Michael Bronsert

Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients

PURPOSE We investigated whether clinicians’ explicit and implicit ethnic/racial bias is related to black and Latino patients’ perceptions of their care in established clinical relationships. METHODS We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians’ interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. RESULTS Levels of explicit bias were low among clinicians and unrelated to patients’ perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians’ implicit bias (P = .98). CONCLUSIONS This is among the first studies to investigate clinicians’ implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians’ implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine’s suggestion that clinician bias may contribute to health disparities. Latinos’ overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.

Frequency and Variety of Inpatient Pediatric Surgical Procedures in the United States

OBJECTIVE: Pediatric surgical procedures are being performed in a variety of hospitals with large differences in surgical volume. We examined the frequency and variety of inpatient pediatric surgical procedures in the United States by hospital type and geographic region using a nationally representative sample. METHODS: The 2009 Kids’ Inpatient Database for patients <18 years old was used to calculate surgical frequencies by using International Classification of Diseases, Ninth Revision, Clinical Modification, (ICD-9-CM) codes. We performed stratified analysis by hospital type (free-standing children’s hospital, children’s unit within an adult hospital, and general hospital) and geographic region (South, West, Midwest, Northeast) to compare frequencies of surgical procedures. RESULTS: A total of 216 081 procedures were projected for 2009 with the top 20 procedures accounting for >90% of cases. As many as 40% of all pediatric inpatient surgical procedures are being performed in adult general hospitals. Infrequent complex low-volume neonatal surgical procedures (pullthrough for Hirschsprung disease, surgery for malrotation, esophageal atresia repair, and diaphragmatic hernia repair) were 6.8 to 16 times more likely to occur in a childrens hospital. Significant regional variation in procedure frequency rates occurred for appendectomy and cholecystectomy. CONCLUSIONS: This report is the first to characterize pediatric surgical inpatient volume in the United States. Such data may influence the distribution of pediatric surgeons, number of trainees, and training curricula for pediatric surgeons, pediatricians, general surgeons and other surgical specialists who might operate on children. In addition, it raises the question of whether complex pediatric surgical procedures should preferably be performed at dedicated high volume childrens hospitals.

Glasgow motor scale alone is equivalent to Glasgow Coma Scale at identifying children at risk for serious traumatic brain injury.

BACKGROUND Glasgow Coma Scale (GCS) is a validated assessment of neurologic state. Assessment of the eye and verbal components is difficult to reliably obtain in children. We hypothesized that an abnormal Glasgow motor scale (GMS) score alone will reliably identify children with serious traumatic brain injury (TBI). METHODS We reviewed all children with a diagnosis of TBI from 2002 to 2011 at two urban Level I pediatric trauma centers. We used logistic regression to model GCS, GMS, Glasgow verbal scale (GVS), and Glasgow eye scale (GES) for seven outcomes: need for craniotomy, intracranial pressure monitoring, admission to the intensive care unit, hospital stay of 5 days or longer, discharge to rehabilitation, dependence on caretakers at follow-up, and survival to hospital discharge. We then used three measures of fit analysis to determine which scale offered the best fit for each of the outcomes. RESULTS A total of 2,341 patients (mean [SD] age, 6.9 [5.8] years; 64.7% male) with TBI and GCS data available were identified. The median GCS on presentation was 15 (interquartile range [IQR], 8–15); the median GMS on presentation was 6 (IQR, 4–6). The median GVS was 5 (IQR, 1–5), and the median GES was 4 (IQR, 2–4). GCS as a whole offered the best fit for the data in predicting need for intensive care unit admission, need for intracranial pressure monitoring, prolonged hospital length of stay, and discharge to rehabilitation but was equivalent to GMS in predicting need for craniotomy, survival to hospital discharge, or dependence on a caretaker at follow-up. Further analysis revealed that GMS was more predictive of these outcomes than GVS + GES, indicating that GMS provides the greatest contribution to the predictive ability of the GCS. CONCLUSION GMS score alone and GCS do not differ in identifying children with serious TBI. Eliminating the eye and verbal components of GCS does not adversely affect the accuracy of this tool to identify children at risk for serious TBI. LEVEL OF EVIDENCE Prognostic study, level III.

Retrospective analysis of facial dog bite injuries at a Level I trauma center in the Denver metro area.

BACKGROUND Facial dog bite injuries pose a significant public health problem. METHODS Seventy-five consecutive patients (45 males, 30 females) treated solely by plastic surgery service for facial dog bite injuries at a Level I trauma center in the Denver Metro area between 2006 and 2012 were retrospectively reviewed. The following information were recorded: breed, relationship of patient to dog, location and number of wounds, the duration between injury and surgical repair and dog bite incident, type of repair, and antibiotic prophylaxis. Primary end points measured were wound infection, the need for revision surgery, and patient satisfaction. RESULTS Ninety-eight wounds in the head and neck region were repaired (46 children; mean age, 6.8 years) and (29 adults; mean age, 47.3 years). Twelve different breeds were identified. There was no significant association between the type of dog breed and the number of bite injuries. The duration between injury and repair ranged from 4 hours to 72 hours (mean [SD], 13.7 [10.9] hours). The majority of bite wounds (76 of 98) involved the cheek, lip, nose, and chin region. Direct repair was the most common surgical approach (60 of 98 wounds) (p < 0.05). There was no statistically significant association between wounds needing reconstruction versus direct repair according to dog breed (p = 0.25). Ten wounds required grafting. Twenty-five wounds were managed by one-stage or two-stage flaps. Only three patients (3.06 %) underwent replantation/revascularization of amputated partial lip (n = 2) and of cheek (n = 1). There was one postoperative infection. Data from five-point Likert scale were available for fifty-two patients. Forty patients were satisfied (5) with the outcome, while five patients were somewhat satisfied (4), and seven were neutral. CONCLUSION Availability of the plastic surgery service at a Level I trauma center is vital for the optimal treatment of facial dog bite injuries. Direct repair and reconstruction of facial dog bite injuries at the earliest opportunity resulted in good outcomes as evidenced by the satisfaction survey data and low complication rate. LEVEL OF EVIDENCE Therapeutic study, level V. Epidemiologic study, level III.

Blood component transfusion increases the risk of death in children with traumatic brain injury.

BACKGROUND Blood transfusion has been associated with worse outcomes in adult trauma patients with traumatic brain injury (TBI). However, the effects in injured children have not been evaluated. We hypothesize that blood transfusion is also associated with worse outcomes in children with TBI. METHODS A retrospective review of the trauma database at two Level I pediatric trauma centers was performed. We reviewed all patients 18 years and younger with TBI, who survived at least 24 hours, from 2002 to 2011. Exclusion criteria include those who underwent craniotomy, thoracotomy, exploratory laparotomy, and any orthopedic procedure. RESULTS A total of 1,607 children with TBI were included in the study population (mean age, 6.4 [5.7] years; 65% male), 178 of whom received a blood transfusion. Mean Injury Severity Score (ISS) was 16.5 (9.1). Patients who received a transfusion had a higher ISS than those who did not (26.7 vs. 15.3). After controlling for age, sex, ISS, Glasgow Coma Scale (GCS) score on presentation, and mechanism of injury, patients who received a blood transfusion were more likely to be admitted to the intensive care unit (p < 0.0001), less likely to survive to hospital discharge (p = 0.02), more likely to be discharged to a rehabilitation facility (p = 0.01) and be dependent on caretakers at follow-up (p < 0.0001), as well as more likely to develop urinary tract infection (p = 0.02) and bacteremia (p = 0.02) during their hospital stay. These differences in outcomes among those who did and did not receive a blood transfusion began to disappear in patients with a nadir hemoglobin of less than 8.0 g/dL. CONCLUSION Pediatric patients sustaining TBI who receive blood transfusion and do not require operative intervention have worse outcomes compared with patients who do not receive transfusion. This includes an increased risk of death. These data suggest that a transfusion trigger of hemoglobin level at 8.0 g/dL in injured children with TBI may be beneficial. LEVEL OF EVIDENCE Epidemiologic study, level III. Therapeutic study, level IV.

Drivers of readmissions in vascular surgery patients

OBJECTIVE Postoperative readmissions are frequent in vascular surgery patients, but it is not clear which factors are the main drivers of readmissions. Specifically, the relative contributions of patient comorbidities vs those of operative factors and postoperative complications are unknown. We sought to study the multiple potential drivers of readmission and to create a model for predicting the risk of readmission in vascular patients. METHODS The 2012-2013 American College of Surgeons National Surgical Quality Improvement Program data set was queried for unplanned readmissions in 86,238 vascular patients. Multivariable forward selection logistic regression analysis was used to model the relative contributions of patient comorbidities, operative factors, and postoperative complications for readmission. RESULTS The unplanned readmission rate was 9.3%. The preoperative model based on patient demographics and comorbidities predicted readmission risk with a low C index of .67; the top five predictors of readmission were American Society of Anesthesiologists class, preoperative open wound, inpatient operation, dialysis dependence, and diabetes mellitus. The postoperative model using operative factors and postoperative complications predicted readmission risk better (C index, .78); postoperative complications were the most significant predictor of readmission, overpowering patient comorbidities. Importantly, postoperative complications identified before discharge from the hospital were not a strong predictor of readmission as the model using predischarge postoperative complications had a similar C index to our preoperative model (.68). However, the inclusion of complications identified after discharge from the hospital appreciably improved the predictive power of the model (C index, .78). The top five predictors of readmission in the final model based on patient comorbidities and postoperative complications were postdischarge deep space infection, superficial surgical site infection, pneumonia, myocardial infection, and sepsis. CONCLUSIONS Readmissions in vascular surgery patients are mainly driven by postoperative complications identified after discharge. Thus, efforts to reduce vascular readmissions focusing on inpatient hospital data may prove ineffective. Our study suggests that interventions to reduce vascular readmissions should focus on prompt identification of modifiable postdischarge complications.

Contributions of planned readmissions and patient comorbidities to high readmission rates in vascular surgery patients.

OBJECTIVE Administrative data show that among surgical patients, readmission rates are highest in vascular surgery. Herein we analyze the contribution of planned readmissions and patient comorbidities to high readmission rates in vascular surgery. METHODS The 2012 to 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set was analyzed for overall and unplanned readmissions. Bivariable and multivariable risk adjustment analyses were performed using patient comorbidities to compare risks of overall and unplanned readmissions in vascular surgery compared with other specialties. RESULTS Among 1,164,421 surgical patients, 86,403 underwent a vascular operation (other specialties included general surgery, 587,829 [51%]; orthopedic surgery, 211,507 [18%]; gynecology, 82,771 [7%]; urology, 62,153 [5%]; neurosurgery, 55,030 [4.7%]; plastic surgery, 32,318 [3%]; otolaryngology, 31,070 [2.6%]; and thoracic surgery, 15,340 [1%]). Incidence of 30-day readmission was 10.2% for vascular and 5.5% for other specialties (P < .0001). Planned readmissions were more frequent for vascular than for other specialties (8.8% vs 5.4%; P < .0001). In unadjusted analysis, vascular patients had significantly greater risk for overall readmission (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.93-2.02; P < .0001) and unplanned readmission (OR, 1.89; 95% CI, 1.84-1.93; P < .0001) compared with other specialties. In bivariable analysis, vascular patients were older (67 ± 13 vs 56 ± 17 years) and had more comorbidities such as diabetes (31% vs 14%), dialysis dependence (6.3% vs 0.9%), American Society of Anesthesiology class III/IV status (84% vs 41%), and many others (all P < .0001). After risk adjustment for baseline differences between groups, vascular patients had a marginally greater overall risk of readmission compared with other specialties (OR, 1.04; 95% CI, 1.01-1.07; P < .0001), but the risk of unplanned readmission was not significantly different (OR, 0.98; 95% CI, 0.95-1.01; P = .13). CONCLUSIONS Incidence of 30-day readmission after vascular surgery appears high, but after account for planned readmissions and risk adjustment, the risk of unplanned readmission is similar to that in other surgical patients. Thus, the use of readmission rate as a quality measure must account for more frequent planned vascular readmissions and patient-specific differences between vascular surgery and other specialties.

Shared decision making in prostate-specific antigen testing: the effect of a mailed patient flyer prior to an annual exam.

Introduction and aims: Professional societies recommend that the decision to screen for prostate cancer involves a shared discussion between patient and provider. Many men are tested without this discussion. Prostate cancer screening decision aids increase patient knowledge and participation in prostate-specific antigen (PSA) testing decisions under ideal circumstances but are often resource intensive and elaborate. There is a need for evaluation of interventions that are low cost, low literacy, and practical for widespread distribution. The authors evaluated the effect of a mailed low-literacy informational patient flyer about the PSA test on measures of shared decision making. Methods: A pragmatic randomized controlled trial comparing the mailed flyer versus usual care was conducted among 303 men aged 50 to 74 years who were scheduled for annual health maintenance exams in 2 general internal medicine clinics (University of Colorado and University of Colorado Hospital). Charts were reviewed after the visits for documentation of PSA screening discussions and PSA testing rates. Follow-up patient surveys assessed include perceived participation in PSA screening decisions, knowledge of the PSA test, and flyer acceptability. Results: Rates of chart-documented PSA discussions were low with no difference between the flyer and control groups (17.7% and 13.6%, respectively; P = .28). Rates of PSA testing were also similar in both groups (62.5% vs 58.5%; P = .48). Rates of patient-reported PSA discussions were higher than the documented rates but also without differences between the groups (71.8% vs 62.3%; P = .22). The intervention had no effect in the PSA knowledge scores (3.5/5 vs 3.3/5, P = .60). Patients found the flyer to be highly acceptable. Conclusions: A mailed low-literacy informational flyer was well received by patients but had no effect on rates of PSA discussions, PSA testing, or patient knowledge of prostate cancer screening.

Chronic School Absenteeism and the Role of Adverse Childhood Experiences

OBJECTIVE To examine the association between chronic school absenteeism and adverse childhood experiences (ACEs) among school-age children. METHODS We conducted a secondary analysis of data from the 2011-2012 National Survey of Childrens Health including children 6 to 17 years old. The primary outcome variable was chronic school absenteeism (≥15 days absent in the past year). We examined the association between chronic school absenteeism and ACEs by logistic regression with weighting for individual ACEs, summed ACE score, and latent class analysis of ACEs. RESULTS Among the 58,765 school-age children in the study sample, 2416 (4.1%) experienced chronic school absenteeism. Witnessing or experiencing neighborhood violence was the only individual ACE significantly associated with chronic absenteeism (adjusted odds ratio [aOR] 1.55, 95% confidence interval [CI] 1.20-2.01). Having 1 or more ACE was significantly associated with chronic absenteeism: 1 ACE (aOR 1.35, 95% CI 1.02-1.79), 2 to 3 ACEs (aOR 1.81, 95% CI 1.39-2.36), and ≥4 ACEs (aOR 1.79, 95% CI 1.32-2.43). Three of the latent classes were also associated with chronic absenteeism, and children in these classes had a high probability of endorsing neighborhood violence, family substance use, or having multiple ACEs. CONCLUSIONS ACE exposure was associated with chronic school absenteeism in school-age children. To improve school attendance, along with future graduation rates and long-term health, these findings highlight the need for an interdisciplinary approach to address child adversity that involves pediatricians, mental health providers, schools, and public health partners.

Head injury and unclear mechanism of injury: Initial hematocrit less than 30 is predictive of abusive head trauma in young children

PURPOSE Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT. METHODS A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002-2011. RESULTS A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P<.0001), as was a platelet count of greater than 400,000 (P<.0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P<.05). CONCLUSIONS In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years.