- Email: [email protected]
Cervical plain films should be eliminated in the high risk patient: Results from decision analysis using an institutional cost perspective
Vol. 199, No. 3S, September 2004
Surgical Education
S77
Table: Temporal distribution of patients entering surgery. Patients often underwent multiple operations by multidisciplinary teams, yielding overall proportions of ⬎ 100%. Length of surgery is not described. Data regarding time of entry to surgery were not reported for 6 patients. 1–29 min
30–59 min
1–1.5 hr
1.5–2 hr
2–2.5 hr
2.5–3 hr
3–4 hr
4–5 hr
5–6 hr
6–12 hr
12–24 hr
24ⴙ hr
4 ⫾ 6.6
4.5 ⫾ 6.8
8.5 ⫾ 9.9
3.1 ⫾ 6.1
5.7 ⫾ 6.8
16.2 ⫾ 14.1
8.9 ⫾ 11.1
3.7 ⫾ 7.0 0
A. Percent of patients entering surgery by time from arrival of first patient 4.5 ⫾ 10.9
11.1 ⫾ 10.7
17.5 ⫾ 10.3
9.7 ⫾ 9.3
B. Percent of patients entering surgery by the various surgical specialties and by time from arrival of first patient Neurosurgery
0
19
32
40
20
14
17
50
0
12
0
Eye
17
13
8
20
0
0
0
25
0
12
0
0
Thoracic
83
38
28
27
0
14
25
0
0
4
0
0
Vascular
33
31
24
7
0
0
8
0
29
0
0
0
Abdominal
100
81
56
47
20
29
17
0
0
8
6
17
Orthopedic
17
44
44
67
40
71
58
50
57
58
44
17
CONCLUSIONS: Analysis of resource utilization in response to an MCI reveals the following: 1. Staffing demands for ER, OR and ICU overlap 2. Anesthesiologists, general and thoracic surgeons are in immediate demand. 3. Most ICU admissions follow surgery. 4. Most patients operated within the first 2 hours require multidisciplinary surgery. 5. Demand for orthopedic surgery and anesthesiology services continues for ⬎ 24hrs.
Male gender is an independent risk factor for major infection after severe blunt trauma Jeffrey L Johnson MD, Ernest Moore MD, FACS, David Ciesla MD, Catherine Cothren MD, Angela Sauaia MD, PhD Denver Health Medical Center and University of Colorado Health Sciences CTR Denver, CO INTRODUCTION: Epidemiological studies and animal models suggest that the immunoinflammatory response to injury is gender dimorphic. In general, females appear protected from infection. However, others have observed that gender-related risk is modulated by type and extent of injury and other covariates. We hypothesized that males are more prone to major infection after critical injury. METHODS: We analyzed data from 1277 consecutive injured patients prospectively over 10 years ending September, 2003. Standardized criteria for major infection were used and included sepsis, pneumonia, and cavitary abscesses. Multiple logistic regression (MLR) was used to estimate the independent effect of gender on major infection risk. Covariates considered included ISS, age and amount of blood transfusion. RESULTS: Of the 1277 patients, 835 (74%) suffered a blunt injury, of which 571 (68%) were men. Male gender was significantly associated with major infections among blunt trauma patients (51% vs 44%, p ⫽ .047), but not among those with non-blunt mechanisms. Adjustment for confounders by MLR showed a persistent effect of male gender. The adjusted odds ratio (AdjOR) for male gender was 1.74 with a 95% confidence interval of 1.24–2.44. The AdjOR for Age (⬎ 50) was 1.25 (0.87–1.81) and that for ISS (⬎ 25) 3.09 (2.13–4.26). As expected, major infections significantly contributed to excess multiple organ failure (AdjOR ⫽ 5.19, 3.37–8.01), and mortality (AdjOR ⫽ 2.16, 1.2–3.9).
CONCLUSIONS: Male patients suffering a critical blunt injury are at a higher risk for infection than female patients, independent of injury severity and age.
Cervical plain films should be eliminated in the high risk patient: Results from decision analysis using an institutional cost perspective Eric L Grogan MD, Derek Moore MD, Theodore Speroff PhD, Jose Diaz, Jr., MD, FACS, Robert Dittus MD, MPH, John Morris, Jr., MD, FACS Vanderbilt University, Nashville, TN Nashville, TN INTRODUCTION: In the evaluation of the cervical spine, Helical CT scan has higher sensitivity and specificity than plain radiographs in the high-risk trauma population but is more costly. We hypothesized that institutional indemnity payments associated with missed injuries make helical CT scan the least-costly approach. METHODS: A decision analytic model was created for helical CT scan vs. radiographic evaluation of the c-spine. Model variables obtained from the literature: probability of c-spine fracture (11–11.5%), probability of paralysis after missed injury (1.0–10.5%), sensitivity of plain films (44–84%), specificity of plain films (72–89%), sensitivity of CT scan (95–97%), specificity of CT scan (93–100%). Costs from Level 1 trauma center: helical CT scan ($329), plain radiography ($120), missed injuries resulting in paralysis ($500k-$1M). Sensitivity analysis tested model strength, accounted for parameter variability, and determined threshold values for individual parameters. RESULTS: Evaluation of c-spine with helical CT scan has expected cost of $444 compared to $1155 for plain films. CT scan is the least costly alternative if threshold values exceed: $113,616 for indemnity payments, 2.6 % for probability of c-spine fracture, and 1.1% for probability of paralysis. Plain films are a cost-effective alternative if institutional costs of CT scan exceed $1040 or the sensitivity of plain films is greater than 90%. CONCLUSIONS: Decision analysis from an institutional perspective shows an economic advantage for helical CT scan. This combined with CT scan’s enhanced sensitivity and specificity suggests that plain film evaluation of the c-spine should be eliminated in the high risk trauma patient.
Surgical Education
S77
Table: Temporal distribution of patients entering surgery. Patients often underwent multiple operations by multidisciplinary teams, yielding overall proportions of ⬎ 100%. Length of surgery is not described. Data regarding time of entry to surgery were not reported for 6 patients. 1–29 min
30–59 min
1–1.5 hr
1.5–2 hr
2–2.5 hr
2.5–3 hr
3–4 hr
4–5 hr
5–6 hr
6–12 hr
12–24 hr
24ⴙ hr
4 ⫾ 6.6
4.5 ⫾ 6.8
8.5 ⫾ 9.9
3.1 ⫾ 6.1
5.7 ⫾ 6.8
16.2 ⫾ 14.1
8.9 ⫾ 11.1
3.7 ⫾ 7.0 0
A. Percent of patients entering surgery by time from arrival of first patient 4.5 ⫾ 10.9
11.1 ⫾ 10.7
17.5 ⫾ 10.3
9.7 ⫾ 9.3
B. Percent of patients entering surgery by the various surgical specialties and by time from arrival of first patient Neurosurgery
0
19
32
40
20
14
17
50
0
12
0
Eye
17
13
8
20
0
0
0
25
0
12
0
0
Thoracic
83
38
28
27
0
14
25
0
0
4
0
0
Vascular
33
31
24
7
0
0
8
0
29
0
0
0
Abdominal
100
81
56
47
20
29
17
0
0
8
6
17
Orthopedic
17
44
44
67
40
71
58
50
57
58
44
17
CONCLUSIONS: Analysis of resource utilization in response to an MCI reveals the following: 1. Staffing demands for ER, OR and ICU overlap 2. Anesthesiologists, general and thoracic surgeons are in immediate demand. 3. Most ICU admissions follow surgery. 4. Most patients operated within the first 2 hours require multidisciplinary surgery. 5. Demand for orthopedic surgery and anesthesiology services continues for ⬎ 24hrs.
Male gender is an independent risk factor for major infection after severe blunt trauma Jeffrey L Johnson MD, Ernest Moore MD, FACS, David Ciesla MD, Catherine Cothren MD, Angela Sauaia MD, PhD Denver Health Medical Center and University of Colorado Health Sciences CTR Denver, CO INTRODUCTION: Epidemiological studies and animal models suggest that the immunoinflammatory response to injury is gender dimorphic. In general, females appear protected from infection. However, others have observed that gender-related risk is modulated by type and extent of injury and other covariates. We hypothesized that males are more prone to major infection after critical injury. METHODS: We analyzed data from 1277 consecutive injured patients prospectively over 10 years ending September, 2003. Standardized criteria for major infection were used and included sepsis, pneumonia, and cavitary abscesses. Multiple logistic regression (MLR) was used to estimate the independent effect of gender on major infection risk. Covariates considered included ISS, age and amount of blood transfusion. RESULTS: Of the 1277 patients, 835 (74%) suffered a blunt injury, of which 571 (68%) were men. Male gender was significantly associated with major infections among blunt trauma patients (51% vs 44%, p ⫽ .047), but not among those with non-blunt mechanisms. Adjustment for confounders by MLR showed a persistent effect of male gender. The adjusted odds ratio (AdjOR) for male gender was 1.74 with a 95% confidence interval of 1.24–2.44. The AdjOR for Age (⬎ 50) was 1.25 (0.87–1.81) and that for ISS (⬎ 25) 3.09 (2.13–4.26). As expected, major infections significantly contributed to excess multiple organ failure (AdjOR ⫽ 5.19, 3.37–8.01), and mortality (AdjOR ⫽ 2.16, 1.2–3.9).
CONCLUSIONS: Male patients suffering a critical blunt injury are at a higher risk for infection than female patients, independent of injury severity and age.
Cervical plain films should be eliminated in the high risk patient: Results from decision analysis using an institutional cost perspective Eric L Grogan MD, Derek Moore MD, Theodore Speroff PhD, Jose Diaz, Jr., MD, FACS, Robert Dittus MD, MPH, John Morris, Jr., MD, FACS Vanderbilt University, Nashville, TN Nashville, TN INTRODUCTION: In the evaluation of the cervical spine, Helical CT scan has higher sensitivity and specificity than plain radiographs in the high-risk trauma population but is more costly. We hypothesized that institutional indemnity payments associated with missed injuries make helical CT scan the least-costly approach. METHODS: A decision analytic model was created for helical CT scan vs. radiographic evaluation of the c-spine. Model variables obtained from the literature: probability of c-spine fracture (11–11.5%), probability of paralysis after missed injury (1.0–10.5%), sensitivity of plain films (44–84%), specificity of plain films (72–89%), sensitivity of CT scan (95–97%), specificity of CT scan (93–100%). Costs from Level 1 trauma center: helical CT scan ($329), plain radiography ($120), missed injuries resulting in paralysis ($500k-$1M). Sensitivity analysis tested model strength, accounted for parameter variability, and determined threshold values for individual parameters. RESULTS: Evaluation of c-spine with helical CT scan has expected cost of $444 compared to $1155 for plain films. CT scan is the least costly alternative if threshold values exceed: $113,616 for indemnity payments, 2.6 % for probability of c-spine fracture, and 1.1% for probability of paralysis. Plain films are a cost-effective alternative if institutional costs of CT scan exceed $1040 or the sensitivity of plain films is greater than 90%. CONCLUSIONS: Decision analysis from an institutional perspective shows an economic advantage for helical CT scan. This combined with CT scan’s enhanced sensitivity and specificity suggests that plain film evaluation of the c-spine should be eliminated in the high risk trauma patient.