Marie Crandall

Race and Insurance Status as Risk Factors for Trauma Mortality

OBJECTIVE To determine the effect of race and insurance status on trauma mortality. METHODS Review of patients (aged 18-64 years; Injury Severity Score > or = 9) included in the National Trauma Data Bank (2001-2005). African American and Hispanic patients were each compared with white patients and insured patients were compared with uninsured patients. Multiple logistic regression analyses determined differences in survival rates after adjusting for demographics, injury severity (Injury Severity Score and revised Trauma Score), severity of head and/or extremity injury, and injury mechanism. RESULTS A total of 429 751 patients met inclusion criteria. African American (n = 72,249) and Hispanic (n = 41,770) patients were less likely to be insured and more likely to sustain penetrating trauma than white patients (n = 262,878). African American and Hispanic patients had higher unadjusted mortality rates (white, 5.7%; African American, 8.2%; Hispanic, 9.1%; P = .05 for African American and Hispanic patients) and an increased adjusted odds ratio (OR) of death compared with white patients (African American OR, 1.17; 95% confidence interval [CI], 1.10-1.23; Hispanic OR, 1.47; 95% CI, 1.39-1.57). Insured patients (47%) had lower crude mortality rates than uninsured patients (4.4% vs 8.6%; P = .05). Insured African American and Hispanic patients had increased mortality rates compared with insured white patients. This effect worsened for uninsured patients across groups (insured African American OR, 1.2; 95% CI, 1.08-1.33; insured Hispanic OR, 1.51; 95% CI, 1.36-1.64; uninsured white OR, 1.55; 95% CI, 1.46-1.64; uninsured African American OR, 1.78; 95% CI, 1.65-1.90; uninsured Hispanic OR, 2.30; 95% CI, 2.13-2.49). The reference group was insured white patients. CONCLUSION Race and insurance status each independently predicts outcome disparities after trauma. African American, Hispanic, and uninsured patients have worse outcomes, but insurance status appears to have the stronger association with mortality after trauma.

Selective Nonoperative Management of Blunt Splenic Injury: An Eastern Association for the Surgery of Trauma Practice Management Guideline

BACKGROUND During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline

Background During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. Methods The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. Results One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. Conclusion Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

Emergency general surgery: definition and estimated burden of disease.

BACKGROUND Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This article describes the work of the American Association for the Surgery of Trauma to define EGS. METHODS A total of 621 unique International Classification of Diseases—9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease. RESULTS Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases. CONCLUSION This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.

Disparities in trauma care and outcomes in the United States: a systematic review and meta-analysis.

Disparities in health outcomes have been uncovered for many conditions. Data indicate that black patients currently have higher mortality than white patients for 9 of the leading 15 causes of death. The life expectancy gap between black patients and white patients persists, although it has gradually

Association Between Hospitals Caring for a Disproportionately High Percentage of Minority Trauma Patients and Increased Mortality: A Nationwide Analysis of 434 Hospitals

OBJECTIVE To determine whether there is an increased odds of mortality among trauma patients treated at hospitals with higher proportions of minority patients (ie, black and Hispanic patients combined). DESIGN Hospitals were categorized on the basis of the percentage of minority patients admitted with trauma. The adjusted odds of in-hospital mortality were compared between hospitals with less than 25% of patients who were minorities (the reference group) and hospitals with 25% to 50% of patients who were minorities and hospitals with more than 50% of patients who were minorities. Multivariate logistic regression (with generalized linear modeling and a cluster-correlated robust estimate of variance) was used to control for multiple patient and injury severity characteristics. SETTING A total of 434 hospitals in the National Trauma Data Bank. PARTICIPANTS Patients aged 18 to 64 years whose medical records were included in the National Trauma Data Bank for the years 2007 and 2008 with an Injury Severity Score of 9 or greater and who were white, black, or Hispanic. MAIN OUTCOME MEASURES Crude mortality and adjusted odds of in-hospital mortality. RESULTS A total of 311,568 patients were examined. Hospitals in which the percentage of minority patients was more than 50% also had younger patients, fewer female patients, more patients with penetrating trauma, and the highest crude mortality. After adjustment for potential confounders, patients treated at hospitals in which the percentage of minority patients was 25% to 50% and at hospitals in which the percentage of minority patients was more than 50% demonstrated increased odds of death (adjusted odds ratio, 1.16 [95% confidence interval, 1.01-1.34] and adjusted odds ratio, 1.37 [95% confidence interval, 1.16-1.61], respectively), compared with the reference group. This disparity increased further on subset analysis of patients with a blunt injury. Uninsured patients had significantly increased odds of mortality within all 3 hospital groups. CONCLUSIONS Patients treated at hospitals with higher proportions of minority trauma patients have increased odds of dying, even after adjusting for potential confounders. Differences in outcomes between trauma hospitals may partly explain racial disparities.

Multiple imputation in trauma disparity research.

BACKGROUND Missing data has remained a major disparity in trauma outcomes research due to missing race and insurance data. Multiple imputation (M.IMP) has been recommended as a solution to deal with this major drawback. STUDY DESIGN Using the National Data Trauma Bank (NTDB) as an example, a complete dataset was developed by deleting cases with missing data across variables of interest. An incomplete dataset was then created from the complete set using random deletion to simulate the original NTDB, followed by five M.IMP rounds to generate a final imputed dataset. Identical multivariate analyses were performed to investigate the effect of race and insurance on mortality in both datasets. RESULTS Missing data proportions for known trauma mortality covariates were as follows: age-4%, gender-0.4%, race-8%, insurance-17%, injury severity score-6%, revised trauma score-20%, and trauma type-3%. The M.IMP dataset results were qualitatively similar to the original dataset. CONCLUSION M.IMP is a feasible tool in NTDB for handling missing race and insurance data.

“No Way Out” Russian-Speaking Women’s Experiences With Domestic Violence

This article explores the experience of domestic violence and utilization of domestic violence resources among immigrant women who were Russian speaking. Participants, many of whom came to the United States as so-called mail-order brides, reported diverse forms of abuse, including isolation and financial restrictions, and were reluctant to get outside help because of embarrassment about their circumstances. Survivors stressed the importance of language- and culture-appropriate outreach and services and urged that women receive information about domestic violence services and laws on immigration. Assistance with housing, child care, and job searches is integral to safe transitions out of abusive relationships.

Measuring anatomic severity of disease in emergency general surgery

BACKGROUND Currently, there is no established system for assessing disease severity in emergency general surgery (EGS) patients. The purpose of this project was to develop a uniform grading system for measuring anatomic severity of disease in this patient population. METHODS The Committee on Patient Assessment and Outcomes of the American Association for the Surgery of Trauma developed a proposal by consensus of experts for grading severity of EGS diseases. It was then reviewed and approved by the Board of Managers of the American Association for the Surgery of Trauma. RESULTS A uniform grading system for measuring anatomic severity of disease in EGS is described, with specific grades for eight commonly encountered gastrointestinal conditions. These grades range from Grade I through Grade V, reflecting an escalating clinical progression from mild disease limited within the organ itself to severe disease that is widespread. CONCLUSION This article provides a unified grading system for measuring anatomic severity of disease that is essential to advance the science of EGS. Once validated, a description of disease grade should be included in the emerging EGS registries and in research studies involving EGS patients.

Pre-hospital transport times and survival for Hypotensive patients with penetrating thoracic trauma

Background: Achieving definitive care within the “Golden Hour” by minimizing response times is a consistent goal of regional trauma systems. This study hypothesizes that in urban Level I Trauma Centers, shorter pre-hospital times would predict outcomes in penetrating thoracic injuries. Materials and Methods: A retrospective cohort study was performed using a statewide trauma registry for the years 1999-2003. Total pre-hospital times were measured for urban victims of penetrating thoracic trauma. Crude and adjusted mortality rates were compared by pre-hospital time using STATA statistical software. Results: During the study period, 908 patients presented to the hospital after penetrating thoracic trauma, with 79% surviving. Patients with higher injury severity scores (ISS) were transported more quickly. Injury severity scores (ISS) ≥16 and emergency department (ED) hypotension (systolic blood pressure, SBP <90) strongly predicted mortality (P < 0.05 for each). In a logistic regression model including age, race, and ISS, longer transport times for hypotensive patients were associated with higher mortality rates (all P values <0.05). This was seen most significantly when comparing patient transport times 0-15 min and 46-60 min (P < 0.001). Conclusion: In victims of penetrating thoracic trauma, more severely injured patients arrive at urban trauma centers sooner. Mortality is strongly predicted by injury severity, although shorter pre-hospital times are associated with improved survival. These results suggest that careful planning to optimize transport time-encompassing hospital capacity and existing resources, traffic patterns, and trauma incident densities may be beneficial in areas with a high burden of penetrating trauma.