Melanie Arthur

Rib fracture pain and disability: can we do better?

OBJECTIVE The purpose of this study was to determine the magnitude and duration of pain and disability in patients with rib fractures treated using current standard therapy. This was a prospective case series. METHODS Injured patients with a chest radiographic diagnosis of one or more rib fractures between June 1, 2001, and October 31, 2001, were asked to participate. Pain levels were assessed at days 1, 5, 30, and 120 after injury using a visual pain scale (0-10). Disability at 30 days was assessed using the SF-36 Health Status Survey, and the total number of days lost from work/usual activity was recorded at day 120. The setting was a university-based Level I trauma center. RESULTS Forty patients with a mean of 2.7 +/- 1.6 rib fractures were enrolled. Twenty-three patients had isolated rib fractures and 17 patients had associated extrathoracic injuries. Mean rib fracture pain was 3.5 +/- 2.1 at 30 days and 1.0 +/- 1.4 at 120 days. For patients with associated extrathoracic injuries, rib pain was equivalent to pain in the rest of the body at all intervals. When compared with the chronically ill reference population of the RAND Medical Outcomes Study, our patients as a group were more disabled at 30 days (p < 0.001) in all categories except emotional stability, where they showed equivalent disability, and in their perception of general health, where they were significantly less disabled (p < 0.001). The total mean days lost from work/usual activity was 70 +/- 41. Patients with isolated rib fractures went back to work/usual activity at a mean of 51 +/- 39 days compared with 91 +/- 33 days in patients with associated extrathoracic injuries (p < 0.01). CONCLUSION Rib fractures are a significant cause of pain and disability in patients with isolated thoracic injury and in patients with associated extrathoracic injuries. Developing new therapies to accelerate pain relief and healing would substantially improve the outcome of patients with rib fractures.

Mortality Benefit of Transfer to Level I versus Level II Trauma Centers for Head-Injured Patients

OBJECTIVE To determine whether head-injured patients transferred to level I trauma centers have reduced mortality relative to transfers to level II trauma centers. DATA SOURCE/STUDY SETTING Retrospective cohort study of 542 patients with head injury who initially presented to 1 of 31 rural trauma centers in Oregon and Washington, and were transferred from the emergency department to 1 of 15 level I or level II trauma centers, between 1991 and 1994. STUDY DESIGN A bivariate probit, instrumental variables model was used to estimate the effect of transfer to level I versus level II trauma centers on 30-day postdischarge mortality. Independent variables included age, gender, Injury Severity Scale (ISS), other indicators of injury severity, and a dichotomous variable indicating transfer to a level I trauma center. The differential distance between the nearest level I and level II trauma centers was used as an instrument. PRINCIPAL FINDINGS Patients transferred to level I trauma centers differ in unmeasured ways from patients transferred to level II trauma centers, biasing estimates based on standard statistical methods. Transfer to a level I trauma center reduced absolute mortality risk by 10.1% (95% confidence interval 0.3%, 22.2%) compared with transfer to level II trauma centers. CONCLUSIONS Patients with severe head injuries transferred from rural trauma centers to level I centers are likely to have improved survival relative to transfer to level II centers.

Racial disparities in mortality among adults hospitalized after injury.

Background:Injury is a major cause of death in adults. Although racial disparities in healthcare access and health outcomes are well documented for medical conditions, the influence of race on access to emergent care after injury has received little scrutiny. Objectives:We sought to determine whether race was associated with risk of in-hospital death after injury. Research Design:Data from the Healthcare Cost and Utilization Project (1998–2002) were used to estimate multivariate models of in-hospital mortality, controlling for age, race, gender, comorbid conditions, injury severity, primary payer, median income of zip code of residence, and hospital type. Additional multivariate models were estimated among stratified subsets of patients, including injury severity and hospital type. Subjects:Patients age 18–64 with a primary diagnosis of injury. Results:Relative to injured white patients, black and Asian patients had a higher risk of death [1.5% vs. 2.1% and 2.0%, multivariate odds ratios (OR) = 1.14 and 1.39]. Other racial/ethnic groups showed no significant mortality difference from white patients. In stratified analyses, we found large black-white mortality disparities among mild to moderately injured patients (OR = 1.40, 95% confidence interval: 1.18–1.66), whereas Asian-white disparities were concentrated among more severely injured patients (OR = 1.37, 95% confidence interval: 1.03–1.80). Conclusions:Black and Asian patients have a higher risk of death after injury than white patients. These data raise important questions about access to quality trauma care for racial minority patients.

Incidence and cost of treating axis fractures in the United States from 2000 to 2010.

Study Design. Retrospective database analysis. Objective. To examine the incidence of hospitalization, treatment, and cost of caring for patients with axis (C2) fractures. Summary of Background Data. The incidence of C2 fractures in the elderly seems to be increasing, however, a comprehensive analysis of the incidence, treatment, and cost of treating C2 fractures has not been previously reported. Methods. The Nationwide Inpatient Sample from 2000 to 2010 was used to identify patients with C2 fracture without neurological injury (International Classification of Disease, Ninth Revision, Clinical Modification code 805.02). Examined variables included age, International Classification of Disease, Ninth Revision, Clinical Modification injury severity score, comorbidities, mortality, hospital length of stay, treatments, and total inpatient hospitalization charge. Charges were adjusted for inflation to 2010 US dollars as well as for cost-to-charge ratios. Results. In total, 31,129 patients with C2 fracture were identified. From 2000 to 2010 the incidence of C2 fracture hospitalization increased in all age groups (P < 0.0001). The most rapid increase was in patients older than 84 years, who experienced a 3-fold increase from 3.18 to 9.77 hospitalizations per 10,000 individuals per year (P < 0.0001). From 2000 to 2010, the rate of halo vest placement decreased from 25.2% to 10.4% (P < 0.0001), whereas the rate of surgical intervention increased from 13.1% to 16.5% (P = 0.029). For nonoperatively treated patients, the mean hospitalization charge per patient increased from

Proportion of seriously injured patients admitted to hospitals in the US with a high annual injured patient volume: a metric of regionalized trauma care

39,346 in 2000 to

Variability in rates of arthrodesis procedures for patients with cervical spine injuries with and without associated spinal cord injury.

63,222 in 2010, and for surgically treated patients, it increased from

Early neurosurgical procedures enhance survival in blunt head injury: propensity score analysis.

70,784 in 2000 to

Variability in rates of arthrodesis for patients with thoracolumbar spine fractures with and without associated neurologic injury.

133,064 in 2010 (P < 0.0001). During the decade, the estimated charges for annual inpatient care for patients with C2 fracture in the United States increased 4.7-fold from

Mortality Benefit of Transfer to Level I versus Level II Trauma Centers for Head-Injured Patients: Mortality Benefit of Level I Trauma Centers

334,138,919 to

A population-based survival assessment of categorizing level III and IV rural hospitals as trauma centers.

1,577,254,958 (P < 0.0001). Conclusion. The incidence of C2 fracture hospitalizations increased dramatically from 2000 to 2010, with the most rapid increase in the elderly represented by a greater than 3-fold increase for patients older than 84 years. The inpatient charges for treating C2 fractures have risen faster than the increased incidence, with a 4.7-fold increase in hospital charges resulting in estimated annual charges of more than