer patients triaged to a trauma center (TC) a survival advantage and cost-effective treatment. Three questions were asked: 1) Does treatment at a TC versus a nontrauma center (NTC) improve survival? 2) Is the system cost-effective? 3) Is access to the system equitable? Methods:The 2003 Florida discharge database identified patients with ICD9 codes 800 to 959. Survival risk ratios (SRR) were calculated using1999–2000 data and ICISS were produced for each code. Using 2003 data, mortality rates were calculated for matched patients at TCs and NTCs. Instrumental variables methodology was used to account for differences in mortality risks of patients triaged to TCs versus NTCs. Logistic regression analysis was used to determine differences in mortality. Charge/cost ratios were analyzed to compute the cost care and cost/life saved. Accessibility to a TC within 85 minutes of injury was assessed. Results:Treatment at a TC was associated with an 18% reduction in mortality. Mean costs of care in TCs and NTCs were

Do pediatric patients with trauma in Florida have reduced mortality rates when treated in designated trauma centers

11,910 and

High-volume trauma centers have better outcomes treating traumatic brain injury.

6019, respectively. Dividing the mean cost difference by the reduction in mortality yields a cost of

Survival advantage for elderly trauma patients treated in a designated trauma center

34,887/life saved. A total of 42% of patients returned to work within 24 months of injury. Using an expected median of 19 years of employment for a 33-year-old individual and proposed state funding figures for the trauma system, a life saved results in an approximate annual cost to the state of between

Survival Advantage Associated with Treatment of Injury at Designated Trauma Centers: A Bivariate Probit Model with Instrumental Variables

100 and

The burden of neurological disease in the United States: A summary report and call to action

500. Currently, 95% of citizens of the state have access to the trauma system within 85 minutes of injury; however, only 38% of trauma patients are triaged to a TC. Addition of 3 TCs would increase these percentages to 99% and 65%. Conclusions:Triage to a Florida TC is associated with a decreased risk of death. Moreover, cost/life year saved is favorable when compared with societal expenditures for other health problems. Improved deployment of TCs is necessary to optimize access. This assessment methodology is a useful model for evaluation of mature trauma systems.

Fifteen-year trauma system performance analysis demonstrates optimal coverage for most severely injured patients and identifies a vulnerable population.

OBJECTIVE The purposes of the study were to compare the survival associated with treatment of seriously injured patients with pediatric trauma in Florida at designated trauma centers (DTCs) with nontrauma center (NCs) acute care hospitals and to evaluate differences in mortality between designated pediatric and nonpediatric trauma centers. METHODS Trauma-related inpatient hospital discharge records from 1995 to 2004 were analyzed for children aged from 0 to 19 years. Age, sex, ethnicity, injury mechanism, discharge diagnoses, and severity as defined by the International Classification Injury Severity Score were analyzed, using mortality during hospitalization as the outcome measure. Children with central nervous system, spine, torso, and vascular injuries and burns were evaluated. Instrumental variable analysis was used to control for triage bias, and mortality was compared by probabilistic regression and bivariate probit modeling. Children treated at a DTC were compared with those treated at a nontrauma center. Within the population treated at a DTC, those treated at a DTC with pediatric capability were compared with those treated at a DTC without additional pediatric capability. Models were analyzed for children aged 0 to 19 years and 0 to 15 years. RESULTS For the 27,313 patients between ages 0 and 19 years, treatment in DTCs was associated with a 3.15% reduction in the probability of mortality (P < .0001, bivariate probit). The survival advantage for children aged 0 to 15 years was 1.6%, which is not statistically significant. Treatment of 16,607 children in a designated pediatric DTC, as opposed to a nonpediatric DTC, was associated with an additional 4.84% reduction in mortality in the 0- to 19-year age group and 4.5% in the 0 to 15 years group (P < .001, bivariate probit). CONCLUSIONS Optimal care of the seriously injured child requires both the extensive and immediate resources of a DTC as well as pediatric-specific specialty support.

Geographic distribution of severely injured patients: implications for trauma system development.

BACKGROUND Survival and discharge status from severe traumatic brain injury (TBI) patients treated during the past 11 years in seven state-designated Level I trauma centers was analyzed to test for a relationship between patient volume and outcome. METHODS Data for patients age 16 years to 64 years were aggregated by quarter for years 2000 to 2010. TBI patients were identified using DRG International Classification of Diseases—9th Rev.—Clinical Modification codes: 800 to 804 and 850.1 to 854. Severity was defined using the International Classification Injury Severity Score (ICISS) less than 0.85 (risk of death > 15%). Using a random effects model controlling for sex, race, ethnicity, and insurance status, TBI volume was analyzed against quarterly inpatient mortality and functional recovery, defined as discharge to home or rehabilitation versus transfer to skilled nursing facilities. Hospitals were categorized into quarterly TBI volume quintiles, using the top quintile (highest-volume center) as control. To account for overall injury severity influence, ICISS was further categorized as less than 20%, 20% to 40%, and 40% to 60%. RESULTS Two high-volume hospitals consistently treated more TBI patients (>40 patients per quarter). Four treated less than 40 patients per quarter, and one transitioned to high-volume midway through the study period. After controlling for severity, demographics, and insurance status, highest-volume centers demonstrated a 9% lower mortality risk (p < 0.001). Lower-volume hospitals discharged a significantly larger proportion of TBI patients to skilled nursing facilities and fewer patients to home or rehabilitation facilities (p < 0.01). CONCLUSION High volume (>40 patients per quarter) is associated with improved severe TBI patient survival and, probably, improved quality of life. Efforts to identify best practices and implement educational interventions to improve compliance with best-practice standards will benefit patients with severe traumatic brain injury. LEVEL OF EVIDENCE Epidemiologic study, level III.

Uncompensated care provided by emergency physicians in Florida emergency departments.

BACKGROUND This article analyzes the effectiveness of designated trauma centers (DTCs) in Florida concerning reduction in the mortality risk of severely injured elderly trauma victims. METHODS Inpatient hospital data collected by the Agency for Health Care Administration were used to identify elderly trauma patients. An instrumental variables method was used to adjust for prehospital selection bias in addition to the influence of age, gender, race, risk of mortality, comorbidities, and type of injury. The model was estimated using a bivariate probit full information maximum likelihood model to determine the impact of triage to a trauma center as opposed to a nontrauma hospital. RESULTS After adjusting for confounding influences, treatment at a DTC was associated with a statistically significant reduction of 0.072, 0.040, and 0.036 in the probability of mortality for patients in the age groups 65 years to 74 years, 75 years to 84 years, and ≥ 85 years, respectively. CONCLUSIONS Treatment of severely injured elderly trauma patients in DTCs is associated with statistically significant gains in the probability of survival.

Interest Groups and State Medicaid Drug Programs

This article analyzes the effectiveness of designated trauma centers in Florida concerning reduction in the mortality risk of severely injured trauma victims. A bivariate probit model is used to compute the differential impact of two alternative acute care treatment sites. The alternative sites are defined as (1) a nontrauma center (NC) or (2) a designated trauma center (DTC). An instrumental-variables method was used to adjust for prehospital selection bias in addition to the influence of age, gender, race, risk of mortality, and type of injury. Treatment at a DTC was associated with a reduction of 0.13 in the probability of mortality.