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Injury is reported as one of the leading causes of morbidity and mortality globally. However, its burden stays under-reported in low- and middle-income countries, which prevents understanding of the true distribution and impact of injury worldwide. This dearth of data not only includes the burden of trauma-associated mortality but also involves the identification of long-term patient-reported outcomes after injury. High-income countries have shown that the development of trauma registries can achieve proper data collection, the findings from which can ultimately decrease trauma-associated morbidity and mortality. Expanding such an initiative to low-resource settings with high injury proportions can aid in understanding the long-term outcomes of post-trauma patients, identifying the factors that continue to contribute to its injury burden, and developing strategies catered to reducing it. Here, we discuss the variation in the global injury burden and go a step beyond mortality to highlight the importance of capturing long-term patient-reported outcomes post-trauma. We describe the process of developing trauma registries in high-income countries and extrapolate the findings from this experience to set up similar registries in resource-limited settings. Lastly, we demonstrate the feasibility and initial impact of using its data on identifying predictors of in-hospital mortality and determining long-term patient-reported outcomes in the context of low-resource settings. Through these findings, we share the outlook of an evolved trauma care system in both high- and low-income regions with reduced morbidity and mortality globally., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To compare the needs based assessment of trauma systems (NBATS) tool estimates of trauma center need to the existing trauma infrastructure using observed national trauma volume., Summary of Background Data: Robust trauma systems have improved outcomes for severely injured patients. The NBATS tool was created by the American College of Surgeons to align trauma resource allocation with regional needs., Methods: Data from the Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases, the Trauma Information Exchange Program, and US Census was used to calculate an NBATS score for each trauma service area (TSA) as defined by the Pittsburgh Atlas. This score was used to estimate the number of trauma centers allocated to each TSA and compared to the number of existing trauma centers., Results: NBATS predicts the need for 117 additional trauma centers across the United States to provide adequate access to trauma care nationwide. At least 1 additional trauma center is needed in 49% of TSAs., Conclusions: Application of the NBATS tool nationally shows the need for additional trauma infrastructure across a large segment of the United States. We identified some limitations of the NBATS tool, including preferential weighting based on current infrastructure. The NBATS tool provides a good framework to begin the national discussion around investing in the expansion of trauma systems nationally, however, in many instances lacks the granularity to drive change at the local level., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: We sought to examine the association and potential mediators between sex and long-term trauma outcomes., Methods: Moderately-to-severely injured patients admitted to 3 level-1 trauma centers were contacted between 6 and 12-months post-injury to assess for functional limitations, use of pain medications, and posttraumatic stress disorder (PTSD). Multivariable adjusted regression analyses were used to compare long-term outcomes by sex. Potential mediators of the relationship between sex and outcomes was explored using mediation analysis., Results: 2607 patients were followed, of which 45% were female. Compared to male, female patients were more likely to have functional limitations (OR: 1.45; 95% CI: 1.31-1.60), take pain medications (OR: 1.17; 95% CI: 1.02-1.38), and screen positive for PTSD (OR: 1.60; 95% CI: 1.46-1.76) post-injury. Age, extremity injury, previous psychiatric illness, and pre-injury unemployment, partially mediated the effect of female sex on long-term outcomes., Conclusions: There are significant sex differences in long-term trauma outcomes, which are partially driven by patient and injury-related factors., Competing Interests: Declaration of competing interest The authors of this manuscript certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Violence continues to be a significant public health burden, but little is known about the long-term outcomes of these patients. Our goal was to determine the impact of violence-related trauma on long-term functional and psychosocial outcomes., Methods: We identified trauma patients with moderate to severe injuries (Injury Severity Score, ≥9) treated at one of three level 1 trauma centers. These patients were asked to complete a survey over the phone between 6 and 12 months after injury evaluating both functional and psychosocial outcomes (12-item Short Form Survey, Trauma Quality of Life, posttraumatic stress disorder [PTSD] screen, chronic pain, return to work). Patients were classified as having suffered a violent injury if the mechanism of injury was a stab, gunshot, or assault. Self-inflicted wounds were excluded. Adjusted logistic regression models were built to determine the association between a violent mechanism of injury and long-term outcomes., Results: A total of 1,050 moderate to severely injured patients were successfully followed, of whom 176 (16.8%) were victims of violence. For the victims of violence, mean age was 34.4 years (SD, 12.5 years), 85% were male, and 57.5% were Black; 30.7% reported newly needing help with at least one activity of daily living after the violence-related event. Fifty-nine (49.2%) of 120 patients who were working before their injury had not yet returned to work; 47.1% screened positive for PTSD, and 52.3% reported chronic pain. On multivariate analysis, a violent mechanism was significantly associated with PTSD (odds ratio, 2.57; 95% confidence interval, 1.59-4.17; p < 0.001) but not associated with chronic pain, return to work, or functional outcomes., Conclusion: The physical and mental health burden after violence-related trauma is not insignificant. Further work is needed to identify intervention strategies and social support systems that may be beneficial to reduce this burden., Level of Evidence: Prognostic and epidemiological, level III., (Copyright © 2021 American Association for the Surgery of Trauma.)

Background: The aim of this scoping review is to identify and summarize patient-reported outcome measures (PROMs) that are being used to track long-term patient-reported outcomes (PROs) after injury and can potentially be included in trauma registries., Methods: Online databases were used to identify studies published between 2013 and 2019, from which we selected 747 articles that involved survivors of acute physical traumatic injury aged 18 years or older at time of injury and used PROMs to evaluate recovery between 6 months and 10 years postinjury. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results., Results: Most studies were observational, with relatively small sample sizes, and predominantly on traumatic brain injury or orthopedic patients. The number of PROs assessed per study varied from one to 12, for a total of 2052 PROs extracted, yielding 74 unique constructs (physical health, 25 [34%]; mental health, 27 [37%]; social health, 12 [16%]; cognitive health, 7 [10%]; and quality of life, 3 [4%]). These 74 constructs were assessed using 355 different PROMs. Mental health was the most frequently examined outcome domain followed by physical health. Health-related quality of life, which appeared in more than half of the studies (n = 401), was the most common PRO evaluated, followed by depressive symptoms. Physical health was the domain with the highest number of PROMs used (n = 157), and lower-extremity functionality was the PRO that contributed most PROMs (n = 33)., Conclusion: We identified a wide variety of PROMs available to track long-term PROs after injury in five different health domains: physical, mental, social, cognitive, and quality of life. However, efforts to fully understand the health outcomes of trauma patients remain inconsistent and insufficient. Defining PROs that should be prioritized and standardizing the PROMs to measure them will facilitate the incorporation of long-term outcomes in national registries to improve research and quality of care., Level of Evidence: Systematic Reviews & Meta-analyses, Level IV., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Background: Nearly 4 million Americans present to hospitals with conditions requiring emergency general surgery (EGS) annually, facing significant morbidity and mortality. Unlike elective surgery and trauma, there is no dedicated national quality improvement program to improve EGS outcomes. Our objective was to estimate the number of excess deaths that could potentially be averted through EGS quality improvement in the United States., Methods: Adults with the American Association for the Surgery of Trauma-defined EGS diagnoses were identified in the Nationwide Emergency Department Sample 2006 to 2014. Hierarchical logistic regression was performed to benchmark treating hospitals into reliability adjusted mortality quintiles. Weighted generalized linear modeling was used to calculate the relative risk of mortality at each hospital quintile, relative to best-performing quintile. We then calculated the number of excess deaths at each hospital quintile versus the best-performing quintile using techniques previously used to quantify potentially preventable trauma deaths., Results: Twenty-six million EGS patients were admitted, and 6.5 million (25%) underwent an operation. In-hospital mortality varied from 0.3% to 4.1% across the treating hospitals. Relative to the best-performing hospital quintile, an estimated 158,177 (153,509-162,736) excess EGS deaths occurred at lower-performing hospital quintiles. Overall, 47% of excess deaths occurred at the worst-performing hospitals, while 27% of all excess deaths occurred among the operative cohort., Conclusion: Nearly 200,000 excess EGS deaths occur across the United States each decade. A national initiative to enable structures and processes of care associated with optimal EGS outcomes is urgently needed to achieve "Zero Preventable Deaths after Emergency General Surgery.", Level of Evidence: Care management, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: There are well-documented disparities in outcomes for injured Black and Hispanic patients in the United States. However, patient level characteristics cannot fully explain the differences in outcomes and system-level factors, including the trauma center designation of the hospital to which a patient presents, may contribute to their worse outcomes. We aim to determine if Black and Hispanic patients are more likely to be undertriaged, compared with white patients., Methods: This is a retrospective, cross-sectional, population-based study that uses data from the 2014 Agency for Healthcare Research and Quality Healthcare Costs and Utilization Project State Inpatient Databases. We included data from all states with available State Inpatient Databases data that included both race and hospital characteristics needed for analysis (n = 18). Logistic regression was used to identify predictors of severely injured (Injury Severity Score ≥16) patients being brought to a trauma center., Results: We identified 70,970 severely injured trauma patients with complete data. Non-Hispanic White represented 74.1% of the study population, 9.8% were non-Hispanic Black, and 9.7% were Hispanic. After adjustment for other demographic and injury characteristics, Non-Hispanic Black and Hispanic patients were more likely to be undertriaged, compared with white patients (odds ratio, 1.20; 95% confidence interval, 1.12-1.29 and odds ratio, 1.39; 95% confidence interval, 1.29-1.48, respectively). Male sex and older age were associated with higher odds of undertriage, whereas urban residence, high injury severity, and penetrating injury were associated with lower odds of undertriage., Conclusions: Severely injured Black and Hispanic trauma patients are more likely to be undertriaged than otherwise similar white patients. The factors that contribute to racial and ethnic disparities in receiving trauma center care need to be identified and addressed to provide equitable trauma care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: We sought to compare outcomes 6-12 months post-injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF)., Methods: Trauma patients admitted to 3 Level-I trauma centers were interviewed to evaluate the presence of daily pain requiring medication, functional outcomes, and physical and mental health-related quality-of-life at 6-12 months post-injury. Inverse-probability-of-treatment-weighting (IPTW)-adjusted analyses were performed to compare outcomes between patients who were discharged to IRF vs SNF., Results: A total of 519 patients were included: 389 discharged to IRFs and 130 to SNFs. In adjusted analyses, IRF was associated with a significant reduction in the likelihood of chronic pain after injury (28.3% vs. 44.7%; OR:0.49; 95% CI, 0.26-0.91; P = .02). However, there were no significant differences in functional outcome or SF-12 composite scores between groups., Conclusion: Our findings suggest that injured patients discharged to an IRF as compared to a SNF had less chronic pain and analgesic use., Competing Interests: Declaration of competing interest The authors of this manuscript certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Addressing the burden of injury in low-resource settings requires development of trauma systems. This study aimed to describe perceptions of trauma in Santa Cruz, Bolivia to better inform strategies for trauma system development. In 2015-2016, we conducted 16 individual and 11 group interviews with key stakeholders involved with or exposed to trauma. A pile sorting activity showed participants pictures of injury mechanisms to explore perceptions of trauma. Responses were analysed for themes using content and discourse analysis. Among 27 interviews, six were with physicians, seven with first responders, three with community members, and 11 with trauma patients. Pictures commonly categorised as trauma depicted a road traffic incident (92.6%), fall (88.9%), gunshot wound (88.9%), and burn (85.2%). Fewer respondents stated intoxication (51.9%) or drowning (40.7%) were trauma. Coding of responses revealed five themes: trauma definition, mechanism, physical injury, management, and psychological trauma. Medical personnel focused more on trauma as mechanism, physical injury, and management, whereas laypersons commonly described trauma as psychological. Varied understanding of what represents trauma could influence trauma registry data collection. Laypersons' focus on psychological trauma may affect use of designated trauma care hospitals. These viewpoints must be considered when designing policies and interventions for trauma system strengthening.

Objective: The aim of this study was to determine factors associated with patient-reported outcomes, 6 to 12 months after moderate to severe injury., Summary of Background Data: Due to limitations of trauma registries, we have an incomplete understanding of factors that impact long-term patient-reported outcomes after injury. As 96% of patients survive their injuries, several entities including the National Academies of Science, Engineering and Medicine have called for a mechanism to routinely follow trauma patients and determine factors associated with survival, patient-reported outcomes, and reintegration into society after trauma., Methods: Over 30 months, major trauma patients [Injury Severity Score (ISS) ≥9] admitted to 3 Level-I trauma centers in Boston were assessed via telephone between 6 and 12 months after injury. Outcome measures evaluated long-term functional, physical, and mental-health outcomes. Multiple regression models were utilized to identify patient and injury factors associated with outcomes., Results: We successfully followed 1736 patients (65% of patients contacted). More than half (62%) reported current physical limitations, 37% needed help for at least 1 activity of daily living, 20% screened positive for posttraumatic stress disorder (PTSD), all SF-12 physical health subdomain scores were significantly below US norms, and 41% of patients who were working previously were unable to return to work. Age, sex, and education were associated with long-term outcomes, while almost none of the traditional measures of injury severity were., Conclusion: The long-term sequelae of trauma are more significant than previously expected. Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery. This suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severity.

Background: Management of orthopedic injuries is a critical component of comprehensive trauma care. As patterns of injury incidence and recovery change in the face of emerging injury prevention efforts and technologies and an aging US population, assessment of the burden of orthopedic injury is essential to optimize trauma system planning. We sought to estimate the incidence of orthopedic injury requiring emergency orthopedic surgery in the United States., Methods: Using nationally representative samples from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, we estimated the incidence of orthopedic injury, polytrauma with orthopedic injury, and emergency operative orthopedic procedures performed for the management of traumatic injury. We used multivariable logistic regression to identify patient, injury, and hospital characteristics associated with odds of emergency orthopedic surgery., Results: A total of 7,214,915 patients were diagnosed with orthopedic injury in 2013-2014, resulting in 1,167,656 emergency orthopedic surgical procedures. Fall-related injuries accounted for 51% of health care encounters and 61% of emergency orthopedic surgical procedures. Odds of emergency orthopedic surgery were 2.04 times greater for patients with polytrauma, compared with isolated orthopedic injury (P < 0.001)., Conclusions: The total burden or orthopedic injury in the United States is substantial, and there is considerable heterogeneity in demand for care and practice patterns in the orthopedic trauma community. Population-based trauma system planning and tailored care delivery models would likely optimize initial treatment, recovery, and health outcomes for orthopedic trauma patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Objective: To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level., Methods: Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation., Results: Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles., Conclusion: Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed., (Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Racial disparities in trauma outcomes have been documented, but little is known about racial differences in post-discharge healthcare utilization. This study compares the utilization of post-discharge healthcare services by African-American and Caucasian trauma patients., Methods: Trauma patients with an Injury Severity Score (ISS)≥9 from three Level-I trauma centers were contacted between 6 and 12 months post-injury. Utilization of trauma-related healthcare services was asked. Coarsened exact matching (CEM) was used to match African-American and Caucasian patients. Conditional logistic regression then compared matched patients in terms of post-discharge healthcare utilization., Results: 182 African-American and 1,117 Caucasian patients were followed. Of these, 141 African-Americans were matched to 628 Caucasians. After CEM, we found that African-American patients were less likely to use rehabilitation services [OR:0.64 (95% CI:0.43-0.95)] and had fewer injury-related outpatient visits [OR:0.59 (95% CI:0.40-0.86)] after discharge., Conclusions: This study shows the existence of racial disparities in post-discharge healthcare utilization after trauma for otherwise similarly injured, matched patients., (Copyright © 2019. Published by Elsevier Inc.)

Background: Given the scarce literature data on chronic post-traumatic pain, we aim to identify early predictors of long-term pain and pain medication use after major trauma., Methods: Major trauma patients (Injury Severity Score ≥ 9) from three Level I Trauma Centers at 12 months after injury were interviewed for daily pain using the Trauma Quality of Life questionnaire. Multivariate logistic regression models identified patient- and injury-related independent predictors of pain and use of pain medication., Results: Of 1238 patients, 612 patients (49%) felt daily pain and 300 patients (24%) used pain medication 1 year after injury. Of a total of 8 independent predictors for chronic pain and 9 independent predictors for daily pain medication, 4 were common (pre-injury alcohol use, pre-injury drug use, hospital stay ≥ 5 days, and education limited to high school). Combinations of independent predictors yielded weak predictability for both outcomes, ranging from 20% to 72%., Conclusions: One year after injury, approximately half of trauma patients report daily pain and one-fourth use daily pain medication. These outcomes are hard to predict., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Social functioning-the ability to participate in organized or informal family, friend, or peer groups and communal activities-is intertwined with physical and emotional health. Although trauma can have a lasting effect on both the physical and emotional well-being of patients, little is known about the long-term impact of injury on social functioning. We sought to determine the prevalence of, risk factors for, and outcomes associated with long-term social dysfunction after trauma., Methods: Adults with moderate-to-severe injuries managed at three Level I trauma centers were contacted at 6 to 12 months after injury to inquire about social dysfunction. Demographics, socioeconomic parameters, and injury-related and hospital course information were also obtained. A stepwise backward logistic regression model was fitted to determine independent risk factors of social dysfunction, and multiple logistic regression models were used to determine associations between social dysfunction and post-traumatic stress disorder, functional limitations, and return to work., Results: Of the 805 screened patients, 45.2% reported social dysfunction. Patients with social dysfunction were more likely to be African American, be Medicaid beneficiaries, be of lower education, require mechanical ventilation, be discharged less often to home, have a lower mean age and had longer hospital stays. In multivariable analysis, low education, longer hospital stay, past psychiatric illness, and African-American race independently increased the risk for social dysfunction. Furthermore, patients with social dysfunction were more likely to screen positive for post-traumatic stress disorder (odds ratio: 16.25 [95% confidence interval: 9.49-27.85]), be experiencing functional limitations (odds ratio: 2.80 [95% confidence interval: 1.76-4.44]), and to not have returned to work (odds ratio: 5.65 [95% confidence interval: 3.92-8.14])., Conclusion: Lower educational attainment, long hospital stay, past pyschiatric illness, and African-American race appear to predispose to social dysfunction after trauma, which in turn is associated with a positive post-traumatic stress disorder screen, functional limitations, and delayed return to work., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Trauma and emergency general surgery (EGS) patients who are uninsured have worse outcomes as compared with insured patients. Partially modeled after the 2006 Massachusetts Healthcare Reform (MHR), the Patient Protection and Affordable Care Act was passed in 2010 with the goal of expanding health insurance coverage, primarily through state-based Medicaid expansion (ME). We evaluated the impact of ME and MHR on outcomes for trauma patients, EGS patients, and trauma systems., Methods: This study was approved by the Eastern Association for the Surgery of Trauma Guidelines Committee. Using Grading of Recommendations Assessment, Development and Evaluation methodology, we defined three populations of interest (trauma patients, EGS patients, and trauma systems) and identified the critical outcomes (mortality, access to care, change in insurance status, reimbursement, funding). We performed a systematic review of the literature. Random effect meta-analyses and meta-regression analyses were calculated for outcomes with sufficient data., Results: From 4,593 citations, we found 18 studies addressing all seven predefined outcomes of interest for trauma patients, three studies addressing six of seven outcomes for EGS patients, and three studies addressing three of eight outcomes for trauma systems. On meta-analysis, trauma patients were less likely to be uninsured after ME or MHR (odds ratio, 0.49; 95% confidence interval, 0.37-0.66). These coverage expansion policies were not associated with a change in the odds of inpatient mortality for trauma (odds ratio, 0.96; 95% confidence interval, 0.88-1.05). Emergency general surgery patients also experienced a significant insurance coverage gains and no change in inpatient mortality. Insurance expansion was often associated with increased access to postacute care at discharge. The evidence for trauma systems was heterogeneous., Conclusion: Given the evidence quality, we conditionally recommend ME/MHR to improve insurance coverage and access to postacute care for trauma and EGS patients. We have no specific recommendation with respect to the impact of ME/MHR on trauma systems. Additional research into these questions is needed., Level of Evidence: Review, Economic/Decision, level III.

Introduction: Prior research on patients with traumatic injury suggests high in-hospital survivability. However, little is known about their long-term outcomes, especially in the context of a prolonged ICU length-of-stay (LOS). We sought to determine the association between prolonged ICU-LOS and 1-year survival in trauma patients., Methods: TRICARE claims data (2011-2015) were queried for trauma patients with an Injury Severity Score > 9. Risk-adjusted Cox models were used to determine the influence of prolonged ICU LOS on 1-year mortality., Results: Of 19,155 patients included, 40% were admitted to the ICU. The overall 1-year mortality was 3.9% and 4.7% in patients with ICU LOS >9 days. In the multivariable model older age (55-64 vs. 18-24 years) (HR: 47.8, CI:20.8-109.9), prior comorbidities (>1 vs. 0) (HR: 2.6, CI: 2.1-3.2), discharge disposition (transfer vs discharge) (HR: 2.3 CI: 1.7-3.1) and ICU-LOS (>7 vs. 1 days) (HR:2.6, CI:1.7-4.0) were associated with 1-year mortality., Conclusion: Prolonged ICU-LOS is a risk factor for 1-year mortality in trauma patients. But an overall high survival (>96%) reinforces the justification for such use of the ICU in trauma patients when clinically necessary., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Lower socioeconomic status (SES) is known to be associated with higher morbidity and mortality following injury. However, the impact of individual SES on long-term outcomes after trauma is unknown. The objective of this study was to determine the impact of educational level and income on long-term outcomes after injury., Methods: Trauma patients with moderate to severe injuries admitted to three Level-I trauma centers were contacted 6 months to 12 months after injury to evaluate functional status, return to work/school, chronic pain, and posttraumatic stress disorder (PTSD). Lower SES status was determined by educational level and income. Adjusted logistic regression models were built to determine the association between educational level and income (lowest vs. highest quartile determined by census-tract area) on each of the long-term outcomes. A sensitivity analysis was performed using the national median household income ($57,617) as threshold for defining low versus high income., Results: A total of 1,516 patients were followed during a 36-month period. Forty-nine percent had a low educational level, and 26% were categorized in the low-income group. Mean (SD) age and injury severity score were 60 (21.5) and 14.3 (7.3), respectively, with most patients (94%) having blunt injuries. After adjusting for confounders, low educational level was associated with poor long-term outcomes: functional limitation [odds ratio (OR), 1.78 (95% confidence interval (CI), 1.41-2.26)], has not yet returned to work/school [OR, 2.48 (95% CI, 1.70-3.62)], chronic pain [OR, 1.63 (95% CI, 1.27-2.10)], and PTSD [OR, 2.23 (95% CI, 1.60-3.11)]. Similarly, low-income level was associated with not yet return to work/school [OR, 1.97 (95% CI, 1.09-3.56)], chronic pain [OR,1.70 (95% CI, 1.14-2.53)], and PTSD [OR, 2.20 (95% CI, 1.21-3.98)]. In sensitivity analyses, there were no significant differences in long-term outcomes between income levels., Conclusion: Low educational level is strongly associated with worse long-term outcomes after injury. However, although household income is associated with long-term outcomes, it matters where the threshold is. The impact of different socioeconomic measures on long-term outcomes after trauma cannot be assumed to be interchangeable., Level of Evidence: Prognostic and epidemiological, level III.

Background: Few studies of trauma care access and quality account for prehospital injury mortality. Little is known about geographic variation in prehospital mortality or the impact of prehospital care on injury disparities., Methods: Using the Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research database, we queried county-level incidence of prehospital injury mortality from 1999 to 2016. We linked mortality incidence with county-level urban-rural classifications from the National Center for Health Statistics and population data from the US Census Bureau. We used negative binomial regression to estimate the relationship between rurality and prehospital injury mortality, adjusting for county-level distribution of race, sex, age, income, and insurance coverage. Models were then stratified by injury mechanism (motor vehicle traffic [MVT] vs. penetrating) to determine if prehospital mortality rates varied by type of injury., Results: Prehospital injury mortality rates were elevated for all urban-rural county classes, relative to large central metro counties, with incidence rate ratios (IRR) ranging from 1.25 (95% confidence interval [CI], 1.16-1.35) for fringe metro counties to 1.69 (95% CI, 1.58-1.82) for noncore counties. For MVT injury, IRRs for urban-rural classes compared with large central metro counties ranged from 2.02 (95% CI, 1.85-2.21) for fringe metro counties to 3.02 (95% CI, 2.76-3.30) to noncore counties. Incidence of prehospital mortality from penetrating injury was 14% higher for noncore counties compared to large central metro counties (IRR, 1.14; 95% CI, 1.05-1.23)., Conclusion: There is substantial geographic variation in prehospital injury mortality in the United States, with risk of prehospital death increasing with rurality. Patterns of prehospital death associated with penetrating and MVT injuries suggest that improvements to both trauma center access, prehospital care, and primary injury prevention are essential to reduce preventable injury deaths., Level of Evidence: Retrospective ecological analysis, level III.

Background: Prior opioid use has been shown to be associated with adverse outcomes in surgical and trauma patients. We sought to evaluate the influence of prior opioid use on prescription opioid requirements after orthopedic trauma., Materials and Methods: This was a retrospective review of TRICARE claims (2006-2014). We evaluated the records of 11,752 patients treated for orthopedic injuries. Surveillance for prior opioid exposure extended to 6 mo before the traumatic event, with similar postinjury surveillance. Preinjury opioid use was categorized as unexposed, exposed without sustained use (nonsustained users), and sustained use (6 mo or longer of continuous opioid prescriptions without interruption). Multivariable Cox proportional hazard models were used to adjust for confounding and determine factors independently associated with the discontinuation of prescription opioid use after traumatic injury., Results: Prior opioid exposure among nonsustained users (hazard ratio 0.78; 95% CI 0.74, 0.83) and sustained use at the time of injury (hazard ratio 0.40; 95% CI: 0.35, 0.47) were associated with lower likelihoods of opioid discontinuation. Additional factors associated with lower likelihoods of opioid discontinuation included our proxy for lower socioeconomic status, history of depression or anxiety, injury severity, and intensive care unit admission., Conclusions: Prior opioid use is one of the strongest predictors of continued use following treatment, along with socioeconomic status, behavioral health disorders, and severity of injury. Appropriate discharge planning and early engagement of ancillary services in individuals with one or more of the risk factors identified here may reduce the likelihood of sustained opioid use after injury., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation., Objective: To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act., Design, Setting, and Participants: Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states., Interventions/exposure: Policy implementation in January 2014., Main Outcomes and Measures: Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation., Results: A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation., Conclusions and Relevance: This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

Background: Timely access to trauma center (TC) care is critical to achieve "Zero Preventable Deaths after Injury." However, the impact of timely access to TC care on pre-hospital deaths in each US state remains unknown. We sought to determine the state-level relationship between the proportion of pre-hospital deaths, age-adjusted mortality, and timely access to trauma center care., Study Design: We analyzed state-level analysis of adult trauma deaths reported to the CDC Wide-ranging Online Data for Epidemiological Research (WONDER) (1999 to 2016). Correlation between the state-level pre-hospital:in-hospital death ratio (PH:IH), the proportion of population with access to Level-I/II TC, and the age-adjusted mortality rate (AAMR) was determined. Population proportion with timely access to TC care was compared between states with a high pre-hospital death burden vs all other states. National estimates of potentially preventable pre-hospital deaths were calculated., Results: There were 1,949,375 trauma deaths analyzed. Overall, 1.19 times more deaths occurred pre-hospital (49%, n = 960,554) than in-hospital (42%, n = 810,387). States with better TC access had a lower AAMR (r = -0.71, p < 0.05) and relatively fewer pre-hospital deaths (r = -0.64, p < 0.05); states with higher AAMR had relatively more pre-hospital deaths (r = 0.70, p < 0.05). States with a high pre-hospital death burden had a lower proportion of population with access to Level-I/II TC within 1 hour vs all other states (63.2% vs 90.2%, p < 0.001). If all states had the same PH:IH death ratio as those among the best quartile for access, 129,213 pre-hospital deaths may potentially have been averted., Conclusions: States with poor TC access have more pre-hospital deaths, which contribute to higher overall injury mortality. This suggests that in these states, improving TC access will be critical to achieve "Zero Preventable Deaths after Injury.", (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Application of extremity tourniquets is a central tenet of multiple national initiatives to empower laypersons to provide hemorrhage control (HC). However, the efficacy of the general population who self-report prior first-aid (FA) or HC training on individual's ability to control bleeding with a tourniquet remains unknown. Therefore, the objective of this study was to assess the effectiveness of laypeople with self-reported prior FA or HC training to control bleeding with a tourniquet., Study Design: Employees of a stadium were assessed via simulation in their ability to apply a Combat Application Tourniquet. As a subgroup analysis of a larger study, participants who self-reported: 1) No prior training, 2) FA training only or 2) FA + HC training were compared. Logistic regression adjusting for age, gender, education, willingness-to-assist, and comfort level in HC was performed., Results: 317 participants were included. Compared to participants with no prior training (14.4%,n = 16/111), those with FA training only (25.2%,n = 35/139) had a 2.12-higher odds (95%CI:1.07-4.18) of correct tourniquet application while those with FA + HC (35.8%,n = 24/67) had a 3.50-higher odds (95%CI:1.59-7.72) of correct application. Participants with prior FA + HC were more willing-to-assist and comfortable performing HC than those without prior training (p < 0.05). However, reporting being very willing-to-assist [OR0.83,95%CI:0.43-1.60] or very comfortable [OR1.11,95%CI:0.55-2.25] was not associated with correct tourniquet application., Conclusion: Self-reported prior FA + HC training, while associated with increased likelihood to correctly apply a tourniquet, results in only 1/3 of individuals correctly performing the skill. As work continues in empowering and training laypeople to act as immediate responders, these findings highlight the importance of effective layperson education techniques., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Traumatic injury is strongly associated with long-term mental health disorders, but the risk factors for developing these disorders are poorly understood. We report on a multi-institutional collaboration to collect long-term patient-centered outcomes after trauma, including screening for post-traumatic stress disorder. The objective of this study is to determine the prevalence of and risk factors for the development of post-traumatic stress disorder after traumatic injury., Methods: Adult trauma patients (aged 18-64) with moderate to severe injuries (Injury Severity Score ≥ 9) admitted to 3 level I trauma centers were screened between 6 and 12 months after injury for post-traumatic stress disorder. Patients were divided by mechanism: fall, road traffic injury, and intentional injury. Multiple logistic regression models were used to determine the association between baseline patient and injury-related characteristics and the development of post-traumatic stress disorder for the overall cohort and by mechanism of injury., Results: A total of 450 patients completed the screen. Overall 32% screened positive for post-traumatic stress disorder, but this differed significantly by mechanism, with the lowest being after a fall (25%) and highest after intentional injury (60%). Injury severity was not associated with post-traumatic stress disorder for any group, but lower educational level was associated with post-traumatic stress disorder within all the groups. Only 21% of patients who screened positive for post-traumatic stress disorder were receiving treatment at the time of the survey., Conclusion: Post-traumatic stress disorder is common after traumatic injury, and the prevalence varies significantly by injury mechanism but is not associated with injury severity. Only a small proportion of patients who screen positive for post-traumatic stress disorder are currently receiving treatment., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients., Methods: This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization., Results: Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80)., Conclusion: Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge., Level of Evidence: Therapeutic/Care management, level III.

Background: Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma., Methods: Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size., Results: There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon., Conclusions: At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To characterize the economic hardship for uninsured patients admitted for trauma using catastrophic health expenditure (CHE) risk., Background: Medical debts are the greatest cause of bankruptcies in the United States. Injuries are often unpredictable, expensive to treat, and disproportionally affect uninsured patients. Current measures of economic hardship are insufficient and exclude those at greatest risk., Methods: We performed a retrospective review, using data from the 2007-2011 Nationwide Inpatient Samples of all uninsured nonelderly adults (18-64 yrs) admitted with primary diagnoses of trauma. We used US Census data to estimate annual postsubsistence income and inhospital charges for trauma-related admission. Our primary outcome measure was catastrophic health expenditure risk, defined as any charges ≥40% of annual postsubsistence income., Results: Our sample represented 579,683 admissions for uninsured nonelderly adults over the 5-year study period. Median estimated annual income was $40,867 (interquartile range: $21,286-$71.733). Median inpatient charges were $27,420 (interquartile range: $15,196-$49,694). Overall, 70.8% (95% posterior confidence interval: 70.7%-71.1%) of patients were at risk for CHE. The risk of CHE was similar across most demographic subgroups. The greatest risk, however, was concentrated among patients from low-income communities (77.5% among patients in the lowest community income quartile) and among patients with severe injuries (81.8% among those with ISS ≥ 16)., Conclusions: Over 7 in 10 uninsured patients admitted for trauma are at risk of catastrophic health expenditures. This analysis is the first application of CHE to a US trauma population and will be an important measure to evaluate the effectiveness of health care and coverage strategies to improve financial risk protection.

Background: Although inequities in trauma care are reported widely, some groups have theorized that universal health insurance would decrease disparities in care for disadvantaged minorities after a traumatic injury. We sought to examine the presence of racial disparities in outcomes and healthcare utilization at 30- and 90-days after discharge in this universally insured, racially diverse, American population treated for traumatic injuries., Methods: This work studied adult beneficiaries of TRICARE treated at both military and civilian trauma centers 2006-2014. We included patients with an inpatient trauma encounter based on International Classification of Diseases, 9th revision (ICD-9) code. The mechanism and severity of injury, medical comorbidities, region and environment of care, and demographic factors were used as covariates. Race was considered the main predictor variable with Black patients compared to Whites. Logistic regression models were employed to assess for risk-adjusted differences in 30- and 90-day outcomes between Blacks and Whites., Results: A total of 87,112 patients met the inclusion criteria. Traditionally encountered disparities for Black patients after trauma, including increased rates of mortality, were absent. We found a statistically significant decrease in the odds of 90-day complications for Blacks (OR 0.91; 95% CI 0.84-0.98; P = 0.01). Blacks also had lesser odds of readmission at 30-days (OR 0.87; 95% CI 0.79-0.94; P = 0.002) and 90-days (OR 0.86; 95% CI 0.79-0.93; P < 0.001)., Conclusion: Our findings support the idea that in a universally insured, equal access system, historic disparities for racial and ethnic minorities, including increased postinjury morbidity, hospital readmission, and postdischarge healthcare utilization, are decreased or even eliminated., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality., Methods: Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile., Results: Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01)., Conclusions: Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes., Level of Evidence: Epidemiological, level III; Care management, level IV.

Background: Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge., Methods: We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients., Results: Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge., Conclusions: Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Severely injured trauma patients have higher in-hospital mortality at Level II versus Level I trauma centers (TCs). To better understand these differences, we sought to determine if there were any periods during which hemodynamically unstable trauma patients are at higher risk of death at Level II versus Level I TCs within the first 24 hours postadmission., Study Design: Trauma patients aged 18 years to 64 years, with Injury Severity Score of 15 or greater, systolic blood pressure less than 90 mm Hg at admission, and treated at Level II or Level I TCs, were identified using the 2007 to 2012 National Trauma Data Bank. Burn patients, transfers, and patients dead on arrival were excluded. Log-binomial regression models, adjusted for patient- and hospital-level confounders, were used to compare mortality at Level II versus Level I TCs over the first 24 hours postadmission., Results: Of 13,846 hemodynamically unstable patients, 4,212 (30.4%) were treated at 149 Level II TCs, and 9,634 (69.6%) at 116 Level I TCs. Within the first 24 hours, 3,059 (22.1%) patients died. In risk-adjusted models, mortality risk was significantly elevated at Level II versus Level I TCs during the 24 hours postadmission (relative risk, 1.08; 95% confidence interval, 1.01-1.16). Hourly mortality risk was significantly different between Level II and Level I TCs during 4 hours to 7 hours postadmission, with a maximal difference at 7 hours (relative risk, 1.70; 95% confidence interval, 1.23-2.36) and comparable mortality risk beyond 7 hours postadmission., Conclusion: The 4-hour to 7-hour time window postadmission is critical for hemodynamically unstable trauma patients. Variations in available treatment modalities may account for higher relative mortality at Level II TCs during this time. Further investigation to elucidate specific risk factors for mortality during this period may lead to reductions in in-hospital mortality among hemodynamically unstable trauma patients., Level of Evidence: Therapeutic/care management, level IV.

Importance: In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored., Objective: To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort., Design, Setting, and Participants: Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration's list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016., Exposures: Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors., Main Outcomes and Measures: Prescription of opioid analgesics at discharge., Results: Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs <9: OR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge., Conclusions and Relevance: The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.

Introduction: The aim of this study was to compare the epidemiology of traumatic injuries and mortality outcomes between two tertiary-care trauma centers in Colombia using data from Pan-American Trauma Registry (PATR)., Methods: January 1-December 31, 2012, data from the Hospital Universitario del Valle (HUV, public) and Fundacion Valle del Lili (FVL, private) in Cali, Colombia, were considered. Differences in demographic and clinical information were compared using descriptive statistics. Propensity score matching was used to match patients on age, gender, and ISS. Within matched cohorts, multivariable logistic regression models were used to assess for differences in in-hospital mortality, further adjusting for insurance type, employment, heart rate, presence of hypotension (SBP < 90), and GCS score., Results: HUV (8539; 78% male) and FVL (10,456; 60% male) had a combined total of 18,995 trauma cases in 2012 with comparable mean ages of 29.7 years. There were significant differences in insurance status, injury severity, and mechanism of injury between patients at HUV and FLV. On risk-adjusted logistic regression analyses with propensity score matched cohorts, the odds of death in HUV was higher compared to patients presenting at FVL hospital (OR [95% CI]:4.93 [3.37-7.21], p < 0.001)., Conclusion: The study established the utility of the PATR and revealed important trends in patient demographics, injury epidemiology, and mortality outcomes, which can be used to target trauma initiatives throughout the region. It underscores the profound importance that differences in case mix play in the risk of trauma-related mortality, further emphasizing the need to monitor and evaluate unique aspects of trauma in LMIC., Level of Evidence: III.

Background: The National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) recently recommended inclusion of postdischarge health-related quality of life (HRQoL) and patient-reported outcomes (PROs) metrics to benchmark the quality of trauma care. Currently, these measures are not routinely collected at most trauma centers. We sought to determine the feasibility and value of adding such long-term outcome measures to trauma registries., Methods: As part of the FORTE (Functional Outcomes and Recovery after Trauma Emergencies) project, we included patients with an Injury Severity Score of 9 or greater, admitted to the Brigham and Women's Hospital in Boston, MA, who were identified retrospectively using the institutional trauma registry and contacted 6 or 12 months after injury to participate in a telephone survey evaluating HRQoL (Short Form 12 [SF-12]), PROs (Trauma Quality of Life), posttraumatic stress disorder, return to work, residential status, and health care utilization., Results: Data were collected for 171 of 394 eligible patients: 85/189 (45%) at 6 months and 86/205 (42%) at 12 months; 25%/29% (6/12 months) patients could not be contacted, 15%/16% (6/12 months) declined to participate, and 15%/13% (6/12 months) were interested in participating at another time but were not reached again. Approximately 20% patients screened positive for posttraumatic stress disorder, and half had not yet returned to work. There were significant reductions in SF-12 physical composite scores relative to population norms (mean, 50 [SD, 10]) at 6 months (mean, 44; 95% confidence interval [CI], 41-47) and 12 months (45; 95% CI, 42-47); no difference was noted in the SF-12 mental composite scores (6 months: 51 [95% CI, 48-54]; 12 months: 50 [95% CI, 46-53])., Conclusions: Trauma patients reported considerable impairment 6 and 12 months after injury. Routine collection of PROs and HRQoL provides important data regarding trauma outcomes beyond mortality and will enable the development of quality improvement metrics that better reflect patients' postinjury experiences. Improved and alternate methods for collection of these data need to be developed to enhance response rates before widespread adoption across trauma centers in the United States., Level of Evidence: Prognostic/epidemiologic, level II; Therapeutic, level III.

Objectives: The aims of this study were to assess for changes in uninsured rates among trauma patients at age 64 versus 65 years and whether there are associated changes in post-discharge rehabilitation; determine whether changes are driven by rehabilitation provided at home, skilled nursing facilities (SNFs), or acute inpatient facilities; and determine whether changes vary among stratified subgroups of trauma-related "best-practice" factors., Summary Background Data: Rehabilitation is an important component of high-quality trauma systems with access heavily influenced by insurance status. In the wake of policy changes affecting insurance coverage, it remains unknown the extent to which insurance changes associate with variations in rehabilitation access/use among otherwise similar patients., Methods: Regression discontinuity models were used to assess for changes in insurance status and rehabilitation at age 64 versus 65 years among adults ages 54 to 75 years (±10 years age-related Medicare eligibility). Data were extracted from the 2007-2012 National Trauma Data Bank., Results: A total of 305,198 patients were included; 40.1% were discharged to rehabilitation. Medicare eligibility was associated with an abrupt 6.4 (95% confidence interval: 5.8-7.0) percentage-point decline in uninsured and a 9.6 (95% confidence interval: 6.5-12.6) percentage-point increase in rehabilitation at age 64 versus 65 years, enabling an additional 1-in-10 patients to access rehabilitation. Differences were driven by SNF use and were greatest among patients with less-severe clinical presentations. Restriction based on Medicare-payment eligibility to patients with length of stay ≥3days (SNF requirement) and ≥1 "presumptive diagnosis codes" (inpatient facilities' 60% rule) demonstrated abrupt gains in both SNF and inpatient care., Conclusions: The results reveal the magnitude of changes in access to rehabilitation associated with changes in insurance coverage at age 65 years. Use of quasiexperimental models enabled meaningful consideration of health-policy change.

Importance: Trauma is the leading cause of death and disability among young adults, who are also among the most likely to be uninsured. Efforts to increase insurance coverage, including passage of the Patient Protection and Affordable Care Act (ACA), were intended to improve access to care and promote improvements in outcomes. However, despite reported gains in coverage, the ACA's success in promoting use of high-quality care and enacting changes in clinical end points remains unclear., Objectives: To assess for observed changes in insurance coverage and rehabilitation use among young adult trauma patients associated with the ACA, including the Dependent Coverage Provision (DCP) and Medicaid expansion/open enrollment, and to consider possible insurance and rehabilitation differences between DCP-eligible vs -ineligible patients and among stratified demographic and community subgroups., Design, Setting, and Participants: A longitudinal assessment of DCP implementation and Medicaid expansion/open enrollment using risk-adjusted before-and-after, difference-in-difference, and interrupted time-series analyses was conducted. Eleven years (January 1, 2005, to September 31, 2015) of Maryland Health Services Cost Review Commission data, representing complete patient records from all payers within the state, were used to identify all hospitalized young adult (aged 18-34 years) trauma patients in Maryland during the study period., Results: Of the 69 507 hospitalized patients included, 50 548 (72.7%) were male, and the mean (SD) age was 25 (5) years. Before implementation of the DCP, 1 of 4 patients was uninsured. After ACA implementation, the number fell to less than 1 of 10, with similar patterns emerging in emergency department and outpatient settings. The change was primarily driven by Medicaid expansion/open enrollment, which corresponded to a 20.1 percentage-point increase in Medicaid (95% CI, 18.9-21.3) and an 18.2 percentage-point decrease in uninsured (95% CI, -19.3 to -17.2). No changes were detected among privately insured patients. Rehabilitation use increased by 5.4 percentage points (95% CI, 4.5-6.2)-a 60% relative increase from a baseline of 9%. Mortality (-0.5; 95% CI, -0.9 to -0.1) and failure-to-rescue rates (-4.5; 95% CI, -7.4 to -1.6) also significantly declined. Stratified changes point to significant differences in the percentage of uninsured patients and rehabilitation access across the board, mitigating or even eradicating disparities in certain cases., Conclusions and Relevance: For patients who are injured, young, and uninsured, Medicaid expansion/open enrollment in Maryland changed insurance coverage and altered patient outcomes in ways that the DCP alone was never intended to do. Implementation of Medicaid expansion/open enrollment transformed the landscape of trauma coverage, directly affecting the health of one of the country's most vulnerable at-risk groups.

Background: The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality., Study Design: We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates., Results: There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year., Conclusions: There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and nonrural residents with traumatic injuries., Methods: Using data from the 2009-2010 Nationwide Emergency Department Sample, multiple logistic regression analyses were conducted to estimate odds of death after traumatic injury for rural residents compared with nonrural residents, while controlling for age, sex, injury type and severity, comorbidities, trauma designation, and Census region., Results: Rural residents were 14% more likely to die after traumatic injury compared with nonrural residents (P < .001). Increased odds of death for rural residents were observed at level I (odds ratio = 1.20, P < .001), level II (odds ratio = 1.34, P < .001), and level IV/nontrauma centers (odds ratio = 1.23, P < .001). The disparity was greatest for injuries occurring in the South and Midwest (odds ratio = 1.54, P < .001 and odds ratio = 2.06, P < .001, respectively) and for cases with an injury severity score <9 or unknown severity (odds ratio = 2.09, P < .001 and odds ratio = 1.31, P < .001, respectively)., Conclusion: Rural residents are significantly more likely than nonrural residents to die after traumatic injury. This disparity varies by trauma center designation, injury severity, and US Census region. Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To better define the shift in the management of renal trauma throughout the United States, with a population-based assessment of community hospital practice patterns. To investigate how hospital, patient, and injury-specific factors influence management strategy by both urologists and nonurologists., Materials and Methods: Using the Premier Hospital database, we performed a retrospective study of all patients with renal trauma between 2003 and 2013. We identified patients using International Classification of Diseases, Ninth Revision diagnosis codes (866.0x, 866.1x), determined management strategy by International Classification of Diseases, Ninth Revision procedure codes, and dichotomized grouping by surgeon specialty. We stratified hospitals by annual renal trauma volume categorized a priori into low, <10 cases per year; intermediate, 10-20 cases per year; and high, >20 cases per year. We performed descriptive statistics and univariate and multivariate regression analyses adjusting for survey weighting and for patient, hospital, and injury-specific characteristics., Results: Our study cohort included a weighted sample size of 21,531 patients. Higher renal trauma hospitals (12.6%) were significantly less likely than low (26.4%) and intermediate (31.3%) volume hospitals to undergo surgical intervention for renal trauma on adjusted models. There was a statistically significant increase in nonoperative management from 65.2% in 2003 to 81.8% in 2013., Conclusion: National rates of surgical intervention for renal trauma are significantly higher than those frequently quoted by the literature, especially among low- and intermediate-volume renal trauma hospitals. Although operative rates are decreasing, further consideration may need to be given to centralization of care in higher-volume teaching hospitals to improve renal salvage., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Prolonged intensive care unit length of stay (ICU-LOS) is associated with high mortality for medical and surgical patients. Existing literature suggests that this may not be true for trauma patients. The objective of this study was to determine mortality associated with varying ICU-LOS among trauma patients and to assess for independent predictors of mortality., Methods: Adult ICU patients (16-64 years) in the National Trauma Data Bank (2007-2012) were categorized by ICU-LOS: 1, 2-9, 10-40, and >40 days (determined based on inflection points). Multivariable logistic regression was used to determine associations with mortality for each. Models accounted for clustering of patients within hospitals and potential confounding associated with: age, gender, race/ethnicity, insurance status, Injury Severity Score, blunt/penetrating injury, Glasgow Coma Scale, in-hospital complications, ventilator dependency, and emergency department disposition., Results: Among the 596,598 patients included, 6.5% (n = 38,812) died. Mortality varied with ICU-LOS: 9.9%, 4.9%, 6.6%, and 9.8%. Age >35 years was a significant predictor of mortality in each. Injury Severity Score and the Glasgow Coma Scale independently predicted mortality in patients with LOS ≤40 days as did penetrating injuries, cardiac arrest, and renal failure. Identification with non-Hispanic black race/ethnicity was also consistently significant. Once patients survived 9 days, mortality steadily decreased, remaining relatively stable until 40 days. Thereafter, trauma patients continued to demonstrate high survival with >87% remaining alive in the ICU >90 days., Conclusion: The results reveal that in contrast to expectations of high mortality associated with prolonged ICU-LOS, critically injured adult trauma patients who do not die within the first few days demonstrate an enhanced ability to survive, with an overall survival of >92% and maintained at >85% among extreme ICU-LOS (>40 days). The data advocate the utility of aggressive critical-care support for trauma patients, irrespective of duration of ICU stay., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: 30-day readmission is increasingly used as a hospital quality metric. The objective of this study was to describe the patient factors associated with unplanned 30-day hospital readmission of orthopaedic trauma patients., Methods: A statewide observational study was undertaken using data from all acute hospitals in California. All hospital inpatients with a primary diagnosis of fracture or dislocation (ICD-9-CM codes 800-829) were included, except for those with isolated injuries to the skull, face, or ribs. The primary outcome measure was unplanned 30-day readmission to any hospital in California., Results: 416,568 trauma admissions were available for analysis. The overall readmission rate was 6.5%, and 27.3% of readmitted patients presented to a different hospital. Factors significantly associated with readmission were male sex (OR 1.23, 95% CI 1.19-1.27), age 46-65 (2.61 [2.27-2.99]), black race (1.19 [1.11-1.27]), entitlement to publicly funded healthcare (1.38 [1.25-1.52]), Charlson Comorbidity Index ≥2 (1.84 [1.79-1.90]), discharge against medical advice (3.13 [2.67-3.68]), and spinal fracture (1.42 [1.34-1.49]). Major reasons for readmission included: cardiopulmonary disease (25.6%), infections (20.1%), musculoskeletal problems (18.1%), and procedural complications (12.0%)., Conclusions: Many orthopaedic trauma readmissions are potentially unrelated to the initial hospitalization. Penalties for unplanned readmissions risk penalizing hospitals that serve disadvantaged communities and treat a high proportion of trauma patients., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Although high absolute hospital geriatric trauma volume (GTV) is associated with improved outcomes among geriatric trauma patients, the actual geriatric trauma proportion (GTP) might be a better predictor of outcomes., Study Design: Adult trauma admissions were identified in the California State Inpatient Database, 2007 to 2011. Hospital characteristics were extracted from the American Hospital Association database. The annual trauma volume of patients 65 years and older was calculated for each hospital. The GTP was derived by dividing the GTV by the overall adult trauma volume and hospitals were categorized into tertiles of GTP. Outcomes were hospital mortality, failure to rescue (FTR), and 30-day readmission in geriatric trauma patients. Independent risk factors were assessed with clustered multivariate logistic regression models adjusted for patient and hospital characteristics., Results: There were 61,915 geriatric trauma patients included from 63 trauma centers. Hospital mortality, FTR, and 30-day readmission rates were 4.99%, 16.07%, and 12.03%, respectively. The adjusted odds ratios and 95% CIs for in-hospital mortality and FTR per 100 patient increase in GTV were 0.91 (95% CI, 0.83-1.00) and 1.01 (95% CI, 0.90-1.14), respectively. As compared with hospitals in the lowest tertile, adjusted odds of mortality and FTR in the highest tertile were 0.71 (95% CI, 0.54-0.94) and 0.67 (95% CI, 0.48-0.92), respectively. None of the hospital factors measured was significantly associated with readmission. The Wald test revealed that GTP played a larger role than GTV in predicting hospital mortality (p = 0.018 vs p = 0.048) and FTR (p = 0.015 vs p = 0.985)., Conclusions: Treatment at hospitals with higher GTP is associated with lower hospital mortality and FTR among geriatric patients. These findings suggest that creation of specialized services for geriatric trauma care can improve outcomes among geriatric trauma patients., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Prior analysis demonstrates improved survival for older trauma patients (age>64years) treated at trauma centres that manage a higher proportion of geriatric patients. We hypothesised that 'failure to rescue' (death after a complication during an in-hospital stay) may be responsible for part of this variation. The objective of the study was to determine if trauma centre failure to rescue rates are associated with the proportion of older trauma seen., Methods: We analysed data from high volume level 1 and 2 trauma centres participating in the National Trauma Data Bank, years 2007-2011. Centres were categorised by the proportion of older trauma patients seen. Logistic regression analyses were used to provide risk-adjusted rates for major complications (MC) and, separately, for mortality following a MC. Models were adjusted for patient demographics, comorbid conditions, mechanism and type of injury, presenting vital signs, injury severity, and multiple facility-level covariates. Risk-adjusted rates were plotted against the proportion of older trauma seen and trends determined., Results: Of the 396,449 older patients at 293 trauma centres that met inclusion criteria, 30,761 (8%) suffered a MC. No difference was found in the risk-adjusted incidence of MC by proportion of older trauma seen. A MC was associated with 34% of all deaths. Of those that suffered a MC, 7413 (24%) died and 76% were successfully rescued. Centres treating higher proportions of older trauma were more successful at rescuing patients after a MC occurred. Patients seen at centres that treat >50% older trauma were 33% (OR=0.67, 95% CI 0.47-0.96) less likely to die following a MC than in centres treating a low proportion (10%) of older trauma., Conclusions: Centres more experienced at managing geriatric trauma are more successful at rescuing older patients with serious complications. Processes of care at these centres need to be further examined and used to inform appropriate interventions., (Copyright © 2015. Published by Elsevier Ltd.)

Background: There is a paucity of data on the causes and associated patient factors for unplanned readmissions among trauma patients., Methods: We examined patients admitted for traumatic injuries between 2007 and 2011 in the California State Inpatient Database. Using chi-square tests and multivariate logistic regression models, we determined rates, reasons, locations, and patient factors associated with 30-day readmissions., Results: Among 252,752 trauma discharges, the overall readmission rate was 7.56%, with 36% of readmissions occurring at a hospital different from the hospital of initial admission. Predictors of readmissions included being discharged against medical advice (odds ratio [OR]: 2.56 [2.35 to 2.76]); Charlson scores ≥2 (OR: 2.00 [1.91 to 2.10]); and age ≥45 years (OR: 1.29 [1.25 to 1.33]). Major reasons for readmissions were musculoskeletal complaints (22.29%), psychiatric conditions (9.40%), and surgical infections (6.69%)., Conclusions: Health and social vulnerabilities influence readmission among trauma patients, with many readmitted at other hospitals. Targeted interventions among high-risk patients may reduce readmissions after traumatic injuries., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Although non-operative management of blunt splenic injury (BSI) is increasingly common, the long-term infectious complications after adjunct splenic artery embolization (SAE) are not well described., Methods: Patients aged 18-64 y with BSI were identified in the California State Inpatient Database (2007-2011) and categorized as receiving either non-operative management (NOM) without SAE, NOM with SAE, or operative management (OM). The cumulative incidence of infections (surgical site infections [SSI], pneumonia, urinary tract infections, and sepsis) requiring readmission at different times up to one y after injury were calculated. Patient and treatment factors associated with infectious readmissions were determined using multivariable logistic regression models., Results: Of the 4,360 patients with BSI, 61.6% had NOM without SAE, 5.8% had NOM with SAE, and 32.6% had OM. The cumulative incidences of infectious complications after each of the management modes were 1.27%, 1.59%, and 1.76%, respectively, during admission (p = 0.446); 2.16%, 5.18%, and 4.85%, respectively, at 30 d after injury (p < 0.001); and 4.69%, 9.16%, and 8.85%, respectively, at one y after injury (p < 0.001). Risk factors for infection-associated readmissions within one y after injury were Charlson score ≥2 (adjusted odds ratio [AOR] 3.9; 95% confidence interval [CI] 2.61-6.02), length of stay >seven d (AOR 2.47; 95% CI 1.58-3.85), NOM with SAE (AOR 2.00; 95% CI 1.19-3.34), and OM (AOR 1.47; 95% CI 1.05-2.07)., Conclusions: The long-term risk of infectious complications in patients with BSI who have NOM with SAE is similar to that in patients who are treated with OM, indicating the need for pro-active strategies to reduce long-term infectious complications after SAE.

Background: Although trauma patients are frequently discharged against medical advice (AMA), the fate of these patients remains mostly unknown., Methods: Patients with traumatic injuries were identified in the California State Inpatient Database, 2007 to 2011. Readmission characteristics of patients discharged AMA were compared with patients discharged home., Results: There were 203,756 (75.65%) patients discharged home and 4,480 (1.66%) discharged AMA. Compared with those discharged home, patients discharged AMA had significantly higher 30-day readmission rates (17.12% vs 6.75%), rates of multiple readmissions (3.83% vs 1.12%), and likelihood of being readmitted at different hospitals (44.83% vs 33.82%) (all P < .001). The commonest reasons for readmission in patients discharged AMA were psychiatric conditions [adjusted odds ratio: 1.67 (1.21 to 2.27)]., Conclusions: Discharge AMA is associated with multiple readmissions and higher rates of readmissions at different hospitals. Early identification of vulnerable patients and improved modalities to prevent discharge AMA among these patients may reduce the negative outcomes associated with discharge AMA among trauma patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Previous research has demonstrated that nonclinical factors are associated with differences in clinical care, with uninsured patients receiving decreased resource use. Studies on trauma populations have also shown unclear relationships between insurance status and hospital length of stay (LOS), a commonly used metric for evaluating quality of care. The objective of this study is to define the relationship between insurance status and LOS after trauma using the largest available national trauma dataset and controlling for significant confounders. Data from 2007 to 2010 National Trauma Data Bank were used to compare differences in LOS among three insurance groups: privately insured, publically insured, and uninsured trauma patients. Multivariable regression models adjusted for potential confounding due to baseline differences in injury severity and demographic and clinical factors. A total of 884,493 patients met the inclusion criteria. After adjusting for the influence of covariates, uninsured patients had significantly shorter hospital stays (0.3 days) relative to privately insured patients. Publicly insured patients had longer risk-adjusted LOS (0.9 days). Stratified differences in discharge disposition and injury severity significantly altered the relationship between insurance status and LOS. In conclusion, this study elucidates the association between insurance status and hospital LOS, demonstrating that a patient's ability to pay could alter LOS in acute trauma patients. Additional research is needed to examine causes and outcomes from these differences to increase efficiency in the health care system, decrease costs, and shrink disparities in health outcomes.

Background: Off-road motorsports are an increasing popular activity, yet the relative safety profile of all-terrain vehicles (ATV) to off-road motorcycles (ORMC) has not been compared., Study Design: A retrospective review of the 2002-2006 US National Trauma Data Bank of ATV and ORMC crash victims. Patients were described according to demographic (age, sex, race and ethnicity, insurance status) and injury characteristics (Injury Severity Score, hypotension, motor component of the Glasgow Coma Score, presence of a severe head or extremity injury) known to affect trauma outcomes. Logistic regression evaluated the independent effect of an ATV vehicle on mortality, intensive care unit (ICU) admission, and placement on a ventilator relative to ORMC. The anatomic distribution of severe injuries was compared between survivors and decedents within each vehicle type., Results: A total of 34,457 patients met inclusion criteria, of whom, 24,582 were ATV patients and 9875 were ORMC patients. ATV patients had 51% higher risk-adjusted odds of death (OR 1.51; 95% CI 1.03-2.20), 55% higher risk-adjusted odds of being admitted to an ICU (OR 1.55; 95% CI 1.42-1.70), and 42% higher risk-adjusted odds of being placed on a ventilator (OR 1.42, 95% CI 1.17-1.72) compared to ORMC crash victims. Decedents in both vehicle types were more likely to suffer severe head, thoracic, and abdominal injuries relative to their surviving counterparts., Conclusion: For injured riders, ATVs are associated with increased mortality and higher resource utilisation compared to ORMCs. Both groups suffer distinct anatomic injuries, suggesting the need for focused areas of injury prevention planning and research., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Mortality prediction in trauma patients has relied upon injury severity scoring tools focused on anatomical injury. This study sought to examine whether an injury severity scoring system which includes physiologic data performs as well as anatomic injury scores in mortality prediction., Methods: Using data collected from 18 Level I trauma centers and 51 non-trauma center hospitals in the US, anatomy based injury severity scores (ISS), new injury severity scores (NISS) were calculated as were scores based on a modified version of the physiology-based Kampala trauma score (KTS). Because pre-hospital intubation, when required, is standard of care in the US, a modified KTS was calculated excluding respiratory rate. The predictive ability of the modified KTS for mortality was compared with the ISS and NISS using receiver operating characteristic (ROC) curves., Results: A total of 4716 individuals were eligible for study. Each of the three scores was a statistically significant predictor of mortality. In this sample, the modified KTS significantly outperformed the ISS (AUC=0.83, 95% CI 0.81-0.84 vs. 0.77, 95% CI 0.76-0.79, respectively) and demonstrated similar predictive ability compared to the NISS (AUC=0.83, 95% CI 0.81-0.84 vs. 0.82, 95% CI 0.80-0.83, respectively)., Conclusions: The modified KTS may represent a useful tool for assessing trauma mortality risk in real time, as well as in administrative data where physiologic measures are available. Further research is warranted and these findings suggest that the collection of physiologic measures in large databases may improve outcome prediction., (Copyright © 2015 Elsevier Ltd. All rights reserved.)