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December 2016 Featured Articles, Volume 223
CONTINUING MEDICAL EDUCATION PROGRAM
December 2016 Featured Articles, Volume 223
Get credit right away by taking all CME tests online http://jacscme.facs.org Article 1: Burn, Trauma, Critical Care; General Surgery
Acute rehabilitation after trauma: does it really matter? Nehra D, Nixon ZA, Lengenfelder C, et al. J Am Coll Surg 2016;223:755e763 Article 2: Burn, Trauma, Critical Care; General Surgery
Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need? Rios-Diaz AJ, Metcalfe D, Olufajo OA, et al. J Am Coll Surg 2016;223:764e773
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME and Self-Assessment credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two articles are available each month in the print version, and usually 4 are available online for each monthly issue, going back 24 months.
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Acute rehabilitation after trauma: does it really matter? Nehra D, Nixon ZA, Lengenfelder C, et al J Am Coll Surg 2016;223:755e763 Learning Objectives: After study of this article, surgeons should recognize that the care of the injured patient does not end upon discharge from the acute care hospital, and that the post-discharge care they receive can significantly influence long-term outcomes. The surgeon should also understand the impact that posthospital discharge care at an inpatient rehabilitation facility can have on the appropriately selected injured patient in terms of functional outcome, likelihood of eventual discharge home, and mortality at 1 year.
Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Question 1 Which of the following correctly defines the most recent trend in mortality for trauma patients in the US?
Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ª 2016 Published by Elsevier Inc. on behalf of the American College of Surgeons.
a. Decrease in inpatient mortality; decrease discharge mortality. b. Decrease in inpatient mortality; increase discharge mortality. c. Increase in inpatient mortality; decrease discharge mortality. d. Increase in inpatient mortality; increase discharge mortality. e. The trend is not known.
825
in postin postin postin post-
http://dx.doi.org/10.1016/j.jamcollsurg.2016.10.028 ISSN 1072-7515/16
826
Continuing Medical Education Program
Critique: Care of the injured patient does not end upon discharge from the acute care hospital, as many of these patients require ongoing rehabilitation after discharge. Unfortunately, definitive studies regarding the optimal post-discharge rehabilitation setting for trauma patients are lacking. This is a particularly important issue because although inpatient mortality for trauma patients continues to decrease, postdischarge mortality for trauma patients has actually increased over time. Short-term outcomes measures achieved during the inpatient hospitalization of the trauma patient are simply not an adequate method for measuring trauma care success. Question 2 Which of the following is TRUE regarding injured patients discharged to inpatient rehabilitation centers after hospitalization for acute injury? a. Patients discharged to inpatient rehabilitation facilities experience significant functional improvement (as measured by functional independence measure [FIM] scores) over the course of their rehabilitation. b. Patients discharged to inpatient rehabilitation facilities do not seem to experience functional benefit (as measured by FIM scores) over the course of their rehabilitation. c. Patients discharged to inpatient rehabilitation facilities are less likely to be eventually discharged home as compared to a propensity score-matched cohort of control patients not discharged to an inpatient rehabilitation facility after hospitalization for an injury. d. Patients discharged to inpatient rehabilitation facilities have a higher 1-year mortality compared to a propensity score-matched cohort of control patients not discharged to an inpatient rehabilitation facility after hospitalization for an injury. e. Patients discharged to inpatient rehabilitation facilities are more likely to be readmitted to the hospital as compared to a propensity score-matched cohort of control patients not discharged to an inpatient rehabilitation facility after hospitalization for an injury. Critique: In the current study we used a unique rehabilitation registry in the state of Washington to look at the effect of post-hospital discharge care at an inpatient rehabilitation facility on functional outcomes. We found that patients discharged to an inpatient rehabilitation facility after hospitalization for an acute traumatic injury experienced significant functional improvement (as measured by FIM scores)
J Am Coll Surg
over the course of their rehabilitation. Additionally, when we compared this group of injured patients who received post-hospital discharge care at an inpatient rehabilitation facility to a propensity scorematched cohort of patients who did not receive posthospital discharge care at an inpatient rehabilitation facility, we found that patients discharged to an inpatient rehabilitation facility were more likely to eventually be discharged home and had a lower 1-year mortality. There was no difference between the 2 groups with regard to the likelihood of re-hospitalization within 1 year. Question 3 Which of the following is a current Centers for Medicaid and Medicare Services (CMS) criteria that must be met for discharge to an inpatient rehabilitation facility? a. The patient must require and be reasonably expected to benefit from intensive rehabilitation therapy that consists of at least 8 hours per day at least 7 days per week. b. The patient must require supervision by a surgeon. c. The patient must be able to walk independently. d. The patient must require therapy in multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/ orthotics). e. The patient must be independent with activities of daily living. Critique: Determination of whether inpatient rehabilitation after hospital discharge is reasonable and necessary is made based upon an assessment of each patient’s individual care needs. In order to meet CMS criteria for discharge to an inpatient rehabilitation facility, the patient must e Require active and ongoing intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), at least one of which must be physical or occupational therapy. e Require an intensive rehabilitation therapy program, generally consisting of 3 hours of therapy per day at least 5 days per week. e Reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program (the patient’s condition and functional status are such that the patient can reasonably be expected to make measurable improvement, expected to be made within a prescribed period of time and as a result
Vol. 223, No. 6, December 2016
of the intensive rehabilitation therapy program, that will be of practical value to improve the patient’s functional capacity or adaptation to impairments). e Require physician supervision by a rehabilitation physician, with face-to-face visits at least 3 days per week to assess the patient both medically and functionally and to modify the course of treatment as needed. e Require an intensive and coordinated interdisciplinary team approach to the delivery of rehabilitative care. Question 4 Which of the following is NOT a task included in the functional independence measure (FIM) score? a. b. c. d. e.
Eating Bathing Social interaction Cognitive comprehension Reaction time to painful stimulus
Critique: The FIM score is a widely used functional assessment scale and has been well-validated in the trauma population. It consists of 13 motor (eating, grooming, bathing, upper body dressing, lower body dressing, toileting, bladder management, bowel management, bed to chair transfer, toilet transfer, shower transfer, locomotion, stairs) and 5 cognitive (cognitive comprehension, expression, social interaction, problem solving, memory) items designed to assess the amount of functional assistance required for a person to perform basic life activities. Each activity is scored on a scale of 1 to 7 resulting in a total FIM score from 18 to 126, a motor FIM score from 13 to 91 and a cognitive FIM score from 5 to 35.
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need? Rios-Diaz AJ, Metcalfe D, Olufajo OA, et al J Am Coll Surg 2016;223:764e773 Learning Objectives: After study of this article, surgeons should be able to identify the geographical distribution of highest and lowest burden of trauma admission and mortality; identify the geographical distribution and state availability of trauma centers,
Continuing Medical Education Program
827
surgical critical care providers and surgical critical care training opportunities; understand the association of clinical need, mortality, and availability of trauma services in the US; and understand the current availability and characteristics of trauma centers in the US. Question 1 States with a higher burden of trauma: a. Tend to have higher per-capita income and increased mortality rates. b. Tend to have lower per-capita income and increased mortality rates. c. Tend to have lower per-capita income and decreased mortality rates. d. Tend to have higher per-capita income and decreased mortality rates. e. Do not have association with per-capita income and tend to have increased mortality rates. Critique: The distribution of trauma admissions was positively associated with Surgical Critical Care provider density and age-adjusted trauma mortality (p<0.001), and inversely associated with per-capita income (p<0.001). In this study, there was an increase of 20.5 admissions per-million-population (PMP) (95% CI: 8.4-32.5; p¼0.001) for every unit increase in age-adjusted trauma mortality rate per 100,000 population, and a decrease of 54 admissions PMP (95% CI: 25.8-82.4; p<0.001) for every $1,000 increase in percapita income. Question 2 Trauma centers: a. Are evenly distributed across the US and there is an association between their location and the burden of trauma. b. Are unevenly distributed across the US but are distributed in accordance to the location of the burden of trauma. c. Are unevenly distributed across the US and there is no association with the location of the burden of trauma. d. Are evenly distributed across the US and there is no association between their location and the burden of trauma. e. Are evenly distributed in some regions of the US but there is no association between their location and the burden of trauma. Critique: The American College of Surgeons Committee on Trauma has stated that trauma centers should function based on local community
828
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Continuing Medical Education Program
requirements rather than on the basis of their resources, capabilities and self-selected levels of designation. Nevertheless, our study suggests that there is marked regional variation and considerable discrepancy between the clinical need and availability of trauma services across the US. There was no association between density of trauma admissions and the location of trauma centers. Question 3 Regarding the geographical location of surgical critical care providers: a. Increases in density of surgical critical care provider were associated with a decrease in state mortality. b. Decreases in density of surgical critical care provider were associated with a decrease in state mortality. c. Increases in density of surgical critical care provider were associated with an increase in state mortality. d. Decreases in density of surgical critical care provider were associated with an increase in state mortality, but only in low income areas. e. There was no association between the density of surgical critical care providers and mortality.
Critique: The results demonstrated that every unit increase in surgical critical providers per million population was associated with a national decrease of 618 trauma deaths per year. These findings raise the possibility that equitable distribution of trauma services could improve trauma outcomes on a national scale. Question 4 Which trauma center level has grown the most in the past decade? a. b. c. d. e.
Trauma Trauma Trauma Trauma Trauma
center center center center center
Level I Level II Levels I and II Level III Levels IV and V
Critique: From 2002 to 2015, there has been a small increase in the number of Level I and II trauma centers by 12% and 17%, respectively. However, Level III and Level IV/V trauma centers increased by a striking 77% and 126%, respectively. This expansion of lower-level trauma centers might not have been equal across the US and could help explain the 40-fold gap observed between states with lower and higher densities of trauma centers.
Vol. 223, No. 6, December 2016
Continuing Medical Education Program
829
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue). Issues are available for the past 24 months. You can print your certificate immediately.
For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
December 2016 Featured Articles, Volume 223 Acute rehabilitation after trauma: does it really matter? Nehra D, Nixon ZA, Lengenfelder C, et al. J Am Coll Surg 2016;223:755e763 Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need? Rios-Diaz AJ, Metcalfe D, Olufajo OA, et al. J Am Coll Surg 2016;223:764e773
December 2016 Featured Articles, Volume 223
Get credit right away by taking all CME tests online http://jacscme.facs.org Article 1: Burn, Trauma, Critical Care; General Surgery
Acute rehabilitation after trauma: does it really matter? Nehra D, Nixon ZA, Lengenfelder C, et al. J Am Coll Surg 2016;223:755e763 Article 2: Burn, Trauma, Critical Care; General Surgery
Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need? Rios-Diaz AJ, Metcalfe D, Olufajo OA, et al. J Am Coll Surg 2016;223:764e773
Objectives: After reading the featured articles published in this issue of the Journal of the American College of Surgeons (JACS) participants in this journal-based CME activity should be able to demonstrate increased understanding of the material specific to the article featured and be able to apply relevant information to clinical practice. A score of 75% is required to receive CME and Self-Assessment credit. The JACS Editor-in-Chief does not assign a manuscript for review to any person who discloses a conflict of interest with the content of the manuscript. Two articles are available each month in the print version, and usually 4 are available online for each monthly issue, going back 24 months.
ARTICLE 1 (Please consider how the content of this article may be applied to your practice.)
Acute rehabilitation after trauma: does it really matter? Nehra D, Nixon ZA, Lengenfelder C, et al J Am Coll Surg 2016;223:755e763 Learning Objectives: After study of this article, surgeons should recognize that the care of the injured patient does not end upon discharge from the acute care hospital, and that the post-discharge care they receive can significantly influence long-term outcomes. The surgeon should also understand the impact that posthospital discharge care at an inpatient rehabilitation facility can have on the appropriately selected injured patient in terms of functional outcome, likelihood of eventual discharge home, and mortality at 1 year.
Accreditation: The American College of Surgeons is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Question 1 Which of the following correctly defines the most recent trend in mortality for trauma patients in the US?
Designation: The American College of Surgeons designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ª 2016 Published by Elsevier Inc. on behalf of the American College of Surgeons.
a. Decrease in inpatient mortality; decrease discharge mortality. b. Decrease in inpatient mortality; increase discharge mortality. c. Increase in inpatient mortality; decrease discharge mortality. d. Increase in inpatient mortality; increase discharge mortality. e. The trend is not known.
825
in postin postin postin post-
http://dx.doi.org/10.1016/j.jamcollsurg.2016.10.028 ISSN 1072-7515/16
826
Continuing Medical Education Program
Critique: Care of the injured patient does not end upon discharge from the acute care hospital, as many of these patients require ongoing rehabilitation after discharge. Unfortunately, definitive studies regarding the optimal post-discharge rehabilitation setting for trauma patients are lacking. This is a particularly important issue because although inpatient mortality for trauma patients continues to decrease, postdischarge mortality for trauma patients has actually increased over time. Short-term outcomes measures achieved during the inpatient hospitalization of the trauma patient are simply not an adequate method for measuring trauma care success. Question 2 Which of the following is TRUE regarding injured patients discharged to inpatient rehabilitation centers after hospitalization for acute injury? a. Patients discharged to inpatient rehabilitation facilities experience significant functional improvement (as measured by functional independence measure [FIM] scores) over the course of their rehabilitation. b. Patients discharged to inpatient rehabilitation facilities do not seem to experience functional benefit (as measured by FIM scores) over the course of their rehabilitation. c. Patients discharged to inpatient rehabilitation facilities are less likely to be eventually discharged home as compared to a propensity score-matched cohort of control patients not discharged to an inpatient rehabilitation facility after hospitalization for an injury. d. Patients discharged to inpatient rehabilitation facilities have a higher 1-year mortality compared to a propensity score-matched cohort of control patients not discharged to an inpatient rehabilitation facility after hospitalization for an injury. e. Patients discharged to inpatient rehabilitation facilities are more likely to be readmitted to the hospital as compared to a propensity score-matched cohort of control patients not discharged to an inpatient rehabilitation facility after hospitalization for an injury. Critique: In the current study we used a unique rehabilitation registry in the state of Washington to look at the effect of post-hospital discharge care at an inpatient rehabilitation facility on functional outcomes. We found that patients discharged to an inpatient rehabilitation facility after hospitalization for an acute traumatic injury experienced significant functional improvement (as measured by FIM scores)
J Am Coll Surg
over the course of their rehabilitation. Additionally, when we compared this group of injured patients who received post-hospital discharge care at an inpatient rehabilitation facility to a propensity scorematched cohort of patients who did not receive posthospital discharge care at an inpatient rehabilitation facility, we found that patients discharged to an inpatient rehabilitation facility were more likely to eventually be discharged home and had a lower 1-year mortality. There was no difference between the 2 groups with regard to the likelihood of re-hospitalization within 1 year. Question 3 Which of the following is a current Centers for Medicaid and Medicare Services (CMS) criteria that must be met for discharge to an inpatient rehabilitation facility? a. The patient must require and be reasonably expected to benefit from intensive rehabilitation therapy that consists of at least 8 hours per day at least 7 days per week. b. The patient must require supervision by a surgeon. c. The patient must be able to walk independently. d. The patient must require therapy in multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/ orthotics). e. The patient must be independent with activities of daily living. Critique: Determination of whether inpatient rehabilitation after hospital discharge is reasonable and necessary is made based upon an assessment of each patient’s individual care needs. In order to meet CMS criteria for discharge to an inpatient rehabilitation facility, the patient must e Require active and ongoing intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), at least one of which must be physical or occupational therapy. e Require an intensive rehabilitation therapy program, generally consisting of 3 hours of therapy per day at least 5 days per week. e Reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program (the patient’s condition and functional status are such that the patient can reasonably be expected to make measurable improvement, expected to be made within a prescribed period of time and as a result
Vol. 223, No. 6, December 2016
of the intensive rehabilitation therapy program, that will be of practical value to improve the patient’s functional capacity or adaptation to impairments). e Require physician supervision by a rehabilitation physician, with face-to-face visits at least 3 days per week to assess the patient both medically and functionally and to modify the course of treatment as needed. e Require an intensive and coordinated interdisciplinary team approach to the delivery of rehabilitative care. Question 4 Which of the following is NOT a task included in the functional independence measure (FIM) score? a. b. c. d. e.
Eating Bathing Social interaction Cognitive comprehension Reaction time to painful stimulus
Critique: The FIM score is a widely used functional assessment scale and has been well-validated in the trauma population. It consists of 13 motor (eating, grooming, bathing, upper body dressing, lower body dressing, toileting, bladder management, bowel management, bed to chair transfer, toilet transfer, shower transfer, locomotion, stairs) and 5 cognitive (cognitive comprehension, expression, social interaction, problem solving, memory) items designed to assess the amount of functional assistance required for a person to perform basic life activities. Each activity is scored on a scale of 1 to 7 resulting in a total FIM score from 18 to 126, a motor FIM score from 13 to 91 and a cognitive FIM score from 5 to 35.
ARTICLE 2 (Please consider how the content of this article may be applied to your practice.)
Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need? Rios-Diaz AJ, Metcalfe D, Olufajo OA, et al J Am Coll Surg 2016;223:764e773 Learning Objectives: After study of this article, surgeons should be able to identify the geographical distribution of highest and lowest burden of trauma admission and mortality; identify the geographical distribution and state availability of trauma centers,
Continuing Medical Education Program
827
surgical critical care providers and surgical critical care training opportunities; understand the association of clinical need, mortality, and availability of trauma services in the US; and understand the current availability and characteristics of trauma centers in the US. Question 1 States with a higher burden of trauma: a. Tend to have higher per-capita income and increased mortality rates. b. Tend to have lower per-capita income and increased mortality rates. c. Tend to have lower per-capita income and decreased mortality rates. d. Tend to have higher per-capita income and decreased mortality rates. e. Do not have association with per-capita income and tend to have increased mortality rates. Critique: The distribution of trauma admissions was positively associated with Surgical Critical Care provider density and age-adjusted trauma mortality (p<0.001), and inversely associated with per-capita income (p<0.001). In this study, there was an increase of 20.5 admissions per-million-population (PMP) (95% CI: 8.4-32.5; p¼0.001) for every unit increase in age-adjusted trauma mortality rate per 100,000 population, and a decrease of 54 admissions PMP (95% CI: 25.8-82.4; p<0.001) for every $1,000 increase in percapita income. Question 2 Trauma centers: a. Are evenly distributed across the US and there is an association between their location and the burden of trauma. b. Are unevenly distributed across the US but are distributed in accordance to the location of the burden of trauma. c. Are unevenly distributed across the US and there is no association with the location of the burden of trauma. d. Are evenly distributed across the US and there is no association between their location and the burden of trauma. e. Are evenly distributed in some regions of the US but there is no association between their location and the burden of trauma. Critique: The American College of Surgeons Committee on Trauma has stated that trauma centers should function based on local community
828
J Am Coll Surg
Continuing Medical Education Program
requirements rather than on the basis of their resources, capabilities and self-selected levels of designation. Nevertheless, our study suggests that there is marked regional variation and considerable discrepancy between the clinical need and availability of trauma services across the US. There was no association between density of trauma admissions and the location of trauma centers. Question 3 Regarding the geographical location of surgical critical care providers: a. Increases in density of surgical critical care provider were associated with a decrease in state mortality. b. Decreases in density of surgical critical care provider were associated with a decrease in state mortality. c. Increases in density of surgical critical care provider were associated with an increase in state mortality. d. Decreases in density of surgical critical care provider were associated with an increase in state mortality, but only in low income areas. e. There was no association between the density of surgical critical care providers and mortality.
Critique: The results demonstrated that every unit increase in surgical critical providers per million population was associated with a national decrease of 618 trauma deaths per year. These findings raise the possibility that equitable distribution of trauma services could improve trauma outcomes on a national scale. Question 4 Which trauma center level has grown the most in the past decade? a. b. c. d. e.
Trauma Trauma Trauma Trauma Trauma
center center center center center
Level I Level II Levels I and II Level III Levels IV and V
Critique: From 2002 to 2015, there has been a small increase in the number of Level I and II trauma centers by 12% and 17%, respectively. However, Level III and Level IV/V trauma centers increased by a striking 77% and 126%, respectively. This expansion of lower-level trauma centers might not have been equal across the US and could help explain the 40-fold gap observed between states with lower and higher densities of trauma centers.
Vol. 223, No. 6, December 2016
Continuing Medical Education Program
829
To complete CME please go to http://jacscme.facs.org Log in with your ACS Member ID# and last name. The JACS CME website has additional articles available for credit (maximum 4 per issue). Issues are available for the past 24 months. You can print your certificate immediately.
For those who are unable to access the internet, fax this page ONLY to 312-202-5027 Your certificate will be faxed or emailed to you; incomplete submissions will not be processed. No mail submissions will be accepted.
December 2016 Featured Articles, Volume 223 Acute rehabilitation after trauma: does it really matter? Nehra D, Nixon ZA, Lengenfelder C, et al. J Am Coll Surg 2016;223:755e763 Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need? Rios-Diaz AJ, Metcalfe D, Olufajo OA, et al. J Am Coll Surg 2016;223:764e773