Wendy R. Greene

Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma

BACKGROUND Patients with penetrating injuries are known to have worse outcomes than those with blunt trauma. We hypothesize that within each injury mechanism there should be no outcome difference between insured and uninsured patients. METHODS The National Trauma Data Bank version 7 was analyzed. Patients aged 65 years and older and burn patients were excluded. The insurance status was categorized as insured (private, government/military, or Medicaid) and uninsured. Multivariate analysis adjusted for insurance status, mechanism of injury, age, race, sex, injury severity score, shock, head injury, extremity injury, teaching hospital status, and year. RESULTS A total of 1,203,243 patients were analyzed, with a mortality rate of 3.7%. The death rate was significantly higher in penetrating trauma patients versus blunt trauma patients (7.9% vs 3.0%; P < .001), and higher in the uninsured (5.3% vs 3.2%; P < .001). On multivariate analysis, uninsured patients had an increased odds of death than insured patients, in both penetrating and blunt trauma patients. Penetrating trauma patients with insurance still had a greater risk of death than blunt trauma patients without insurance. CONCLUSIONS Insurance status is a potent predictor of outcome in both penetrating and blunt trauma.

Negative appendectomy: a 10-year review of a nationally representative sample

BACKGROUND Appendectomy remains one of the most common emergency surgical procedures encountered throughout the United States. With improvements in diagnostic techniques, the efficiency of diagnosis has increased over the years. However, the entity of negative appendectomies still poses a dilemma because these are associated with unnecessary risks and costs to both patients and institutions. This study was conducted to show current statistics and trends in negative appendectomy rates in the United States. METHODS A retrospective analysis was conducted using data from the National Inpatient Sample from 1998 to 2007. Adult patients (>18 y) having undergone appendectomies were identified by the appropriate International Classification of Diseases 9th revision codes. Patients with incidental appendectomy and those with appendiceal pathologies, also identified by relevant International Classification of Diseases 9th revision codes, were excluded. The remaining patients represent those who underwent an appendectomy without appendiceal disease. The patients then were stratified according to sex, women were classified further into younger (18-45 y) and older (>45 y) based on child-bearing age. The primary diagnoses subsequently were categorized by sex to identify the most common conditions mistaken for appendiceal disease in the 2 groups. RESULTS Between 1998 and 2007, there were 475,651 cases of appendectomy that were isolated. Of these, 56,252 were negative appendectomies (11.83%). There was a consistent decrease in the negative appendectomy rates from 14.7% in 1998 to 8.47% in 2007. Women accounted for 71.6% of cases of negative appendectomy, and men accounted for 28.4%. The mortality rate was 1.07%, men were associated with a higher rate of mortality (1.93% vs .74%; P < .001). Ovarian cyst was the most common diagnosis mistaken for appendicitis in younger women, whereas malignant disease of the ovary was the most common condition mistaken for appendiceal disease in women ages 45 and older. The most common misdiagnosis in men was diverticulitis of the colon. CONCLUSIONS There has been a consistent decline in the rates of negative appendectomy. This trend may be attributed to better diagnostics. Gynecologic conditions involving the ovary are the most common to be misdiagnosed as appendiceal disease in women.

Outcomes of trauma care at centers treating a higher proportion of older patients: The case for geriatric trauma centers

BACKGROUND The burden of injury among older patients continues to grow and accounts for a disproportionate number of trauma deaths. We wished to determine if older trauma patients have better outcomes at centers that manage a higher proportion of older trauma patients. METHODS The National Trauma Data Bank years 2007 to 2011 was used. All high-volume Level 1 and Level 2 trauma centers were included. Trauma centers were categorized by the proportion of older patients seen. Adult trauma patients were categorized as older (≥65 years) and younger adults (16–64 years). Coarsened exact matching was used to determine differences in mortality and length of stay between older and younger adults. Risk-adjusted mortality ratios by proportion of older trauma patients seen were analyzed using multivariate logistic regression models and observed-expected ratios. RESULTS A total of 1.9 million patients from 295 centers were included. Older patients accounted for one fourth of trauma visits. Matched analysis revealed that older trauma patients were 4.2 times (95% confidence interval, 3.99–4.50) more likely to die than younger patients. Older patients were 34% less likely to die if they presented at centers treating a high versus low proportion of older trauma (odds ratio, 0.66; 95% confidence interval, 0.54–0.81). These differences were independent of trauma center performance. CONCLUSION Geriatric trauma patients treated at centers that manage a higher proportion of older patients have improved outcomes. This evidence supports the potential advantage of treating older trauma patients at centers specializing in geriatric trauma. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Does the Pattern of Injury in Elderly Pedestrian Trauma Mirror That of The Younger Pedestrian

BACKGROUND Walking is the primary mode of transportation for people aged 65 y and over; hence pedestrian injuries are a substantial source of morbidity and mortality among elderly patients in the United States. This study is aimed at evaluating the pattern of injury in the elderly pedestrians and how it differs from younger patients. METHODS Retrospective analysis of the National Trauma Data Bank (2002-2006) was performed, with inclusion criteria defined as pedestrian injuries based on ICD-9 codes, excluding age < 15 y. The following age categories in years were created: 15-24 (reference group), 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85-89. The injury prevalence was compared, and multivariate regression for mortality was conducted adjusting for demographic and injury characteristics. RESULTS A total of 79,307 patients were analyzed. Superficial injuries were the most common at 29.1%, with lower extremity fractures and intracranial injuries following at 25.1% and 21.4% respectively. The very elderly (75-84 and 85-89) had significantly higher rates of fractures of the pelvis(16.2% and 16.8% versus 8.1% in the youngest group), upper (19.3% and 18.4% versus 9.8%), lower extremities (31.1% and 31.9% versus 22.5%) and intracranial injuries (25.5% and 28.7% versus 22.4%), but sustained lower rates of hepatic (2.3% and 1.7% versus 3.0%) injuries, with no difference seen in pancreatic, splenic, and genitourinary injuries. On multivariate analysis, very elderly patients were six to eight times more likely to die (OR 6.24 and 8.27, P < 0.001). CONCLUSION Elderly patients have higher rates of fractures and intracranial injuries with an extremely worse mortality after pedestrian trauma.

Redefining hypotension in the elderly: normotension is not reassuring.

BACKGROUND Recent debate concerns the most appropriate definition of hypotension. Some have advocated raising the systolic blood pressure (BP) threshold to 110 mm Hg while others favor 80 mm Hg. HYPOTHESIS The optimal definition of hypotension differs by age group. DESIGN An analysis was performed of trauma victims 18 years and older in the National Trauma Data Bank, excluding burn injury patients and those with incomplete data. SETTING Injured patients who were hospitalized in various trauma centers across the continental United States. PATIENTS Three age groups were identified for analysis as follows: 18 to 35 years, 36 to 64 years, and 65 years and older. One hundred one multiple logistic regression analyses were performed for each population. Hypotension was sequentially defined as an emergency department systolic BP (SBP) of 50 to 150 mm Hg to see which model best predicted mortality, adjusting for demographic and injury covariates. The discriminatory power of each model was measured using the area under the receiver operating characteristic (AUROC) curve. Optimally defined hypotension was identified as the model with the highest AUROC curve. MAIN OUTCOMES MEASURE In-hospital mortality. RESULTS A total of 902,852 patients (median age, 44 years; 66.2% men) were analyzed. Overall mortality was 4.1%. Optimal emergency department SBP cutoff values for hypotension were 85 mm Hg for patients aged 18 to 35 years, 96 mm Hg for patients aged 36 to 64 years, and 117 mm Hg for elderly patients. CONCLUSIONS For patients younger than 65 years, the classic definition of hypotension as an emergency department SBP less than 90 mm Hg remains optimal. With increasing involvement of elderly individuals in trauma and their peculiarity as a comorbid state, there is a need to redefine what is presently defined as a cutoff value for hypotension in elderly patients.

Disparities in trauma care: are fewer diagnostic tests conducted for uninsured patients with pelvic fracture?

BACKGROUND Research from other medical specialties suggests that uninsured patients experience treatment delays, receive fewer diagnostic tests, and have reduced health literacy when compared with their insured counterparts. We hypothesized that these disparities in interventions would not be present among patients experiencing trauma. Our objective was to examine differences in diagnostic and therapeutic procedures administered to patients undergoing trauma with pelvic fractures using a national database. METHODS A retrospective analysis was conducted using the National Trauma Data Bank (NTDB), 2002 to 2006. Patients aged 18 to 64 years who experienced blunt injuries with pelvic fractures were analyzed. Patients who were dead on arrival, those with an injury severity score (ISS) less than 9, those with traumatic brain injury, and patients with burns were excluded. The likelihood of the uninsured receiving select diagnostic and therapeutic procedures was compared with the same likelihood in the insured. Multivariate analysis for mortality was conducted, adjusting for age, sex, race, ISS, presence of shock, Glasgow Coma Scale (GCS) motor score, and mechanism of injury. RESULTS Twenty-one thousand patients met the inclusion criteria: 82% of these patients were insured and 18% were uninsured. There was no clinical difference in ISSs (21 vs 20), but the uninsured were more likely to present in shock (P < .001). The mortality rate in the uninsured was 11.6% vs 5.0% in the insured (P < .001). The uninsured were less likely to receive vascular ultrasonography (P = .01) and computed tomography (CT) of the abdomen (P < .005). There was no difference in the rates of CT of the thorax and abdominal ultrasonography, but the uninsured were more likely to receive radiographs. There was no difference in exploratory laparotomy and fracture reduction, but uninsured patients were less likely to receive transfusions, central venous pressure (CVP) monitoring, or arterial catheterization for embolization. Insurance-based disparities were less evident in level 1 trauma centers. CONCLUSIONS Uninsured patients with pelvic fractures get fewer diagnostic procedures compared with their insured counterparts; this disparity is much greater for more invasive and resource-intensive tests and is less apparent in level 1 trauma centers. Differences in care that patients receive after trauma may be 1 of the mechanisms that leads to insurance disparities in outcomes after trauma.

The Impact of Insurance Status on Actuarial Survival in Hospitalized Trauma Patients: When Do They Die?

BACKGROUND Previous work has suggested that insurance status, gender, and ethnicity all have an independent association with mortality after trauma. The purpose of this study is to investigate whether these factors exerted survival impact that could be observed throughout the hospital stay. METHODS Using the National Trauma Data Bank (version 7.0), a Cox proportional hazards survival analysis was performed on young (19-30 years old) trauma patients to mitigate the impact of comorbid confounders. Variables included in the model were age, gender, ethnicity, Injury Severity Score, presence of shock at presentation, mechanism of injury, insurance status, year of admission, teaching status of the hospital, diagnosis of substance abuse or psychotic disorders, and complications after admission. Rate ratios (RRs) comparing the slopes of the adjusted survival curves were calculated using the Mantel-Cox method. RESULTS A total of 192,488 young trauma patients were identified with complete data. Increased hazard of death was seen in patients who were uninsured (hazard ratio [HR]=1.69, 95% confidence interval [CI]=1.59-1.80, p<0.001), of a minority ethnicity (HR=1.08, 95% CI=1.01-1.15, p=0.025) or men (HR=1.14, 95% CI=1.04-1.23, p=0.004). RRs were significantly larger between insurance status (RR=1.75, 95% CI=1.58-1.94, p<0.001) than between race (RR=1.23, 95% CI=1.10-1.37, p<0.001) or between gender (RR=1.16, 95% CI=1.01-1.32, p=0.030). CONCLUSION Risk of death on the first hospital day after injury differs by insurance status, and this disparity becomes more pronounced throughout the hospital stay. Further study is necessary to determine whether this is a result of additional unmeasured patient covariates with insurance status or a difference in provider behavior in response to patient insurance status.

Racial/Ethnic Disparities in Amputation and Revascularization: A Nationwide Inpatient Sample Study

This study investigates whether ethnic minorities presenting with critical limb ischemia (CLI) are more likely to undergo major limb amputation compared to white patients. The Nationwide Inpatient Sample (NIS) database was used to identify all patients admitted with CLI; lower extremity revascularization; and major lower extremity amputation from 1998 to 2005. The NIS identified 240 139 patients presenting with CLI—68.2% white, 19.5% black, 9.0% Hispanic, and 1.24% Asian. In all, 83 328 patients underwent revascularization—73.7% white, 15.9% black, 7.4% Hispanic, and 1.1% Asian. The majority of the interventions were open. In all, 111 548 patients underwent a major lower extremity amputation—61% white, 25.4% black, 10.1% Hispanic, and 1.1% Asian. The mean Charlson comorbidity scores for amputation were 2.1 for whites, 2.0 for blacks, 2.3 for Hispanics, and 2.5 for Asians (for all data, P < .05). Blacks make up a disproportionately higher proportion of patients admitted for CLI and undergoing amputation, with a lower proportion undergoing revascularization.

Laparoscopic surgery for trauma: the realm of therapeutic management

BACKGROUND The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. METHODS We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. RESULTS Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). CONCLUSION Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes.

Predictors for Survival of Penetrating Trauma Using Emergency Department Thoracotomy in an Urban Trauma Center: The Cardiac Instability Score

BACKGROUND Emergency department thoracotomy (EDT) is a procedure used in an attempt to save lives of patients in extremis. This study aims to determine predictors of survival and futility by proposing a scoring scale that measures cardiac instability and its use in predicting survival of victims of penetrating trauma undergoing EDT. METHODS This retrospective study analyzes patients who underwent EDT during a 45-month period at Howard University Hospital, Washington, DC. Vital signs and Glasgow Coma scale (GCS) scores were analyzed at the scene and in the emergency department. A cardiac instability score (CIS) was devised to assign values to vital signs, and the GCS was based on scores from the emergency department. RESULTS Emergency department vital signs, female gender, absence of cardiopulmonary resuscitation (CPR), and high CIS were found to be statistically significant predictors of survival. CONCLUSIONS The CIS correlated with survival of patients who underwent EDT and was found to be statistically significant in determining the outcome of an EDT.