Mark Faul

Using a cost-benefit analysis to estimate outcomes of a clinical treatment guideline: testing theBrain Trauma Foundation guidelines for the treatment of severe traumatic brain injury.

BACKGROUND A decade after promulgation of treatment guidelines by the Brain Trauma Foundation (BTF), few studies exist that examine the application of these guidelines for severe traumatic brain injury (TBI) patients. These studies have reported both cost savings and reduced mortality. MATERIALS We projected the results of previous studies of BTF guideline adoption to estimate the impact of widespread adoption across the United States. We used surveillance systems and national surveys to estimate the number of severely injured TBI patients and compared the lifetime costs of BTF adoption to the current state of treatment. RESULTS After examining the health outcomes and costs, we estimated that a substantial savings in annual medical costs (

Epidemiology of traumatic brain injury

262 million), annual rehabilitation costs (

Reduced Mortality in Injured Adults Transported by Helicopter Emergency Medical Services

43 million) and lifetime societal costs (

Patients with severe traumatic brain injury transferred to a Level I or II trauma center: United States, 2007 to 2009.

3.84 billion) would be achieved if treatment guidelines were used more routinely. Implementation costs were estimated to be

Large Cost Savings Realized from the 2006 Field Triage Guideline: Reduction in Overtriage in U.S. Trauma Centers

61 million. The net savings were primarily because of better health outcomes and a decreased burden on lifetime social support systems. We also estimate that mortality would be reduced by 3,607 lives if the guidelines were followed. CONCLUSIONS Widespread adoption of the BTF guidelines for the treatment of severe TBI would result in substantial savings in costs and lives. The majority of cost savings are societal costs. Further validation work to identify the most effective aspects of the BTF guidelines is warranted.

Disparity in Naloxone Administration by Emergency Medical Service Providers and the Burden of Drug Overdose in US Rural Communities

Traumatic brain injury (TBI) is a leading cause of death, and in a recent analysis it was found that nearly one-third of all injury-related deaths in the US have at least one diagnosis of TBI (CDC-Quickstats, 2010). This chapter presents the burden of TBI as regards age group, gender, costs, race, emergency department (ED) visits, hospitalizations, and deaths. Injury trends over a 15 year period are examined. Rehabilitation estimates and disability estimates are also available. Through good epidemiology we can better understand the causes of TBI and design more effective intervention programs to reduce injury. Important sources of evidence for this chapter include mostly studies from the US because of their leading work in the epidemiology of this important injury.

Leading causes of death in nonmetropolitan and metropolitan areas -- United States, 1999–2014

Abstract Background. Some studies have shown improved outcomes with helicopter emergency medical services (HEMS) transport, while others have not. Safety concerns and cost have prompted reevaluation of the widespread use of HEMS. Objective. To determine whether the mode of transport of trauma patients affects mortality. Methods. Data for 56,744 injured adults aged ≥18 years transported to 62 U.S. trauma centers by helicopter or ground ambulance were obtained from the National Sample Program of the 2007 National Trauma Data Bank. In-hospital mortality was calculated for different demographic and injury severity groups. Adjusted odds ratios (AOR) were produced by utilizing a logistic regression model measuring the association of mortality and type of transport, controlling for age, gender, and injury severity (Injury Severity Score [ISS] and Revised Trauma Score [RTS]). Results. The odds of death were 39% lower in those transported by HEMS compared with those transported by ground ambulance (AOR = 0.61, 95% confidence interval [CI] = 0.54–0.69). Among those aged ≥55 years, the odds of death were not significantly different (AOR = 0.92, 95% CI = 0.74–1.13). Among all transports, male patients had a higher odds of death (AOR = 1.23, 95% CI = 1.10–1.38) than female patients. The odds of death increased with each year of age (AOR = 1.040, 95% CI = 1.037–1.043) and each unit of ISS (AOR = 1.080, 95% CI = 1.075–1.084), and decreased with each unit of RTS (AOR = 0.46, 95% CI = 0.45–0.48). Conclusion. The use of HEMS for the transport of adult trauma patients was associated with reduced mortality for patients aged 18–54 years. In this study, HEMS did not improve mortality in adults aged ≥55 years. Identification of additional variables in the selection of those patients who will benefit from HEMS transport is expected to enhance this reduction in mortality.

Impact of prescription drug monitoring programs and pill mill laws on high-risk opioid prescribers: A comparative interrupted time series analysis

BACKGROUND Patients with severe traumatic brain injury (TBI), head Abbreviated Injury Scale (AIS) score of 3 or greater, who are indirectly transported from the scene of injury to a nontrauma center can experience delays to definitive neurosurgical management. Transport to a hospital with appropriate initial emergency department treatment and rapid admission has been shown to reduce mortality in a state’s trauma system. This study was conducted to see if the same finding holds with a nationally representative sample of patients with severe TBI seen at Level I and II trauma centers. METHODS This study is based on adult (≥18 years), severe TBI patients treated in a nationally representative sample of Level I and II trauma centers, submitting data to the National Trauma Databank National Sample Program from 2007 to 2009. We analyzed independent variables including age, sex, primary payer, race, ethnicity, mode of transport, injury type (blunt vs. penetrating), mechanism of injury, trauma center level, head AIS, initial Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and systolic blood pressure by transfer status. The primary outcome variable was inpatient death, with discharge disposition, neurosurgical procedures, and mean hospital, intensive care unit, and ventilator days serving as secondary outcomes. RESULTS After exclusion criteria were applied (ISS < 16; age < 18 years; GCS motor score = 6; non-head AIS score ≥ 3; head AIS < 3; patients with missing transfer status, and death on arrival), a weighted sample of 51,300 (16%) patients was eligible for analysis. In bivariate analyses, transferred patients were older (≥60 years), white, insured, less severely injured (head AIS score ⩽ 4, ISS ⩽ 25), and less likely to have sustained penetrating trauma (p < 0.001). After controlling for all variables, direct transport, 1 or more comorbidities, advanced age, head AIS score, intracranial hemorrhage, and firearm injury remained significant predictors of death. Being transferred (adjusted odds ratio, 0.79; 95% confidence interval, 0.64–0.96) lowered the risk of death. CONCLUSION Patients with severe TBI who were transferred to a Level I or II trauma center had lower injury severity, including less penetrating trauma, and, as a result, were less likely to die compared with patients who were directly admitted to a Level I or II trauma center. The results may demonstrate adherence with the current Guidelines for Prehospital Management of Traumatic Brain Injury and Guidelines for Field Triage of Injured Patients, which recommend the direct transport of patients with severe TBI to the highest level trauma center. Patients with severe TBI who cannot be taken to a trauma center should be stabilized at a nontrauma center and then transferred to a Level I or II trauma center. Regional and national trauma databases should consider collecting information on patient outcomes at referral facilities and total transport time after injury, to better address the outcomes of patient triage decisions. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Reducing Potentially Excess Deaths from the Five Leading Causes of Death in the Rural United States

Abstract Background. Ambulance transport of injured patients to the most appropriate medical care facility is an important decision. Trauma centers are designed and staffed to treat severely injured patients and are increasingly burdened by cases involving less-serious injury. Yet, a cost evaluation of the Field Triage national guideline has never been performed. Objectives. To examine the potential cost savings associated with overtriage for the 1999 and 2006 versions of the Field Triage Guideline. Methods. Data from the National Hospital Ambulatory Medical Care Survey and the National Trauma Databank (NTDB) produced estimates of injury-related ambulatory transports and exposure to the Field Triage guideline. Case costs were approximated using a cost distribution curve of all cases found in the NTDB. A two-way sensitivity analysis was also used to determine the impact of data uncertainty on medical costs and the reduction in trauma center visits (12%) after implementation of the 2006 Field Triage guideline compared with the 1999 Field Triage guideline. Results. At a 40% overtriage rate, the average case cost was

A Review of Traumatic Brain Injury Trauma Center Visits Meeting Physiologic Criteria from the American College of Surgeons Committee on Trauma/Centers for Disease Control and Prevention Field Triage Guidelines

16,434. The cost average of 44.2% reduction in case costs if patients were treated in a non–trauma center compared with a trauma center was found in the literature. Implementation of the 2006 Field Triage guideline produced a