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Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status.

ABSTRACT: Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs).To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients.Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non–trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region.Inpatient admission vs transfer to another acute care facility.In 2009, a total of 4513 observations from 636 non–trauma center EDs were available for analysis, representing a nationally weighted population of 19,312 non–trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non–trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non–teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10,000 annual ED visits).Patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

SUBMITTER: Delgado MK

PROVIDER: S-EPMC4422057 | biostudies-literature | 2014 May

REPOSITORIES: biostudies-literature

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Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status.

Delgado M Kit MK Yokell Michael A MA Staudenmayer Kristan L KL Spain David A DA Hernandez-Boussard Tina T Wang N Ewen NE

JAMA surgery 20140501 5

<h4>Importance</h4>Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs).<h4>Objectives</h4>To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely ...[more]

PMID: 24554059

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Project description:BACKGROUND: Severely injured trauma patients are exposed to clinically significant radiation doses from computed tomography (CT) imaging in the emergency department. Moreover, this radiation exposure is associated with an increased risk of cancer. The purpose of this study was to determine some effects of a radiation dose reduction strategy for CT in severely injured trauma patients in the emergency department. METHODS: We implemented the radiation dose reduction strategy in May 2009. A prospective observational study design was used to collect data from patients who met the inclusion criteria during this one year study (intervention group) from May 2009 to April 2010. The prospective data were compared with data collected retrospectively for one year prior to the implementation of the radiation dose reduction strategy (control group). By comparison of the cumulative effective dose and the number of CT examinations in the two groups, we evaluated effects of a radiation dose reduction strategy. All the patients met the institutional adult trauma team activation criteria. The radiation doses calculated by the CT scanner were converted to effective doses by multiplication by a conversion coefficient. RESULTS: A total of 118 patients were included in this study. Among them, 33 were admitted before May 2009 (control group), and 85 were admitted after May 2009 (intervention group). There were no significant differences between the two groups regarding baseline characteristics, such as injury severity and mortality. Additionally, there was no difference between the two groups in the mean number of total CT examinations per patient (4.8 vs. 4.5, respectively; p = 0.227). However, the mean effective dose of the total CT examinations per patient significantly decreased from 78.71 mSv to 29.50 mSv (p < 0.001). CONCLUSIONS: The radiation dose reduction strategy for CT in severely injured trauma patients effectively decreased the cumulative effective dose of the total CT examinations in the emergency department. But not effectively decreased the number of CT examinations.

Project description:ImportanceScreening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool.ObjectiveTo compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata.Design, setting, and participantsThe Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023.Main outcomes and measuresThis study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA.ResultsOf 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively).Conclusions and relevanceThis study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

Project description:PurposeWhile survival rates after a trauma are increasing a considerable part of the trauma population are still at risk for both short and long term disabilities. Little is known about prognostic factors over time after a severe trauma. The aim of the present prospective cohort study was to examine trauma and patient related prognostic factors for a lower health status over time after a severe trauma.MethodsA multicentre prospective observational cohort study was conducted. Adult trauma patients with severe injuries (ISS???16) were included from August 2015 until November 2016 if admitted to one of the hospitals in Noord-Brabant (the Netherlands). Outcome measure was health status, measured by the EuroQol-5D (EQ-5D utility and EQ-Visual analogue scale) and the Health Utilities Index (HUI2 and HUI3) one week and one, three, six, and twelve months after injury. Patient and trauma characteristics were analysed as prognostic factors with linear mixed models. The effect of each prognostic factor over time was analysed by adding the interaction term between the prognostic factor and time point in a multivariable linear mixed model, adjusted for confounders. Additionally, the risk factors for problems in the EQ-5 dimensions of HS and cognition were analysed.ResultsIn total 239 severely injured patients participated. Pre-injury health status, hospital length of stay, ISS and comorbidities were significant prognostic factors for a lower health status. A younger age and extremity injury were prognostic factors for a lower health status until one month after trauma and unemployment before trauma and comorbidities six until twelve months after trauma. In the EQ-5 dimensions 44.1% remained problems in mobility, 15.3% in self-care, 46.4% in activity, 53.3% in pain, 32.5% in anxiety and 35.7% in cognition.ConclusionsLower pre-injury health status, longer hospital length of stay, higher ISS, and comorbidities were significant prognostic factors for a lower health status during one year after a severe injury. A younger age and an extremity injury were short-term prognostic factors and unemployment before trauma and comorbidities were long-term prognostic factors. Even after twelve months patients in our population reported more problems in all EQ-5D dimensions when compared to the Dutch reference population.

Project description:ObjectiveTo examine sociodemographic predictors of trauma center (TC) transport of severely injured older adults.Data sourcesThe data source was the Healthcare Cost and Utilization Project, New York Inpatient Database (2014).Study designThis study was a secondary analysis of injured older adults. Key sociodemographic variables were age, gender, race/ethnicity, median household income, and primary payer. Confounding variables were injury severity, geographic location, number of chronic conditions, and injury mechanism. The outcome variable was TC transport.Data collection/extraction methodsThe database was filtered on the following criteria: age =/> 55 years, primary diagnosis of injury (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM], 800.0-957.9, excluding poisoning, late effects, and interfacility transfers), admitted to an acute care hospital in New York.Principal findingsRecords of 33 696 patients were included. Multivariate logistic regression analysis revealed that all variables were statistically significant predictors of TC transport except primary payer. Predictors of TC transport were as follows: higher injury severity (OR 2.1, CI 1.79-2.46; 3.39, CI 2.85-4.05); Asian/Pacific and Hispanic race/ethnicity (OR 2.51, CI 1.92-3.27; OR 1.1, CI 0.86-1.42), highest median household income (OR 1.24, CI 1.01-1.52), high population density (OR 1.32, CI 1.12-1.55; OR 3.2, CI 2.68-2.83), and vehicle crashes (OR 3.39, CI 2.79-4.11). Predictors of non-TC transport were as follows: older age groups (OR 0.92, CI 0.76-1.11; OR 0.79, CI 0.64-0.96; OR 0.77, CI 0.63-0.95), females (OR 0.65, CI 0.57-0.74), Black and "other" race (OR 0.75, CI 0.0.56-1.0; OR 0.96, CI 0.77-1.20), lower median household income (OR 0.76, CI 0.62-0.93; OR 0.86, CI 0.71-1.05), low population density (OR 0.96, CI 0.67-1.36; OR 0.89, CI 0.53-1.51), and number of chronic conditions (OR 0.89, CI 0.87-0.91).ConclusionsSociodemographic factors are a source of disparity for access to TCs. Further research is needed to confirm bias and test bias reduction strategies. Comprehensive education and policies are needed to reduce disparities in access to trauma care.

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Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status.

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Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status.

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