Publications by authors named "Michael K Dalton"

16 Publications

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Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes.

Ann Surg 2021 Feb 25. Epub 2021 Feb 25.

*Yale School of Medicine, New Haven, CT †Center for Surgery and Public Health: Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA ‡Yale School of Public Health, New Haven, CT §Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom ¶The Aga Khan University Medical College, Karachi, Pakistan.

Objective: To critically evaluate whether admission at the beginning-versus-end of the academic year is associated with increased risk of major adverse outcomes.

Summary Background Data: The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989.

Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published prior to December 20, 2019, for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching-versus-non-teaching hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression.

Results: A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Meta-analyses of mortality (OR[95%CI]: 1.01[0.98-1.05]) and major morbidity (1.01[0.99-1.04]) demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions.

Conclusions: The preponderance of negative results over the past 30 years suggests that it may be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.
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http://dx.doi.org/10.1097/SLA.0000000000004805DOI Listing
February 2021

The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-related Trauma (2007-2018).

Ann Surg 2021 Mar 2. Epub 2021 Mar 2.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814 Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115.

Objective: We sought to evaluate long-term healthcare requirements of American military servicemembers with combat-related injuries.

Summary Of Background Data: US military conflicts since 2001 have produced the most combat casualties since Vietnam. Long-term consequences on healthcare utilization and associated costs remain unknown.

Methods: We identified servicemembers who were treated for combat-related injuries between 2007 and 2011. Controls consisted of active-duty servicemembers injured in the civilian sector, without any history of combat-related trauma, matched (1:1) on year of injury, biologic sex injury severity, and age at time of injury. Surveillance was performed through 2018. Total annual healthcare expenditures were evaluated overall and then as expenditures in the first year after injury and for subsequent years. Negative binomial regression was used to identify the adjusted influence of combat injury on healthcare costs.

Results: The combat-injured cohort consisted of 3981 individuals and we identified 3979 controls. Total healthcare utilization during the follow-up period resulted in median costs of $142,214 (IQR $61,428, $323,060) per combat-injured servicemember as compared to $50,741 (IQR $26,669, $104,134) among controls. Median expenditures, adjusted for duration of follow-up, for the combat-injured were $45,211 (IQR $18,698, $105,437). In adjusted analysis, overall costs were 30% higher (1.30; 95% confidence interval: 1.23, 1.37) for combat-injured personnel.

Conclusion: This investigation represents the longest continuous observation of healthcare utilization among individuals after combat injury and the first to assess costs. Expenditures were 30% higher for individuals injured as a result of combat-related trauma when compared to those injured in the civilian sector.
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http://dx.doi.org/10.1097/SLA.0000000000004844DOI Listing
March 2021

National estimates of intestinal ostomy creation and reversal for trauma.

J Trauma Acute Care Surg 2021 03;90(3):459-465

From the Center for Surgery and Public Health, Department of Surgery (Z.G.H., M.K.D., J.C.M., A.S., A.H.H.), Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery (Z.G.H.), Sinai Hospital of Baltimore, Baltimore, Maryland; Department of Surgery (S.S.S.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Surgery (J.C.M.), St. Elizabeth's Medical Center, Boston, Massachusetts; and Medical College (A.H.H.), Aga Khan University, Karachi, Pakistan.

Background: Intestinal ostomy creation after trauma is selectively indicated for destructive colon and rectal injuries. However, the nationwide rates of creation of ostomies for trauma and their reversal are not known. The objective of this study was to ascertain national estimates of trauma ostomy creation and reversal.

Methods: Weighted analysis of Healthcare Cost and Utilization Project Nationwide Readmissions Database 2014 to 2015 was performed. Adult trauma patients (≥16 years) with a hollow viscus injury were included. Patients with preexisting ostomies and permanent ostomies and those who died within 48 hours of admission were excluded. Rates of ostomy creation and same admission ostomy reversal were calculated. Rates of postdischarge ostomy reversal were calculated using the Kaplan-Meier estimator. Multivariable Cox proportional hazards model was used to determine factors associated with postdischarge trauma ostomy reversal.

Results: A total of 22,542 patients sustained a hollow viscus injury resulting in the creation of 2,145 ostomies (9.6%). The rate of same-admission ostomy reversal was 0.7% (n = 16). At 1, 3, 6, and 9 months, the cumulative stoma reversal rates were 0%, 7.6%, 31.0%, and 43.1%, respectively. The mean ± SD time from ostomy creation to reversal was 123 ± 6.7 days for those undergoing reversal. Injury Severity Score greater than 9 was significantly associated with ostomy nonreversal after discharge (hazard ratio, 0.41; 95% confidence interval, 0.26-0.66). Age, sex, insurance status, penetrating injury, Charlson Comorbidity Index, and hospital teaching status were not significantly associated with ostomy reversal.

Conclusion: The nationwide rate of ostomy creation after trauma is nearly 10%. At 6 months postinjury, only one third of patients had undergone ostomy reversal. Future study is needed to understand patient and provider-level factors associated with trauma ostomy reversal.

Level Of Evidence: Epidemiology, level III.
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http://dx.doi.org/10.1097/TA.0000000000003022DOI Listing
March 2021

Strategies for spinal surgery reimbursement: bundling in the working-age population.

BMC Health Serv Res 2021 Feb 2;21(1):112. Epub 2021 Feb 2.

Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, 1620 Tremont Street, 1 Brigham Circle, Boston, MA, 02120, USA.

Introduction: Bundled payments for spine surgery, which is known for having high overall cost with wide variation, have been previously studied in older adults. However, there has been limited work examining bundled payments in working-age patients. We sought to identify the variation in the cost of spine surgery among working age adults in a large, national insurance claims database.

Methods: We queried the TRICARE claims database for all patients, aged 18-64, undergoing cervical and non-cervical spinal fusion surgery between 2012 and 2014. We calculated the case mix adjusted, price standardized payments for all aspects of care during the 60-, 90-, and 180-day periods post operation. Variation was assessed by stratifying Hospital Referral Regions into quintiles.

Results: After adjusting for case mix, there was significant variation in the cost of both cervical ($10,538.23, 60% of first quintile) and non-cervical ($20,155.59, 74%). Relative variation in total cost decreased from 60- to 180-days (63 to 55% and 76 to 69%). Index hospitalization was the primary driver of costs and variation for both cervical (1st-to-5th quintile range: $11,033-$19,960) and non-cervical ($18,565-$36,844) followed by readmissions for cervical ($0-$11,521) and non-cervical ($0-$13,932). Even at the highest quintile, post-acute care remained the lowest contribution to overall cost ($2070 & $2984).

Conclusions: There is wide variation in the cost of spine surgery across the United States for working age adults, driven largely by index procedure and readmissions costs. Our findings suggest that implementing episodes longer than the current 90-day standard would do little to better control cost variation.
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http://dx.doi.org/10.1186/s12913-021-06112-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7852105PMC
February 2021

Identifying Patterns and Predictors of Prescription Opioid Use After Total Joint Arthroplasty.

Mil Med 2021 05;186(5-6):587-592

Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.

Introduction: Total hip arthroplasty and total knee arthroplasty account for over 1 million procedures annually. Opioids are the mainstay of postoperative pain management for these patients. In this context, the objective of this study was to determine patterns of use and factors associated with early discontinuation of opioids after total joint arthroplasty (TJA).

Methods: TRICARE claims data (2006-2014) were queried for adult (18-64 years) patients who underwent total hip arthroplasty or total knee arthroplasty. Prescription opioid use was identified from 6 months before and 6 months after surgical intervention. Prior opioid use was categorized as naïve, exposed (with non-sustained use), and sustained (6 month continuous use before surgery). Cox proportional-hazards models were used to identify factors associated with opioid discontinuation following TJA.

Results: Among the 29,767 patients included in the study, 15,271 (51.3%) had prior opioid exposure and 3,740 (12.5%) were sustained opioid users. At 6 months after the surgical intervention, 3,171 (10.6%) continued opioid use, 3.3% were among opioid naïve, 10.2% among exposed, and 33.3% among sustained users. In risk-adjusted models, prior opioid exposure (hazards ratio: 0.65, 95% CI: 0.62-0.67) and sustained prior use (hazards ratio: 0.33, 95% CI: 0.31-0.35) were the strongest predictors of lower likelihood of opioid discontinuation. Lower socio-economic status, depression, and anxiety were also strong predictors.

Conclusion: Prior opioid exposure was strongly associated with continued opioid dependence after TJA. Although one-third of prior sustained users continued use after surgery, approximately 10% of previously exposed patients became sustained users, making them the prime candidates for targeted interventions to reduce the likelihood of sustained opioid use after TJA.
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http://dx.doi.org/10.1093/milmed/usaa573DOI Listing
May 2021

Emergency Department Utilization in the U.S. Military Health System.

Mil Med 2021 05;186(5-6):606-612

Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA.

Introduction: Emergency department (ED) utilization represents an expensive and growing means of accessing care for a variety of conditions. Prior studies have characterized ED utilization in the general population. We aim to identify the clinical conditions that drive ED utilization in a universally insured population and the impacts of care setting on ED use and admissions in the U.S. Military Health System.

Methods: We queried TRICARE claims data from October 1, 2012, to September 30, 2015, to identify all ED visits for adult patients (age 18-64). The primary presenting diagnoses of all ED visits and those leading to admission are presented with descriptive statistics. Logistic regression was used to identify clinical and sociodemographic factors associated with admission from the ED.

Results: A total of 4,687,205 ED visits were identified, of which 46% took place in the DoD healthcare facilities (direct care). The most common diagnoses across all ED visits were abdominal pain, chest pain, headache, nausea and vomiting, and urinary tract infection. A total of 270,127 (5.8%) ED visits led to inpatient admission. The most common diagnoses leading to admission were chest pain, abdominal pain, depression, conditions relating to acute psychological stress, and pneumonia. For patients presenting with 1 of the 10 most common ED diagnoses, those who were seen at a civilian ED were significantly less likely to be admitted (3.4%) compared to direct care facilities (4.1%) in an adjusted logistic regression model (Adjusted Odds Ratio 0.40 [95% CI: 0.40-0.41], P < .001).

Conclusions: Ultimately, we show that abdominal pain and chest pain are the most common reasons for presentation to the ED in the Military Health System and the most common presenting diagnoses for admission from the ED. Among patients presenting with the most common ED conditions, direct care EDs were significantly more likely to admit patients than civilian facilities.
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http://dx.doi.org/10.1093/milmed/usaa547DOI Listing
May 2021

Super-Utilization of the Emergency Department in a Universally Insured Population.

Mil Med 2020 Nov 28. Epub 2020 Nov 28.

Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School and Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Introduction: Super-utilizers (patients with 4 or more emergency department [ED] visits a year) account for 10% to 26% of all ED visits and are responsible for a growing proportion of healthcare expenditures. Patients recognize the ED as a reliable provider of acute care, as well as a timely resource for diagnosis and treatment. The value of ED care is indisputable in critical and emergent conditions, but in the case of non-urgent conditions, ED utilization may represent an inefficiency in the healthcare system. We sought to identify patient and clinical characteristics associated with ED super-utilization in a universally insured population.

Material And Methods: We performed a retrospective cohort study using TRICARE claims data from the Military Health System Data Repository (2011-2015). We reviewed the claims data of all adult patients (aged 18-64 years) who had at least one encounter at the ED for any cause. Multivariable logistic regression was used to determine independent factors associated with ED super-utilization.

Results: Factors associated with increased odds of ED super-utilization included Charlson Score ≥2 (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI]: 1.90-2.06), being eligible for Medicare (aOR 1.95, 95% CI: 1.90-2.01), and female sex (aOR 1.35, 95% CI: 1.33-1.37). Active duty service members (aOR 0.69, 95% CI 0.68-0.72) and beneficiaries with higher sponsor-rank (Officers: aOR 0.50, 95% CI: 0.55-0.57; Senior enlisted: aOR 0.82, 95% CI: 0.81-0.83) had lower odds of ED super-utilization. The most common primary diagnoses for ED visits among super-utilizers were abdominal pain, headache and migraine, chest pain, urinary tract infection, nausea and vomiting, and low back pain.

Conclusions: Risk of ED super-utilization appears to increase with age and diminished health status. Patient demographic and clinical characteristics of ED super-utilization identified in this study can be used to formulate healthcare policies addressing gaps in primary care in diagnoses associated with ED super-utilization and develop interventions to address modifiable risk factors of ED utilization.
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http://dx.doi.org/10.1093/milmed/usaa399DOI Listing
November 2020

A National Assessment of Trauma Systems Using the American College of Surgeons NBATS Tool: Geographic Distribution of Trauma Center Need.

Ann Surg 2020 Oct 15. Epub 2020 Oct 15.

Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.

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 Background Data: Robust trauma systems have improved outcomes for severely injured patients. The NBATS tool was created by the American College of Surgeons (ACS) 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 in order to provide adequate access to trauma care nationwide. At least one additional trauma center is needed in 49% of trauma service areas.

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.
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http://dx.doi.org/10.1097/SLA.0000000000004555DOI Listing
October 2020

Association Between Patient-Reported Frailty and Non-Home Discharge Among Older Adults Undergoing Surgery.

J Am Geriatr Soc 2020 12 8;68(12):2909-2913. Epub 2020 Oct 8.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background/objectives: Identifying surgical patients at risk for discharge to a post-acute facility has the potential to reduce hospital length of stay, improve postoperative planning, and increase patient satisfaction. We sought to examine the association between a positive response to a preoperative patient-reported frailty screen and non-home discharge (NHD).

Design: Prospective cohort.

Setting: Urban tertiary academic preoperative evaluation center.

Participants: Convenience sample of patients aged 60 and older evaluated from November 2018 to August 2019) undergoing one of 14 major elective general and vascular operations with an expected length of stay of 3 days or longer.

Methods: Items from the previously validated Fatigue, Resistance, Ambulation, Illnesses, Loss of weight (FRAIL) screen were modified, and patients were queried on fatigue, activity against resistance, ambulation, and weight loss. Multivariable logistic regression adjusting for age and sex was used to determine the association between patient-reported items and NHD.

Results: A total of 230 patients were included for analysis. The average age of the cohort was 70.1 (standard deviation = 7.1); 91.7% were White, and 52.4% were female. There were 24 patients (10.4%) who were not discharged home. They were more likely to report fatigue (54% vs 29%; P = .01), weight loss (58% vs 21%; P < .01), and difficulty with activity against resistance (33% vs 7%; P < .01) before surgery. In adjusted analysis, patients who self-reported frailty (FRAIL screen ≥2) were significantly more likely to have an NHD (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 1.7-11.7; P < .01), as were patients who responded "yes" to any question from the FRAIL screen (OR = 2.5; 95% CI = 1.7-3.5; P < .01). A positive response to difficulty with activity against resistance or recent weight loss showed similar odds of NHD (OR = 7.6; 95% CI = 2.6-23.9; P < .01; and OR = 7.9; 95% CI = 2.9-21.6; P < .01, respectively).

Conclusion: Patient response to screening questions on the FRAIL screen identified those at highest risk of NHD. The FRAIL screening tool is practical, easy to apply, and could be used during preoperative counseling to identify patients likely to have increased discharge planning needs.
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http://dx.doi.org/10.1111/jgs.16846DOI Listing
December 2020

A Multistate Study of Race and Ethnic Disparities in Access to Trauma Care.

J Surg Res 2021 01 8;257:486-492. Epub 2020 Sep 8.

Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Harvard T. H. Chan School of Public Health, Boston, Massachusetts. Electronic address:

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.
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http://dx.doi.org/10.1016/j.jss.2020.08.031DOI Listing
January 2021

Patterns and predictors of opioid prescribing and use after rib fractures.

Surgery 2020 10 9;168(4):684-689. Epub 2020 Jul 9.

Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA.

Background: Rib fractures are painful injuries that are treated with aggressive analgesia, which can include opioids. We sought to evaluate the patterns and predictors of opioid prescription and sustained use for rib fracture patients to identify opportunities for opiate reduction.

Methods: We used TRICARE claims data (2006-2014) to identify adult (18-64 years) patients presenting to the emergency department with rib fracture(s) and isolated chest trauma. We used logistic regression and Cox proportional hazards model to identify factors associated with opioid prescription and duration of use.

Results: We identified 29,943 patients meeting inclusion criteria, and 2,542 (9%) patients were prescribed opioids. When prescribed, the median duration opioid use was 16 days (interquartile range 6-31) for opioid naïve patients, compared with 36 days (interquartile range 15-134) for those with prior opioid exposure. Increased number of ribs fractured (6+ fractures) (odds ratio 2.96 [95% confidence interval 2.23-3.94], P < .001) and prior opioid exposure (odds ratio 32.95 [29.36-36.99], P < .001) were significant predictors of initial opioid prescription. Patients with prior opioid exposure (hazard ratio 0.47 [0.43-0.52], P < .001) had lower likelihood of opioid discontinuation. Injury characteristics did not significantly predict discontinuation.

Conclusion: Prior opioid exposure was the strongest predictor of sustained opioid use after rib fractures, while the severity of injury did not predict the duration of use.
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http://dx.doi.org/10.1016/j.surg.2020.05.015DOI Listing
October 2020

Long-term Healthcare Utilization After Combat-related Spinal Trauma.

Spine (Phila Pa 1976) 2020 Jul;45(14):939-941

Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School.

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http://dx.doi.org/10.1097/BRS.0000000000003562DOI Listing
July 2020

Financial Impact of Minor Injury Transfers on a Level 1 Trauma Center.

J Surg Res 2019 01 18;233:403-407. Epub 2018 Sep 18.

Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, New Jersey.

Background: Trauma centers frequently accept patients from other institutions who are being sent due to the need for a higher level of care. We hypothesized that patients with minor traumatic injuries who are transferred from outside institutions would impart a negative financial impact on the receiving trauma center.

Methods: We performed a retrospective review of all trauma patients admitted to our urban level I trauma center from October 1, 2011, through September 30, 2013. Patients were categorized as minor trauma if they did not require operation within 24 h of arrival, did not require ICU admission, did not die, and had a hospital length of stay <24 h. Transferred patients and nontransfers (those received directly from the field) were compared with respect to injury severity, insurance status, and hospital net margin. Student's t-test and z-test for proportions were performed for data analysis.

Results: A total of 6951 trauma patients were identified (transfer n = 2228, nontransfer n = 4724). Minor injury transfers (n = 440) were compared to nontransfers (n = 689). Hospital net margin of transferred patients and nontransferred patients were $2227 and $2569, respectively (P = 0.22). Percentages of uninsured/underinsured for transfers and nontransfers were 27.3% and 36.1%, respectively (P = 0.002).

Conclusions: During our study period, 19.7% of transfers and 14.6% of nontransfers can be categorized as having minor trauma. Minor trauma transfer patients are associated with a positive hospital net margin for the trauma center that is similar to that of the nontransfer group. The data also demonstrate a lower percentage of uninsured/underinsured in the transferred group.
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http://dx.doi.org/10.1016/j.jss.2018.08.036DOI Listing
January 2019

The expedited discharge of patients with multiple traumatic rib fractures is cost-effective.

Injury 2019 Jan 13;50(1):109-112. Epub 2018 Oct 13.

Division of Trauma, Department of Surgery, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103, United States. Electronic address:

Introduction: Rib fractures are a cause of significant morbidity and mortality in trauma patients. It is well documented that optimizing pain control, mobilization, and respiratory care decreases complications. However, the impact of these interventions on hospital costs and length of stay is not well defined. We hypothesized patients with multiple rib fractures can be discharged within three hospital days resulting in decreased hospital costs.

Methods: A retrospective review of adult patients (≥18yrs) admitted to our Level 1 trauma center (2011-2013) with ≥2 rib fractures was performed. Patients were excluded if they were intubated, admitted to the ICU, required chest tube placement, or sustained significant multi-system trauma. (n = 202) Demographics, clinical characteristics, hospital costs, and outcome data were analyzed. Patients discharged within three hospital days of admission were considered to have achieved expedited discharge (ED). Univariate and multivariate analyses determined predictors of failure to achieve ED. A p value of <0.05 was considered significant.

Results: Study patients (n = 202) were 60 (SD = 19) years of age with an injury severity score (ISS) of 10 (SD = 5), and 4 (SD = 2) rib fractures. Of 202 patients, 127 (63%) achieved ED while 75 (37%) did not. No differences in chest AIS, ISS, smoking status or history of pulmonary disease were identified between the two groups (all p > 0.05). Average LOS (2 (SD = 1) vs. 7 (SD = 4) days; p < 0.001) and hospital costs ($2865 (SD = 1200) vs. $6085 (SD = 3033)); p < 0.001). were lower in the ED group A lower percentage of ED patients required placement in rehabilitation facilities (6% vs. 48%; p < 0.001). There were no readmissions within 30 days in either group. After controlling for potential confounding variables, multiple variable logistic regression analysis revealed that advancing age (OR 1.05 per year, 1.02-1.07) independently predicted failure to achieve ED.

Conclusion: The majority of patients admitted to the hospital with multiple rib fractures can be discharged within three days. This expedited discharge results in significant cost savings to the hospital. Early identification of patients who cannot meet the goal of expedited discharge can facilitate improvement in management strategies.
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http://dx.doi.org/10.1016/j.injury.2018.10.014DOI Listing
January 2019

Outpatient follow-up does not prevent emergency department utilization by trauma patients.

J Surg Res 2017 10 15;218:92-98. Epub 2017 Jun 15.

Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, New Jersey.

Background: Although most trauma centers have a regularly scheduled trauma clinic, research demonstrates that trauma patients do not consistently attend follow-up appointments and often use the emergency department (ED) for outpatient care.

Methods: A retrospective review of outpatient follow-up of adult patients admitted to the trauma service (January 2014-December 2014) at an urban level I trauma center was conducted (n = 2134).

Results: A total of 219 patients (10%) were evaluated in trauma clinic after discharge from the hospital. Twenty-one percent of patients seen in trauma clinic visited the ED within 30 d compared with 12% of those not seen in clinic (P < 0.001). A total of 104 patients were readmitted within 30 d of discharge; no difference existed in the rate of hospital readmission between patients seen in clinic and those not seen in clinic (P = 0.25). Stepwise logistic regression showed that clinic follow-up was not a significant predictor of decreased ED utilization (adjusted odds ratio [OR] 1.16 [95% confidence interval 0.78-1.72], P = 0.461) and also showed that while ED use was a significant predictor of readmission (adjusted OR 216 [93-500], P < 0.001), clinic visits were not (adjusted OR 0.74 [0.33-1.69], P = 0.48).

Conclusions: Outpatient follow-up in the trauma clinic does not decrease ED utilization or hospital readmissions indicating that interventions aimed at improving access to a conventional outpatient clinic will not impact ED utilization rates. Further study is necessary to determine the best system for providing clinically appropriate and cost-effective outpatient follow-up for trauma patients.
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http://dx.doi.org/10.1016/j.jss.2017.05.076DOI Listing
October 2017

Outcomes of acute care surgical cases performed at night.

Am J Surg 2016 Nov 11;212(5):831-836. Epub 2016 May 11.

Department of Surgery, Yale School of Medicine, 330 Cedar Street BB 310, PO Box 208062, New Haven, CT 86520-8062, USA. Electronic address:

Background: Acute care surgeons operate during the day and night. Time of day or night may impact the outcome because of surgeon and team fatigue, operative delays, or other unmeasured factors.

Methods: We performed matched retrospective cohort study of patients undergoing operative intervention at night by acute care surgeons over 16 months. Cases were matched on case complexity, age, and sex to daytime cases. Other confounders including comorbidities, presenting characteristics, complications, and mortality were abstracted. Outcomes differences between day and night cases were compared.

Results: Night cases (115) were matched 1:1 to daytime cases. Groups had similar degrees of comorbidity. Those operated at night had trends toward more hypotension and sepsis. After controlling for confounders using conditional logistic regression, surgical care at night was a potent predictor of mortality (odds ratio 30.02; 95% CI 2.33 to 387.40; P = .009) but had little impact on morbidity (odds ratio 1.34; 95% CI .77 to 2.36; P = .303).

Conclusions: Emergency operations performed at night by acute care surgeons may have dissimilar outcomes compared with day cases.
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http://dx.doi.org/10.1016/j.amjsurg.2016.02.024DOI Listing
November 2016