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Demographics and Injury Patterns of Large Animal Related Injury Admissions in the United States
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
TRAUMA AND CRITICAL CARE 6: SOCIOECONOMIC ASPECTS OF TRAUMA 32.1. Relationship of Insurance Status to Hospital Length of Stay after Traumatic Injury: Patients with Publically Funded Insurance Have the Longest Lengths of Stay and Uninsured Patients Are Discharged the Earliest. B. R. Englum, O. B. Bolorundoro, C. Villegas, K. Stevens, E. Haut, E. E. Cornwell, III, D. T. Efron, A. H. Haider; Johns Hopkins School of Medicine, Baltimore, MD Introduction: Research has consistently shown that insurance status significantly impacts health care, including resource use, morbidity, and mortality. Data from several medical specialties demonstrate that patients without insurance have fewer physician visits, receive fewer procedures, and have shorter lengths of hospital stay leading to worse clinical outcomes. Uninsured hospitalized trauma patients are also known to have worse mortality outcomes; however, the impact of insurance on hospital stay in trauma is unknown. Objective: To examine the impact of insurance status on hospital length of stay (LOS) in the setting of acute trauma. Methods: Trauma patients, age 18-64, included in the National Trauma Data Bank (NTDB) between 2002-2006 were analyzed. Patients were categorized in three insurance groups: 1) Private insurance (HMO, PPO, MCO, Workers Comp, No Fault, and other commercial plans), 2) Publically funded insurance (Medicaid & Medicare), and 3) Uninsured (self pay or private charity). In unadjusted analyses Student’s t-test were applied to determine the bivariate relationship between insurance and LOS. In order to control for differences in injury severity and case mix between insurance groups, generalized linear models, an extension of multiple linear regression, were used, and adjusted estimates of LOS calculated. Covariates adjusted for included: age, gender, race, injury severity score (ISS), presence of shock (SBP < 90) on ED arrival, GCS
283
motor score, mechanism of injury (motor vehicle collision, motorcycle collision, fall, etc), type of injury (blunt vs. penetrating), intention of injury, presence of severe head and/or extremity injury, and year of admission. Results: 542,171 patients in the NTDB met inclusion criteria and had complete data for analysis. Unadjusted median hospital LOS for Uninsured patients was 2 days. Private and Publically insured patients had a median LOS of 3 days (respective mean LOS: 4.4, 5.3, and 6.9, p < 0.001). After adjusting for covariates, mean length of stay for Uninsured patients was the lowest followed by Private insurance and then Publically insured patients (see figure). On analysis of patients with moderate to severe injuries (ISS > 9), LOS for Uninsured, Privately insured, and Publically insured patients were 12.7, 13.5, and 15.7 days, respectively. Similarly among the most severely injured patients (ISS > 15), the respective LOS were 13.3, 14.6, and 17.7 days. The differences between adjusted LOS for each insurance group were significant (p < 0.001) across all injury severities. Conclusion: The ability to pay is directly linked to length of hospital stay in acute trauma patients. Those without insurance are discharged the earliest whereas those with publically funded insurance are kept in hospital the longest. These disparities in LOS are even more pronounced among the more severely injured patients with even longer hospital stays. These data become increasingly important given the current debate over health care reform. As a next step towards improving health care disparities after trauma, the relationship between LOS, quality of care, and outcomes needs to be further explored.
32.2. Demographics and Injury Patterns of Large Animal Related Injury Admissions in the United States. P. Shahan, B. Zarzaur, K. Emmett; University of Tennessee Health Science Center, Memphis, TN Introduction: Animal-related injuries are likely to become an afterthought at the local level when compared to more common sources of injury. Nationally these injuries may constitute a more significant public health problem. The purpose of this study was to examine the demographics and injury patterns of persons requiring admission after animal related injury in the United States and to determine factors that may be associated with this injury type. Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Survey (NIS) from 2001 was used to construct a cohort of patients admitted after injury due to either riding an animal or due to being butted by, fallen on, stepped on, or run over by an animal not being ridden. Injury type was determined using ICD-9 codes. Patients were stratified by age (Youngest 0-25; Young 26-50; Old 51-70, Oldest >70), gender, race, and median household income of patient’s zip code. Where available total hospital charges were converted to cost using the hospital’s cost-to-charge ratio. To determine variables associated with injury type, univariable and multivariable logistic regression analysis were used. Results: 2424 animal related admissions were identified within the database, only nine (0.4%) of which resulted in mortality. The largest proportion of admitted patients were female (53.8%), Caucasian (64.6%), and lived in areas with median income greater than $45,000 (41.8%). The average hospital cost was $5,062. Overall, the most common injuries were rib fractures (15.2%), vertebral fractures (11.6%) and hemo-pneumothorax (9%). Multivariable logistic regression analysis revealed that increasing age was associated with rib fractures, hemo-pneumothorax, vertebral fractures, and pelvic fractures. Skull fractures and head injuries were less common as age increased. Females were more likely to have vertebral fractures but less likely to have rib fractures and heart and lung injuries (Table).
284
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
Conclusions: Unlike hospital admissions due to other injury mechanisms, animal-related injuries were more common in females, nonminorities, and among those living in wealthy areas. Using the available cost data these patients contributed approximately $12 million in costs, making the nationwide cost estimate approximately $60 million. These numbers highlight the significance of this often disregarded mechanism of injury. Disparities in injury type by age and gender indicate possible targets of prevention in those groups with higher risk.
32.3. Who Should Receive Retrievable Inferior Vena Cava Filters? A. Rizzo,1 T. Aldaghlas,1 S. Okasun,1 J. Sakran,1 H. Kimberly,1 L. Robinson,1 C. Kim,1 E. King,1 D. Mulford,1 A. Drooz,1 S. Fakhry2; 1Inova fairfax Hospital, Falls Church, VA; 2Medical University of South Carolina, Charleston, SC Introduction: Recent studies have investigated the outcomes of retrievable inferior vena cava filters (IVCF) with varying reports of retrieval rates and complications. Retrievable IVCF were developed to address concerns about the safety and long term complications of permanent IVCF. The purpose of this study was to prospectively document retrieval rate and patient outcomes in all patients with temporary IVCF placed between 2005 and 2007. Methods: 238 patients were followed in whom retrievable IVCF were placed at a tertiary care hospital. These patients were trauma/surgical and medical patients. The patients received temporary IVCF of varying brands such as Cordis, Bard, Tulip and OptEase. Cohort data collected from medical records and patient follow up questionnaires were analyzed to identify patient demographics, retrieval rates and patient outcomes. Results: There were 245 retrievable IVCFs placed in 238 patients with a maximum of 3 filters in 2 patients. Half of the patients were cared for by the trauma service, the remaining were general medical patients. Prolonged immobility and contraindication for anticoagulation were the primary reasons for placement of 69% of the filters. In 2 years, 38% of IVCFs had been removed, 39% (n ¼ 149) were not and 22% were unknown (Fig 1). Those with filters remaining (149) intentionally did not have their filters removed due to illness, death and other causes. General medical patients were more than twice as likely to keep their filter in place and to be significantly older (OR 0.638 CI 0.467-0.872 to 1.506 CI 1.135-2.0) than trauma patients. The only two IVCF related complications were a fatal pulmonary embolism and an IVCF clot causing lower extremity lymphedema. However, there was no IVCF migration or vena cava perforation during the study period. Conclusion: While placement costs of permanent and retrievable IVCF are similar, the retrievable IVCFs carry an additional cost of surveillance, rotation and removal. This data demonstrates a greater likelihood of removal in trauma/surgical patients versus medical patients especially those of older age. Retrievable IVCF should be indicated only in patients that have a reasonable chance for removal.
32.4. Age Is Not Independently Associated with PTSD in Civilian Trauma Patients. K. B. Chiu, A. de T. Roon-Cassini, K. J. Brasel; Medical College of Wisconsin, Milwaukee, WI Introduction: Posttraumatic stress disorder (PTSD) occurs in 1040% of patients with single-incident civilian trauma. Age has been reported as a risk factor, with younger age related to greater risk for distress, suggesting that elderly patients have a very low risk. However, there are factors associated with age that are better predictors of risk for distress. We hypothesized that age was not independently associated with PTSD. Methods: Participants included 556 adult trauma patients admitted to a level one trauma center. Age, gender, ethnicity, trauma type (assaultive versus non-assaultive), injury severity score, scene Glasgow Coma Scale (GCS), and relationship status were obtained from their medical records. The 1999 US Census data was used to assess median household income by zip code. PTSD severity was measured using the PCLC (PTSD Checklist, Civilian). Statistical analysis was done using T-tests and Spearman correlations. Hierarchical linear regression was used to evaluate the independent association of age with PTSD severity. Results: PCLC scores were complete for 527 subjects, 71.9% male. The table below shows the significant associations between patient characteristics and both acute PTSD severity and young age. In the hierarchical regression, trauma type and income predicted PTSD severity, accounting for 11.0% of the variance in PCLC scores. With those factors in the model, age was not a significant predictor of PTSD severity. Conclusions: Although young age is associated with PTSD severity, age itself does not account for the increased risk. Instead, assaultive trauma and low household income, which are associated with young age, explain the increased risk. These results suggest that elderly patients suffering assaultive trauma, especially those with low socioeconomic status, should be screened for PTSD symptoms.
TRAUMA AND CRITICAL CARE 6: SOCIOECONOMIC ASPECTS OF TRAUMA 32.1. Relationship of Insurance Status to Hospital Length of Stay after Traumatic Injury: Patients with Publically Funded Insurance Have the Longest Lengths of Stay and Uninsured Patients Are Discharged the Earliest. B. R. Englum, O. B. Bolorundoro, C. Villegas, K. Stevens, E. Haut, E. E. Cornwell, III, D. T. Efron, A. H. Haider; Johns Hopkins School of Medicine, Baltimore, MD Introduction: Research has consistently shown that insurance status significantly impacts health care, including resource use, morbidity, and mortality. Data from several medical specialties demonstrate that patients without insurance have fewer physician visits, receive fewer procedures, and have shorter lengths of hospital stay leading to worse clinical outcomes. Uninsured hospitalized trauma patients are also known to have worse mortality outcomes; however, the impact of insurance on hospital stay in trauma is unknown. Objective: To examine the impact of insurance status on hospital length of stay (LOS) in the setting of acute trauma. Methods: Trauma patients, age 18-64, included in the National Trauma Data Bank (NTDB) between 2002-2006 were analyzed. Patients were categorized in three insurance groups: 1) Private insurance (HMO, PPO, MCO, Workers Comp, No Fault, and other commercial plans), 2) Publically funded insurance (Medicaid & Medicare), and 3) Uninsured (self pay or private charity). In unadjusted analyses Student’s t-test were applied to determine the bivariate relationship between insurance and LOS. In order to control for differences in injury severity and case mix between insurance groups, generalized linear models, an extension of multiple linear regression, were used, and adjusted estimates of LOS calculated. Covariates adjusted for included: age, gender, race, injury severity score (ISS), presence of shock (SBP < 90) on ED arrival, GCS
283
motor score, mechanism of injury (motor vehicle collision, motorcycle collision, fall, etc), type of injury (blunt vs. penetrating), intention of injury, presence of severe head and/or extremity injury, and year of admission. Results: 542,171 patients in the NTDB met inclusion criteria and had complete data for analysis. Unadjusted median hospital LOS for Uninsured patients was 2 days. Private and Publically insured patients had a median LOS of 3 days (respective mean LOS: 4.4, 5.3, and 6.9, p < 0.001). After adjusting for covariates, mean length of stay for Uninsured patients was the lowest followed by Private insurance and then Publically insured patients (see figure). On analysis of patients with moderate to severe injuries (ISS > 9), LOS for Uninsured, Privately insured, and Publically insured patients were 12.7, 13.5, and 15.7 days, respectively. Similarly among the most severely injured patients (ISS > 15), the respective LOS were 13.3, 14.6, and 17.7 days. The differences between adjusted LOS for each insurance group were significant (p < 0.001) across all injury severities. Conclusion: The ability to pay is directly linked to length of hospital stay in acute trauma patients. Those without insurance are discharged the earliest whereas those with publically funded insurance are kept in hospital the longest. These disparities in LOS are even more pronounced among the more severely injured patients with even longer hospital stays. These data become increasingly important given the current debate over health care reform. As a next step towards improving health care disparities after trauma, the relationship between LOS, quality of care, and outcomes needs to be further explored.
32.2. Demographics and Injury Patterns of Large Animal Related Injury Admissions in the United States. P. Shahan, B. Zarzaur, K. Emmett; University of Tennessee Health Science Center, Memphis, TN Introduction: Animal-related injuries are likely to become an afterthought at the local level when compared to more common sources of injury. Nationally these injuries may constitute a more significant public health problem. The purpose of this study was to examine the demographics and injury patterns of persons requiring admission after animal related injury in the United States and to determine factors that may be associated with this injury type. Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Survey (NIS) from 2001 was used to construct a cohort of patients admitted after injury due to either riding an animal or due to being butted by, fallen on, stepped on, or run over by an animal not being ridden. Injury type was determined using ICD-9 codes. Patients were stratified by age (Youngest 0-25; Young 26-50; Old 51-70, Oldest >70), gender, race, and median household income of patient’s zip code. Where available total hospital charges were converted to cost using the hospital’s cost-to-charge ratio. To determine variables associated with injury type, univariable and multivariable logistic regression analysis were used. Results: 2424 animal related admissions were identified within the database, only nine (0.4%) of which resulted in mortality. The largest proportion of admitted patients were female (53.8%), Caucasian (64.6%), and lived in areas with median income greater than $45,000 (41.8%). The average hospital cost was $5,062. Overall, the most common injuries were rib fractures (15.2%), vertebral fractures (11.6%) and hemo-pneumothorax (9%). Multivariable logistic regression analysis revealed that increasing age was associated with rib fractures, hemo-pneumothorax, vertebral fractures, and pelvic fractures. Skull fractures and head injuries were less common as age increased. Females were more likely to have vertebral fractures but less likely to have rib fractures and heart and lung injuries (Table).
284
ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS
Conclusions: Unlike hospital admissions due to other injury mechanisms, animal-related injuries were more common in females, nonminorities, and among those living in wealthy areas. Using the available cost data these patients contributed approximately $12 million in costs, making the nationwide cost estimate approximately $60 million. These numbers highlight the significance of this often disregarded mechanism of injury. Disparities in injury type by age and gender indicate possible targets of prevention in those groups with higher risk.
32.3. Who Should Receive Retrievable Inferior Vena Cava Filters? A. Rizzo,1 T. Aldaghlas,1 S. Okasun,1 J. Sakran,1 H. Kimberly,1 L. Robinson,1 C. Kim,1 E. King,1 D. Mulford,1 A. Drooz,1 S. Fakhry2; 1Inova fairfax Hospital, Falls Church, VA; 2Medical University of South Carolina, Charleston, SC Introduction: Recent studies have investigated the outcomes of retrievable inferior vena cava filters (IVCF) with varying reports of retrieval rates and complications. Retrievable IVCF were developed to address concerns about the safety and long term complications of permanent IVCF. The purpose of this study was to prospectively document retrieval rate and patient outcomes in all patients with temporary IVCF placed between 2005 and 2007. Methods: 238 patients were followed in whom retrievable IVCF were placed at a tertiary care hospital. These patients were trauma/surgical and medical patients. The patients received temporary IVCF of varying brands such as Cordis, Bard, Tulip and OptEase. Cohort data collected from medical records and patient follow up questionnaires were analyzed to identify patient demographics, retrieval rates and patient outcomes. Results: There were 245 retrievable IVCFs placed in 238 patients with a maximum of 3 filters in 2 patients. Half of the patients were cared for by the trauma service, the remaining were general medical patients. Prolonged immobility and contraindication for anticoagulation were the primary reasons for placement of 69% of the filters. In 2 years, 38% of IVCFs had been removed, 39% (n ¼ 149) were not and 22% were unknown (Fig 1). Those with filters remaining (149) intentionally did not have their filters removed due to illness, death and other causes. General medical patients were more than twice as likely to keep their filter in place and to be significantly older (OR 0.638 CI 0.467-0.872 to 1.506 CI 1.135-2.0) than trauma patients. The only two IVCF related complications were a fatal pulmonary embolism and an IVCF clot causing lower extremity lymphedema. However, there was no IVCF migration or vena cava perforation during the study period. Conclusion: While placement costs of permanent and retrievable IVCF are similar, the retrievable IVCFs carry an additional cost of surveillance, rotation and removal. This data demonstrates a greater likelihood of removal in trauma/surgical patients versus medical patients especially those of older age. Retrievable IVCF should be indicated only in patients that have a reasonable chance for removal.
32.4. Age Is Not Independently Associated with PTSD in Civilian Trauma Patients. K. B. Chiu, A. de T. Roon-Cassini, K. J. Brasel; Medical College of Wisconsin, Milwaukee, WI Introduction: Posttraumatic stress disorder (PTSD) occurs in 1040% of patients with single-incident civilian trauma. Age has been reported as a risk factor, with younger age related to greater risk for distress, suggesting that elderly patients have a very low risk. However, there are factors associated with age that are better predictors of risk for distress. We hypothesized that age was not independently associated with PTSD. Methods: Participants included 556 adult trauma patients admitted to a level one trauma center. Age, gender, ethnicity, trauma type (assaultive versus non-assaultive), injury severity score, scene Glasgow Coma Scale (GCS), and relationship status were obtained from their medical records. The 1999 US Census data was used to assess median household income by zip code. PTSD severity was measured using the PCLC (PTSD Checklist, Civilian). Statistical analysis was done using T-tests and Spearman correlations. Hierarchical linear regression was used to evaluate the independent association of age with PTSD severity. Results: PCLC scores were complete for 527 subjects, 71.9% male. The table below shows the significant associations between patient characteristics and both acute PTSD severity and young age. In the hierarchical regression, trauma type and income predicted PTSD severity, accounting for 11.0% of the variance in PCLC scores. With those factors in the model, age was not a significant predictor of PTSD severity. Conclusions: Although young age is associated with PTSD severity, age itself does not account for the increased risk. Instead, assaultive trauma and low household income, which are associated with young age, explain the increased risk. These results suggest that elderly patients suffering assaultive trauma, especially those with low socioeconomic status, should be screened for PTSD symptoms.