Teresa M. Bell

Insurance status is a predictor of failure to rescue in trauma patients at both safety net and non-safety net hospitals.

BACKGROUND Disparities in outcomes for uninsured trauma patients have been well documented. This study investigates whether failure to rescue (FTR) is a driver of mortality disparities after injury and whether patients treated at hospitals with a large volume of uninsured patients are more likely to die after complication. METHODS A retrospective cohort study that analyzed patient records included in the National Trauma Data Bank from years 2008 to 2010 was performed. Hierarchical logistic regression was used to examine the probability that insurance type would be associated with complications, FTR, and in-hospital mortality while controlling for injury severity, mechanism of trauma, age, sex, race, comorbidities, head injury, hypotension, and hospital clustering. Additional regression models that stratified insurance subgroups and hospital subgroups were also performed. RESULTS The uninsured patients had the lowest likelihood of developing a complication, and publicly insured patients were most likely to develop a complication compared with privately insured patients (uninsured odds ratio [OR], 0.86; government OR, 1.44). Despite having a lower risk of complication, the uninsured group was significantly more likely to experience FTR than publicly or privately insured patients (OR, 1.34). There was no significant difference in the FTR outcome between private and publicly insured patients. Both the uninsured and publicly insured patients were significantly more likely to die in the hospital than privately insured patients (uninsured OR, 1.26l; government OR, 1.17). There were no differences in complications, FTR, or mortality between safety net and non–safety net hospitals. CONCLUSION The uninsured patients are more likely to experience FTR than the privately insured patients. Resources should be focused on this patient population to prevent complications and to study the reasons for higher mortality in these patients after they experience a complication. LEVEL OF EVIDENCE Prognostic study, level III.

Determining the Drivers of Academic Success in Surgery: An Analysis of 3,850 Faculty

Objective Determine drivers of academic productivity within U.S. departments of surgery. Methods Eighty academic metrics for 3,850 faculty at the top 50 NIH-funded university- and 5 outstanding hospital-based surgical departments were collected using websites, Scopus, and NIH RePORTER. Results Mean faculty size was 76. Overall, there were 35.3% assistant, 27.8% associate, and 36.9% full professors. Women comprised 21.8%; 4.9% were MD-PhDs and 6.1% PhDs. By faculty-rank, median publications/citations were: assistant, 14/175, associate, 39/649 and full-professor, 97/2250. General surgery divisions contributed the most publications and citations. Highest performing sub-specialties per faculty member were: research (58/1683), transplantation (51/1067), oncology (41/777), and cardiothoracic surgery (48/860). Overall, 23.5% of faculty were principal investigators for a current or former NIH grant, 9.5% for a current or former R01/U01/P01. The 10 most cited faculty (MCF) within each department contributed to 42% of all publications and 55% of all citations. MCF were most commonly general (25%), oncology (19%), or transplant surgeons (15%). Fifty-one-percent of MCF had current/former NIH funding, compared with 20% of the rest (p<0.05); funding rates for R01/U01/P01 grants was 25.1% vs. 6.8% (p<0.05). Rate of current-NIH MCF funding correlated with higher total departmental NIH rank (p < 0.05). Conclusions Departmental academic productivity as defined by citations and NIH funding is highly driven by sections or divisions of research, general and transplantation surgery. MCF, regardless of subspecialty, contribute disproportionally to major grants and publications. Approaches that attract, develop, and retain funded MCF may be associated with dramatic increases in total departmental citations and NIH-funding.

Emergency general surgery outcomes at safety net hospitals

BACKGROUND The United States hospital safety net is defined by the Agency for Healthcare Research and Quality as the top decile of hospitals, which see the greatest proportion of uninsured patients. These hospitals provide important access to health care for uninsured patients but are commonly believed to have worse outcomes. The aim of this study was to compare the outcomes of emergency general surgery procedures performed at safety net and nonsafety net hospitals. MATERIAL AND METHODS The Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2008-2010 was used to create a cohort of inpatients who underwent emergency appendectomy, cholecystectomy, or herniorrhaphy. Outcomes measured included length of stay, charge, cost, death in hospital, complications, and failure to rescue (FTR). Univariate and logistic regression analysis was performed to associate variables with outcomes. RESULTS A total of 187,913 emergency general surgery cases were identified, 11.5% of which were performed at safety net hospitals. The safety net cohort had increased length of stay but lower mean charge and cost. Age, comorbidity score, black race, male gender, and Medicaid and Medicare insurance were associated with mortality, complication, and FTR. Lower socioeconomic status was associated with mortality and complication. Safety net status was positively associated with complication but not mortality or FTR. CONCLUSIONS Safety net hospitals had higher complication rates but no difference in FTR or mortality. This may mean that the hospitals are able to effectively recognize and treat patient complications and do so without increased cost.

A Novel Approach in Combined Liver and Kidney Transplantation with Long-term Outcomes

Objective: The aim of this study was to compare the outcomes of simultaneous and delayed implantation of kidney grafts in combined liver-kidney transplantation (CLKT). Background Data: Delayed function of the renal graft (DGF), which can result from hypotension and pressor use related to the liver transplantation (LT), may cause worse outcomes in CLKT. Methods: A total of 130 CLKTs were performed at Indiana University between 2002 and 2015 and studied in an observational cohort study. All kidneys underwent continuous hypothermic pulsatile machine perfusion until transplant: 69 with simultaneous kidney transplantation (KT) (at time of LT, group 1) and 61 with delayed KT (performed at a later time as a second operation, group 2). All patients received continuous veno-venous hemodialysis during the LT. Propensity score match analysis in a 1:1 case-match was performed. Results: Mean kidney cold ischemia time was 10 ± 3 and 50 ± 15 hours, for groups 1 and 2 (P < 0.0001), respectively. The rate of DGF was 7.3% in group 1, but no DGF was seen in group 2 (P = 0.0600). Kidney function was significantly better in group 2, if the implantation of kidneys was delayed >48 hours (P < 0.01). Patient survival was greater in group 2 at 1 year (91%), and 5 year (87%) post-transplantation (P = 0.0019). On multivariate analysis, DGF [hazard ratio (HR), 165.7; 95% confidence interval (CI), 9.4–2926], extended criteria donor kidneys (HR, 15.9; 95% CI 1.8–145.2), and recipient hepatitis C (HR, 5.5; 95% CI 1.7–17.8) were significant independent risk factors for patient survival. Conclusions: Delayed KT in CLKT (especially if delayed >48 h) is associated with improved kidney function with no DGF post-KT, and improved patient and graft survival.

State all-driver distracted driving laws and high school students' texting while driving behavior

ABSTRACT Objective: Texting while driving is highly prevalent among adolescents and young adults in the United States. Texting while driving can significantly increase the risk of road crashes and is associated with other risky driving behaviors. Most states have enacted distracted driving laws to prohibit texting while driving. This study examines effects of different all-driver distracted driving laws on texting while driving among high school students. Methods: High school student data were extracted from the 2013 National Youth Risk Behavior Survey. Distracted driving law information was collected from the National Conference of State Legislatures. The final sample included 6,168 high school students above the restricted driving age in their states and with access to a vehicle. Logistic regression was applied to estimate odds ratios of laws on texting while driving. Results: All-driver text messaging bans with primary enforcement were associated with a significant reduction in odds of texting while driving among high school students (odds ratio = 0.703; 95% confidence interval, 0.513–0.964), whereas all-driver phone use bans with primary enforcement did not have a significant association with texting while driving (odds ratio = 0.846; 95% confidence interval, 0.501–1.429). Conclusions: The findings indicate that all-driver distracted driving laws that specifically target texting while driving as opposed to all types of phone use are effective in reducing the behavior among high school students.

Right Ventricular Outflow Tract Reconstruction With a Polytetrafluoroethylene Monocusp Valve: A 20-Year Experience

In patients with tetralogy of Fallot (TOF), pulmonary atresia (PA), and other congenital right ventricular outflow tract (RVOT) malformations, polytetrafluoroethylene (PTFE) monocusp outflow tract patches (MOTP) relieve obstruction and provide pulmonary valve competence. The purpose of this study was to determine whether our PTFE-MOTP was an acceptable short- and mid-term remedy for patients with TOF or PA as assessed by freedom from severe pulmonary regurgitation and freedom from reoperation. From 1994-2014, 171 patients (mean age 1.5 ± 1.5 years; median 1.1 years) with TOF or PA underwent initial right ventricular outflow tract (RVOT) reconstruction with a PTFE-MOTP. Patients were studied intraoperatively and serially postoperatively using echocardiography and cardiac magnetic resonance imaging (CMR) to determine pulmonary valve dysfunction defined as a peak gradient >40mmHg or valve regurgitation>moderate. The mean follow-up duration was 10.9 ± 5.8 years (range: 1 month-20 years). There were 5 late deaths and 1 early death. There was a significant difference between the preoperative and postoperative peak RVOT gradients (74.0 vs 25.2mmHg). Of the 171 patients, 25 were lost to follow-up, and 42 have required replacement of their monocusp valves 10.1 ± 5.0 years (range: 5 months-19 years) after original monocusp insertion. At 10-year follow-up, severe pulmonary regurgitation was seen in less than 25% of patients, and severe pulmonary stenosis was seen in less than 10% of patients. Since 2007, CMR was used in 44 patients to characterize cardiac function in patients under consideration for PTFE-MOTP replacement. The average right ventricular-to-left ventricular (RV/LV) ratio on CMR was 1.7 ± 0.5 in these patients. CMR also showed that RV ejection fraction (52 ± 9%) and left ventricular ejection fraction (58 ± 7%) were both preserved in most patients. The PTFE-MOTP is an excellent short-term and mid-term option for initial RVOT reconstruction, particularly in children with TOF with nonsalvageable pulmonary valve or PA-ventricular septal defect.

The impact of preexisting comorbidities on failure to rescue outcomes in nonelderly trauma patients.

BACKGROUND Death after complication or “failure to rescue” (FTR) contributes to differences in risk-adjusted mortality rates among trauma centers and is considered an indicator of quality of care. Successful management of trauma patients requires not only appropriately responding to complications but also timely recognition of adverse events. Identifying associations between patient characteristics, such as the presence of comorbidities, and FTR outcomes can potentially improve early detection of complications and can reduce the risk of in-hospital mortality. METHODS We performed a retrospective cohort study that analyzed patient records included in the National Trauma Data Bank from years 2008 to 2010. Cox regression modeling was used to determine the contribution of individual comorbidities to FTR outcomes while controlling for confounding variables. RESULTS Diabetes, congestive heart failure, history of myocardial infarction, and dialysis were associated with greater hazard ratios (HRs) (95% confidence interval [CI]) for FTR (1.19 [1.05–1.35], 1.63 [1.30–2.05], 1.40 [1.08–1.81], 2.34 [1.72–3.19], respectively). Smoking, alcoholism, and respiratory disease were associated with a lower risk of FTR (HR [95% CI], 0.68 [0.60–0.77]; 0.88 [0.80–0.98]; and 0.77 [0.66–0.91], respectively). Obesity and hypertension were not associated with increased risk of FTR. CONCLUSION Preexisting comorbidities contributed significantly to risk of death after complication in the trauma population. Identifying processes of care that lead to better management of complications in patients with comorbidities would improve trauma centers’ overall mortality outcomes. LEVEL OF EVIDENCE Prognostic study, level IV.

Variation in Surgical Antibiotic Prophylaxis for Outpatient Pediatric Urological Procedures at United States Children’s Hospitals

Purpose: Guidelines recommend surgical antibiotic prophylaxis for clean‐contaminated procedures but none for clean procedures. The purpose of this study was to describe variations in surgical antibiotic prophylaxis for outpatient urological procedures at United States children’s hospitals. Materials and Methods: Using the PHIS (Pediatric Health Information System®) database we performed a retrospective cohort study of patients younger than 18 years who underwent clean and/or clean‐contaminated outpatient urological procedures from 2012 to 2014. We excluded those with concurrent nonurological procedures or an abscess/infected wound. We compared perioperative antibiotic charges for clean vs clean‐contaminated procedures using a multilevel logistic regression model with a random effect for hospital. We also examined whether hospitals that were guideline compliant for clean procedures, defined as no surgical antibiotic prophylaxis, were also compliant for clean‐contaminated procedures using the Pearson correlation coefficient. We examined hospital level variation in antibiotic rates using the coefficient of variation. Results: A total of 131,256 patients with a median age of 34 months at 39 hospitals met study inclusion criteria. Patients undergoing clean procedures were 14% less likely to receive guideline compliant surgical antibiotic prophylaxis than patients undergoing clean‐contaminated procedures (OR 0.86, 95% CI 0.84–0.88, p <0.0001). Hospitals that used antibiotics appropriately for clean‐contaminated procedures were more likely to use antibiotics inappropriately for clean procedures (r = 0.7, p = 0.01). Greater variation was seen for hospital level compliance with surgical antibiotic prophylaxis for clean‐contaminated procedures (range 9.8% to 97.8%, coefficient of variation 0.36) than for clean procedures (range 35.0% to 98.2%, coefficient of variation 0.20). Conclusions: Hospitals that used surgical antibiotic prophylaxis appropriately for clean‐contaminated procedures were likely to use surgical antibiotic prophylaxis inappropriately for clean procedures. More variation was seen in hospital level guideline compliance for clean‐contaminated procedures.

The Role of PhD Faculty in Advancing Research in Departments of Surgery.

Objective: To determine the academic contribution as measured by number of publications, citations, and National Institutes of Health (NIH) funding from PhD scientists in US departments of surgery. Summary Background Data: The number of PhD faculty working in US medical school clinical departments now exceeds the number working in basic science departments. The academic impact of PhDs in surgery has not been previously evaluated. Methods: Academic metrics for 3850 faculties at the top 55 NIH-funded university and hospital-based departments of surgery were collected using NIH RePORTER, Scopus, and departmental websites. Results: MD/PhDs and PhDs had significantly higher numbers of publications and citations than MDs, regardless of academic or institutional rank. PhDs had the greatest proportion of NIH funding compared to both MDs and MD/PhDs. Across all academic ranks, 50.2% of PhDs had received NIH funding compared with 15.2% of MDs and 33.9% of MD/PhDs (P < 0.001). The proportion of PhDs with NIH funding in the top 10 departments did not differ from those working in departments ranked 11 to 50 (P = 0.456). A greater percentage of departmental PhD faculty was associated with increased rates of MD funding. Conclusions: The presence of dedicated research faculty with PhDs supports the academic mission of surgery departments by increasing both NIH funding and scholarly productivity. In contrast to MDs and MD/PhDs, PhDs seem to have similar levels of academic output and funding independent of the overall NIH funding environment of their department. This suggests that research programs in departments with limited resources may be enhanced by the recruitment of PhD faculty.

Tissue damage volume predicts organ dysfunction and inflammation after injury

BACKGROUND Multiply injured patients (MIPs) are at risk to develop multiple-organ failure (MOF) and prolonged systemic inflammation response syndrome (SIRS). It is difficult to predict which MIPs are at the highest risk to develop these complications. We have developed a novel method that quantifies the distribution and physical magnitude of all injuries identified on admission computed tomography scanning called the Tissue Damage Volume (TDV) score. We explored how individualized TDV scores corresponded to MOF and SIRS. MATERIALS AND METHODS A retrospective study on 74 MIPs measured mechanical TDV by calculating injury volumes on admission computed tomography scans of all injuries in the head/neck, chest, abdomen, and pelvis. Regional and total TDV scores were compared between patients that did or did not develop MOF or sustained SIRS. The magnitude of organ dysfunction was also stratified by the magnitude of TDV. RESULTS Mean total and pelvic TDV scores were significantly increased in patients who developed MOF. Mean total, chest, and abdominal TDV scores were increased in patients who developed sustained SIRS. The magnitude of organ dysfunction was significantly higher in patients who sustained large volume injuries in the pelvis or abdomen, and in patients who sustained injuries in at least three anatomic regions. CONCLUSIONS A novel index that quantifies the magnitude and distribution of mechanical tissue damage volume is a patient-specific index that can be used to identify patients who have sustained injury patterns that predict progression to MOF and SIRS. The preliminary methods will need refinement and prospective validation.