Melanie J. Zimmer-Gembeck

Influence of a statewide trauma system on location of hospitalization and outcome of injured patients

OBJECTIVE Evaluate the influence of implementing the Oregon statewide trauma system on admission distribution and risk of death. DESIGN Retrospective pre- and posttrauma system analyses of hospital discharge data regarding injured patients with one or more of the following injuries: head, chest, spleen/liver, pelvic fracture, and femur/tibia fracture. MATERIALS AND METHODS Risk-adjusted odds ratio of admission to Level I or II (tertiary care) trauma centers, and odds ratio of death were determined using hospital discharge abstract data on 27,633 patients. Patients treated in 1985-1987, before trauma system establishment, were compared to patients treated in 1991-1993 after the trauma system was functioning. MEASUREMENTS AND MAIN RESULTS After trauma system implementation, the odds ratio of admission to Level I or II trauma centers increased (odds ratio 2.36, 95% confidence interval 2.24-2.49). In addition, the odds ratio of death for injured patients declined after trauma system establishment (odds ratio 0.82, confidence interval 0.73-0.92). CONCLUSIONS The Oregon trauma system was successfully implemented with more patients with index injuries admitted to hospitals judged most capable of managing trauma patients. The Oregon trauma system also appears beneficial since trauma system establishment is associated with a statewide reduction in risk of death.

Triage in an established trauma system

OBJECTIVE The goal of this study was to determine patient and injury characteristics that predict undertriage and overtriage. DESIGN This study was a retrospective analysis of admissions for acute injury. MATERIALS AND METHODS All admissions for acute injuries in a 2 1/2-year period were included (N = 26,025). ICD-9 clinical modification codes were converted to Injury Severity Scores. MAIN RESULTS Seventy-nine percent of severely injured patients were admitted to level I trauma centers. Severely injured patients admitted to other hospitals (undertriage) were more likely elderly (odds ratio = 5.44) and less likely had multisystem injuries (odds ratio = 0.55). One-fourth of patients with minor injuries were admitted to level I trauma centers (overtriage). Overtriaged patients were more likely intoxicated, obese, or had an injury to the head or face. CONCLUSIONS In a developed trauma system, severely injured elderly trauma patients (especially females) are at risk for undertriage. The characteristics of patients at risk for overtriage reflect the difficulties of prospective out-of-hospital triage.

Stability, Change and Individual Differences in Involvement with Friends and Romantic Partners Among Adolescent Females

The initiation of romantic relationships is a normative developmental task among female adolescents. Friendships with other females may change as part of this task. Using structured interviews, this study collected data from 102 white females (ages 17 to 19) about their history of close peer relationships during high school. Trajectories of involvement (time spent) with close peers were examined using individual growth modeling. Females who increased time with romantic partners more rapidly also decreased time with friends more rapidly. Although most spent more time with partners than with friends at some time, the timing of this change and patterns of involvement with close peers varied. One-fourth of females spent more time with partners than with friends early in high school, but spent less time with friends than others did. Another one-half spent more time with partners than with friends later in high school, gradually increasing time with partners and reducing time with friends. Other females never spent more time with partners than with friends, and maintained high involvement with friends and little involvement with partners.

LOW BIRTHWEIGHT IN A PUBLIC PRENATAL CARE PROGRAM: BEHAVIORAL AND PSYCHOSOCIAL RISK FACTORS AND PSYCHOSOCIAL INTERVENTION

A retrospective, observational study of 3073 low income African American, Latina, and White women receiving comprehensive prenatal care at 26 provider sites was completed. The purpose of the study was to test three hypotheses. First, after adjustment for biomedical complications, the presence of maternal behavioral and psychosocial factors would be associated with an increased rate of low birthweight infants. Second, increased time spent in psychosocial services would negate the relationship between maternal psychosocial factors and low birthweight. Third, after adjusting for biomedical, behavioral, and psychosocial factors, rates of low birthweight would no longer differ by race. Maternal smoking (over five cigarettes per week), maternal low weight for height and/or weight gain, negative mood (depression, anxiety, and/or hostility) and rejection of the pregnancy were found to be related to an increased rate of low birthweight birth (< 2500 g). Receiving more than 45 min of psychosocial services was related to a reduced rate of low birthweight birth for all women regardless of risk profile. The rate of low birthweight remained higher in African American women after adjusting for all significant maternal biomedical, behavioral, and psychosocial risk and intervention factors. Further analyses revealed that the strength and direction of the relationship between time spent in psychosocial services and low birthweight remained after controlling for the number of prenatal care visits, the time spent in nutrition or health educational services, and gestational age. Also, the time spent in psychosocial services was related to a reduced rate of low birthweight even after excluding time spent in psychosocial services in the third trimester of pregnancy or excluding women who received their first psychosocial assessment in the third trimester from the analysis. Although definitive evidence from randomized trials of psychosocial services is lacking, receiving over 45 min of psychosocial services was related to a reduced risk of low birthweight for all women in this study. Therefore, general psychosocial services appears to be an important component of prenatal care for all low income women.

An analysis of Hospital Discharge Index as a trauma data base

STUDY OBJECTIVE To document the validity of a Hospital Discharge Index (HDI) as a data base on injured patients. DESIGN Patient information in trauma registries was compared with information in HDI. POPULATION Injured patients admitted to trauma centers. METHODS Patients in HDI were crossmatched with individuals in one or two trauma registries using deterministic matching techniques. Agreement regarding the presence and severity of injury was assessed. RESULTS A comprehensive trauma registry from a level I trauma center and HDI agreed on the presence of an injury in each of 6 body regions over a range of kappa values from 0.17 to 0.71. The severity of injury score assigned by the two data bases demonstrated agreement over a range of intraclass correlation values from 0.12 to 0.82. CONCLUSION HDI provides adequate information concerning injury for the majority of hospitalized patients, but was primarily limited by incomplete information. Efforts to improve HDI should focus on guidelines for data abstraction.

Practice Variation and the Risk of Low Birth Weight in a Public Prenatal Care Program

OBJECTIVES Use of antepartum tests of fetal well-being is widespread even though effectiveness in preventing fetal damage or stillbirth has not been established. The study objective was to examine whether aggressive use of these tests might contribute to increased rates of other birth outcomes, including low birth weight (LBW). METHODS A total of 3,235 low-income women receiving care from 28 clinic sites were studied. All women were eligible for Medi-Cal benefits. Clinic sites were classified as aggressive, moderate, or low users of antepartum tests. The relations between patient risk factors, clinic testing style, LBW, and other pregnancy outcomes were examined using multiple logistic regression. RESULTS After adjustment for risk factors, patients seen by aggressive testers had a risk of LBW higher than patients receiving care from moderate testers (odds ratio = 1.65; P < 0.01). Rates of LBW within patients receiving care from moderate and low testers did not differ (P = 0.22). Patients seen by aggressive testers also had higher rates of preterm delivery, cesarean delivery, and provided more expensive care. CONCLUSIONS Although antepartum testing is intended to prevent fetal distress, extremely aggressive use of antepartum testing may have unfavorable effects on LBW and other pregnancy outcomes. More attention should be paid to variation in obstetric practices in evaluations of the costs and effectiveness of public prenatal care programs.