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The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank
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Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx https://doi.org/10.1016/j.ijom.2020.01.016, available online at https://www.sciencedirect.com
Research Paper Trauma
The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank
E. Paw1, J. K. Canner2, E. R. Haut1,2,3, M. Manukyan2 1
Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; 2Johns Hopkins Department of Surgery, Division of Acute Care Surgery, Trauma, Emergency Surgery, and Critical Care, Baltimore, MD, USA; 3Johns Hopkins Department of Anesthesiology and Critical Care Medicine, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
E. Paw, J. K. Canner, E. R. Haut, M. Manukyan: The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank. Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Maxillofacial trauma costs emergency departments approximately one billion dollars annually. Facial trauma has increased since 2000 and has been attributed to both increased use of computed tomography and interpersonal violence. Alcohol, male sex, and age 18–35 years are significant risk factors for interpersonal violence. This study is novel in using a large database to look at the effect of alcohol on clinical outcomes in facial trauma. A data analysis was performed in Stata/MP 14.2 using variables coded from the National Trauma Data Bank (NTDB); logistic regression was applied. A total 580,313 patient records were analyzed. Operations for facial fractures were performed in 20.19% of cases (n = 117,139). A positive alcohol test reduced the odds of requiring operative fixation in both the unadjusted (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.79–0.82, P < 0.001) and adjusted (OR 0.67, 95% CI 0.66–0.68, P < 0.001) models. Age and being struck (adjusted OR 1.99, 95% CI 1.91–2.07, P < 0.001) or shot (adjusted OR 1.95, 95% CI 1.84–2.06, P < 0.001) had a significant effect on operative fixation. Injury mechanisms related to interpersonal violence appeared to have higher operative fixation rates. This study did not find a correlation between acute intoxication and the need for an operative intervention. This further demonstrates the multifactorial nature of facial trauma and stresses the importance of injury and violence prevention on clinical outcomes.
Maxillofacial trauma in the United States causes significant morbidity and costs emergency departments approximately one billion dollars annually1. While trends showed a decrease in fractures from the 1990s until the year 2000, there has been 0901-5027/000001+09
an increase in the diagnosis of facial fractures since 20002. A significant proportion of this increase in diagnosis is likely related to the increased use of radiographic imaging with computed tomography; however there also appears to
Key words: trauma; facial fracture; alcohol. Accepted for publication 21 January 2020
have been a change in the etiology of maxillofacial trauma3,4. The increased use of seatbelts and restraints has led to a decrease in motor vehicle-related facial fractures, but the increase in interpersonal violence is thought to be a significant
ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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contributor to the latest upward trend in facial-related trauma3,4. One of the most prominently identified etiological factors in facial trauma is alcohol use associated with interpersonal violence5–7. Intoxication at the time of injury may increase the severity of fractures, in addition to complications such as infection and non-union8. While there are innumerable studies of single-center experiences with alcohol and interpersonal violence, there is a paucity of literature focusing on the effect alcohol has on patient-related factors such as surgical site infection, airway compromise, and disposition upon discharge. These are important factors to examine, as they assist clinicians in determining the most appropriate treatment approach, as well as in anticipating potential complications. From a policy perspective, there has been a push in both the United Kingdom and Australia to restrict alcohol sales in certain areas, with a particular focus on reducing facial and head injuries associated with interpersonal violence. Institutional experiences post implementation of these laws has seen a reduction in this type of presentation, therefore demonstrating the positive effect that these laws can have from a public health perspective9–11. The laws in the United Kingdom were implemented in the early 2000s, but the laws in Australia have been implemented quite recently, and an assessment of the incidence of facial fractures in one of the major centers was published in early 201811. Chopra et al. demonstrated a significant decrease in assault and treatment of facial fractures after the implementation of the laws, particularly in the cities targeted by these alcohol sale restrictions11. All of the studies looking at
the implications for these laws were single-institution experiences, rather than looking at large trauma databases. In the United States, published studies examining facial fractures and alcohol have typically been institutional experiences, with very few utilizing large databases or looking across time periods. There was one study using the American College of Surgeons National Surgical Quality Improvement Program database, which looked specifically at the risks of wound infection and determined that chronic alcohol use was a risk factor for this12. The use of a large database such as the American College of Surgeons National Trauma Data Bank (NTDB) would enable the examination of the effects across heterogeneous populations to examine the strength of association between intoxication on admission and clinical outcomes of interest. The NTDB comprises prospectively collected data and allows for analysis across a number of potential confounders. Alcohol use upon presentation may have an effect on the outcomes of patients, which is relevant from a clinician perspective, but also potentially for public health interventions. With this in mind, the objective of the present study was to determine whether there is any effect of alcohol on facial fracture outcomes, in particular the likelihood of requiring operative fixation and airway complications such as unplanned intubation.
Materials and methods
Institutional Review Board approval was sought and provided for this project via the Johns Hopkins Surgical Outcome Research Group.
Data from The American College of Surgeons NTDB were utilized, drawing from years 2007 to 2016 and including all patients with any facial fracture code in any of their diagnosis codes (i.e., not just the primary diagnosis). This method follows the recommendations for large database research and use of the NTDB, as published previously13–16. Patients aged less than 18 years were excluded from this study, as were those who died on arrival or in the emergency department, as this would likely skew the data on procedural outcomes. Patients with missing data regarding alcohol status and sex were also excluded, and patients who were over the age of 100 years were consolidated into a single age group to protect patient privacy. A total of 580,313 observations were used in the final dataset for analysis after 179,460 records were excluded. Of the excluded records, 86,993 had missing data regarding alcohol status on admission or sex. See Fig. 1 for a flowchart of the patient selection process. Coding of variables
The International Statistical Classification of Diseases and Related Health Problems Ninth Revision (ICD-9) and Tenth Revision (ICD-10) diagnosis codes relating to facial fracture were collated and then used to determine a new set of dichotomous variables defining the fracture subtypes broadly as nasal bone, mandibular, malar/maxillary, orbital, other facial bones, and more than one fracture type. The majority of the data were coded as ICD-9 codes, as ICD-10 only came into use in this dataset after 2015. This affected the granularity of the available data; therefore the variables were coded as broader
Fig. 1. Flowchart of patient selection.
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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The effect of alcohol on facial trauma outcomes categories rather than utilizing a score such as the Facial Injury Severity Score (FISS), which can only be determined from ICD-10 codes. The outcome of operative fixation was coded as a dichotomous variable after identifying all ICD-9 and ICD-10 codes relevant to facial fracture operations. The use of protective devices was coded from the NTDB variable determining which protective device was used and whether the airbag had deployed or not. Only the use of eye protection, helmets, and deployed airbags was examined. The NTDB also codes for various comorbidities, acknowledging that these may not have been completely filled out, particularly given the acute nature of trauma. These were used to code a dichotomous variable for a history of smoking. Complication data present in the NTDB were used to code dichotomous variables for unplanned intubation and for surgical site infection. These complication data are more reliable for the period studied here when compared to early versions of the NTDB17. The other variables examined including age, sex, race, injury intent, mechanism, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score in the emergency department, and hospital trauma level were all used in the analysis in the same format as they were coded in the NTDB. Statistical analysis
The differences between the alcohol and no alcohol groups were first tested with the Pearson x2 test to determine whether there were any significant differences in the baseline characteristics between the two groups. Due to the observational nature of the data, there were differences in the baseline characteristics; hence these were adjusted for as covariates in the final model. A comparative analysis of the effect of alcohol on discharge disposition and fracture subtype was also performed using the Pearson x2 test. Four major outcomes were analyzed: operative fixation of the facial fracture, mechanical ventilation, unplanned intubation, and surgical site infection. Clinical outcomes were coded as dichotomous variables; therefore logistic regression was used for analysis. Univariable and multivariable logistic regression analysis was used to determine which variables had the most significant clinical and statistical effect on the four major outcomes. Forward selection and tests for covariance were used to determine the final model selection. Variance inflation factor testing
and correlation matrices were used to determine variables that were highly collinear. Variables that were collinear were removed; for example, a variable coding blunt and penetrating trauma was collinear with mechanism and therefore was removed, keeping the more granular mechanism data18. Subsequently all variance inflation factors were lower than five. The major independent variables examined were age, sex, race, region, alcohol test on presentation, injury intent, mechanism of injury, and ISS category (score 1–8, 9–15, 16–24, or 25–75). Additional variables were analyzed for confounding effect as noted in Table 1. The analysis was conducted using Stata/ MP 14.219, and a P-value of <0.05 was considered significant when evaluating covariates for inclusion in the multivariable model. Results
Patient characteristics are summarized in Table S1 (see Supplementary Material). The majority of patients were male (75.24%) and in the 18–24 and 25–34 years age groups (38.11%). In regard to the mechanism descriptions, the term ‘struck-by’ is used by the NTDB to describe any injury caused by collision with an object or body part. This classification was further characterized by examining the intent recorded within each category, and 73.84% of the struck-by injuries were characterized as intentional assaults. A fifth of the patients (20.19%, n = 117,139) underwent operative fixation of their facial fracture. The results of these analyses are seen in Fig. 2, with further detail given in Table S2
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(see Supplementary Material). A positive alcohol test reduced the odds of operative fixation in both the unadjusted (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.79–0.82, P < 0.001) and adjusted (OR 0.67, 95% CI 0.66–0.68, P < 0.001) models. The variables with the greatest adjusted effect on the odds ratio (OR) were age, alcohol, injury intent, injury mechanism, ISS, and hospital trauma center level as determined by the American College of Surgeons criteria (level I–IV, with I being the highest level). Being in a younger age group significantly doubled the odds of operative management in comparison to being in the 55–64 years age group (OR 0.50, 95% CI 0.48–0.52, P < 0.001). When adjusting for other factors, the factor that gave the greatest increase in the odds of requiring operative fixation was the mechanism of injury (Fig. 2). In terms of injury mechanism, being struck (adjusted OR 1.99, 95% CI 1.91–2.07, P < 0.001) or shot (adjusted OR 1.95, 95% CI 1.84–2.06, P < 0.001) had a significant effect on operative fixation. Increased hospital trauma acuity significantly increased the odds of operative fixation. In regard to the second outcome, 30.52% of patients required more than 1 day of mechanical ventilation at any point throughout their admission. Fig. 3 and Table S3 (see Supplementary Material) detail the adjusted comparisons for the same variables as investigated for the operative fixation outcome. Similar to the outcome of operative fixation, the odds of requiring mechanical ventilation following a gunshot wound were significantly more than four times the odds of requiring mechanical ventilation for a fall
Table 1. Potential confounding variables. Patient factors
Injury factors
Smoking status
ISS (1–8, 9–15, 16–24, 25–75)
Race
Protection (none, eye, helmet, airbag)
Psychiatric history
Penetrating or blunt injury
History of drug dependence
Intent of injury (assault, self-inflicted, undetermined, unintentional, other) Mechanism of injury (stab, fall, GSW, MVC, pedestrian, struck-by, other)
GCS on arrival in the ED Hospital factors
Time and location
American College of Surgeons Trauma Level Year of admission (2007–2016) (I, II, III, IV) Region (Midwest, Northeast, South, West, not available) ED, emergency department; GCS, Glasgow Coma Scale; GSW, gunshot wound; ISS, Injury Severity Score; MVC, motor vehicle crash.
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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Fig. 2. Log odds ratio of operative fixation in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 2white race; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
Fig. 3. Log odds ratio of mechanical ventilation in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 2white race; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
(adjusted OR 4.34, 95% CI 4.06–4.64, P < 0.001). Stab (adjusted OR 1.46, 95% CI 1.33–1.61, P < 0.001) and motor vehicle crash (adjusted OR 1.47, 95% CI
1.42–1.51, P < 0.001) also had significantly higher odds of mechanical ventilation. An increase in the overall ISS significantly increased the odds of
mechanical ventilation, doubling and quadrupling it in the highest injury categories, when adjusted for other variables. As would be expected, each point increase
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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The effect of alcohol on facial trauma outcomes in GCS score on presentation to the emergency department decreased the odds of mechanical ventilation significantly. Each increase in hospital trauma center level (with level I being the highest) was associated with increased odds of mechanical ventilation. As seen in Fig. 4 and detailed in Table S4 (see Supplementary Material), the odds of the third outcome of unplanned intubation did increase for patients with positive alcohol (unadjusted OR 1.07, 95% CI 1.01–1.13, P < 0.02; adjusted OR 1.25, 95% CI 1.16–1.36, P < 0.001). Age 55 and older increased the odds of unplanned intubation three to four times in the adjusted and unadjusted analyses (age 55–65 years, adjusted OR 2.98, 95% CI 2.60– 3.42, P < 0.001). While injury intent did increase the odds of unplanned intubation, when other factors were adjusted for, assault and undetermined intent had the greatest odds of unplanned intubation. The mechanism of injury played a lesser role in unplanned intubation when compared to the other outcomes. The odds of unplanned intubation increased manyfold with increasing ISS and with lower GCS score on presentation. Smoking also
almost doubled the odds of unplanned intubation. Finally, the outcome of surgical site infection showed a positive association with alcohol (Fig. 5; Supplementary Material, Table S5) (unadjusted OR 1.16, 95% CI 1.08–1.25, P < 0.001; adjusted OR 1.10, 95% CI 1.00–1.21, P = 0.06). When adjusted for other factors, the effect of injury intent on the odds of surgical site infection were reduced. However, the mechanisms of motor vehicle crash (adjusted OR 2.26, 95% CI 1.92– 2.66, P < 0.001) and gunshot wound (adjusted OR 3.59, 95% CI 2.62–4.93, P < 0.001) still increased the odds of surgical site infection two to three times. With regard to the ISS, the odds of surgical site infection increased up to nine times for the highest category. Figs 2–5 more clearly visualize the noted effects of the variables on the adjusted log OR of the four outcomes. Figure 6 demonstrates the effect of alcohol on discharge disposition (P < 0.01); of note more patients with alcohol were discharged home without services or discharged themselves against medical advice. Patients who presented and were
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not intoxicated were more likely to be discharged under an organized home health service, for inpatient rehabilitation, or to a skilled nursing facility. The breakdown of fracture subtypes is demonstrated in Fig. 7 (P < 0.01), and alcohol was associated with both nasal bone fractures and an increased frequency of multiple fracture subtypes. Discussion
The primary focus of this study was to determine whether a positive alcohol test increases the need for operative fixation and is associated with increased complication rates in facial-related trauma. Of note, 15% of patients in the 2015 NTDB tested positive for alcohol, as opposed to 31.45% seen in this patient population20. The study results showed that a positive alcohol test had a negative effect on the likelihood of requiring operative fixation of facial fractures. However, if the injury intent was assault or if the mechanism was a struck-by, which is frequently associated with assault, it appeared that there was a significantly higher rate of operative fixation. Patients with the lowest ISS had the
Fig. 4. Log odds ratio of unplanned intubation in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 2white race; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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Fig. 5. Log odds ratio of surgical site infection in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
highest odds of operative fixation, perhaps due to those with higher scores having more life-threatening injuries. For the other outcomes examining complications of hospital stay (need for mechanical ventilation, unplanned intubation, and surgical site infection), alcohol did increase the odds of these occurring. These results somewhat contradict those of previously published studies. This is likely due to the nature of those studies being single-center studies and largely looking at simple associations without controlling for other factors. The present study controlled for other hospital, patient, injury, and temporal factors that could affect clinical outcomes. This was made possible by utilizing a large database, the NTDB. The results showed that intoxicated patients were less likely to require operative fixation and this raises an interesting question of whether the patient’s alcohol level is a relevant measure. Interpersonal violence appeared to be associated with higher levels of operative fixation. It is possible that other additional exacerbating social factors in the situation of interpersonal violence would be more important to measure, such as the alcohol level of the perpetrators. The published
literature also notes a strong association between alcohol and violence, and investigating this may be valuable in further ascertaining the role alcohol plays in facial-related trauma7,10,21,22. It is possible that variations by country exist, as many of the prior studies were not based in the United States, from where the NTDB derives the majority of its patients. Patients who were seen at higher trauma level hospitals (with level I being highest) were significantly more likely to have operative fixation. This could be related to the availability of surgical specialties. It is possible that lower acuity trauma centers may need to transfer patients to higher acuity centers for operative fixation. This relationship may be because there are generally patients with more acute injuries at these centers; however, a higher ISS appeared to be negatively correlated with the odds of operative fixation. In regard to the effect of these clinical outcomes, a costs analysis could help guide the value of potential preventative interventions in this instance. Specific interventions targeted at changing alcohol sales, such as those instituted in other countries, could potentially be less cost-effective than interventions aimed at reducing interpersonal violence.
Mechanical ventilation and unplanned intubation were the second and third outcome measures, and both saw an increase in odds with intoxication on presentation (adjusted OR 1.35 for mechanical ventilation and 1.25 for unplanned intubation). It was interesting to note that while the unadjusted odds of mechanical ventilation showed a decrease with age, once other factors were adjusted for this variability almost disappeared. It is unlikely that these changes were clinically significant, since the change in ORs represents a maximum of a 4% change in the probability of mechanical ventilation. Gunshot wounds carried much higher odds of mechanical ventilation when compared to the other mechanisms, but this did not apply for unplanned intubation. Increase in ISS and decrease in GCS scores were associated with both airway outcomes. This would be expected, as patients with more injuries are more likely to be unstable and therefore require airway support during their admission. Being in a higher acuity trauma center increased the odds of airway complications, likely because patients with more severe or complex injuries are more likely to be treated at these centers.
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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Fig. 6. Histogram of discharge destination by alcohol on presentation after maxillofacial trauma in the National Trauma Data Bank (NTDB). 1, died; 2, discharged home with no home services; 3, discharged to home or self-care (routine discharge); 4, discharged/transferred to long-term care hospital; 5, discharged/transferred to skilled nursing facility; 6, discharged/transferred to a short-term general hospital for inpatient care; 7, discharged/transferred to an intermediate care facility (ICF); 8, discharged/transferred to another acute care hospital using emergency medical services; 9, discharged/transferred to another type of rehabilitation or long-term care; 10, discharged/transferred to court/law enforcement; 11, discharged/transferred to home under care of organized home health service; 12, discharged/transferred to hospice care; 13, discharged/transferred to inpatient rehabilitation or designated unit; 14, discharged/transferred to a psychiatric hospital or psychiatric facility; 15, left against medical advice or discontinued care; 16, not admitted to hospital.
Surgical site infection as the final outcome also increased with positive alcohol; however when adjusted, the confidence interval encompassed no effect. Mechanisms of motor vehicle crash and gunshot wound are typically associated with debris in the wounds, which is a likely contributor to their effect on surgical site infection. In regard to the discharge destination, shown in Fig. 6, far fewer intoxicated patients appeared to be discharged with services and they appeared to be at greater risk of discharging themselves against medical advice. Also, the pattern of fractures in intoxicated patients, as demonstrated in Fig. 7, was different to that in non-intoxicated patients, and it is useful for clinicians to note the increased likelihood of multiple fracture subtypes in the former group of patients. There are a number of limitations to a large database analysis. It is not possible to infer causality as the data are
observational in nature. A large number of missing values could potentially skew the results, therefore observations with missing values in the variables of interest were excluded. Variables that are drawn from pre-existing diagnoses have the potential for inaccuracy due to the data not having been recorded. However, due to the size of the dataset, a small number of missing values is unlikely to impact the overall conclusions. Having a large dataset could contribute to statistically significant values that may not be of clinical significance, and so the interpretation of these results has focused on those variables that have the greatest effect on the clinical outcomes23. Of note in this dataset, across each year of the NTDB examined, there was a slight decrease in the odds of operative fixation, ranging from 0.8 to 1; while this was not thought to be a clinically significant fluctuation over time, it may represent a change in trauma care across this period.
The next step with this dataset is to look with granularity at patients with fractures resulting from interpersonal violence. Specifically, this would be to examine whether there is a difference in type of mechanism by sex, for example a greater likelihood of interpersonal violence related to domestic violence in females. This could be analyzed using E codes if sufficient information has been recorded. Also, while there was some information on drug utilization available in this study, a closer look at the use of other substances where they could be better characterized with more granular data would be useful. A number of other studies have investigated the link between illicit drug use and facial trauma as single-center studies24,25. A second analysis of interest would be a comparison of geriatric and non-geriatric patients to assist with identifying risk factors. These are likely to become more important as the population continues to age.
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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Fig. 7. Histogram of fracture type by alcohol on presentation after maxillofacial trauma in the National Trauma Data Bank (NTDB). 1, nasal bone; 2, mandible; 3, malar/maxillary bones; 4, orbital; 5, other facial bones; 6, more than one fracture type.
In conclusion, despite this study’s focus on alcohol as an independent variable in facial trauma, it appears that the effects of alcohol are not consistent across this patient population. However, injuries related to interpersonal violence do appear to increase the severity of facial fracture as measured by the odds of requiring operative fixation and also appear to be associated with complications. This in itself has interesting clinical and public health implications in regard to injury and violence prevention. Interpersonal violence may not only increase the occurrence of facial fractures, but also potentially leads to worse clinical outcomes. Further research into the factors leading to interpersonal violence to guide injury prevention programs would benefit these patients.
Funding
None.
Competing interests
None.
Ethical approval
Johns Hopkins Medicine IRB Approval #IRB00053752.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.ijom.2020. 01.016.
Patient consent
Not required as only de-identified data were used.
Disclosures
Dr Haut was the paid author of a paper commissioned by the National Academies of Medicine titled ‘‘Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making’’ which was used to support the report titled ‘‘A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.’’
Acknowledgements. This project was part of the Johns Hopkins Center for Surgical Outcomes Research (JSCOR) Program.
References 1. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011;69:2613–8. 2. VandeGriend ZP, Hashemi A, Shkoukani M. Changing trends in adult facial trauma epidemiology. J Craniofac Surg 2015;26:108–12. 3. Shapiro AJ, Michael Johnson R, Miller SF, McCarthy MC. Facial fractures in a level I trauma centre: the importance of protective devices and alcohol abuse. Injury 2001;32:353–6. 4. Adkinson JM, Murphy Jr RX. Impact of automobile restraint device utilization on facial fractures and fiscal implications for plastic surgeons. Ann Plast Surg 2011;66:472–5. 5. Hutchison IL, Magennis P, Shepherd JP, Brown AE. The BAOMS United Kingdom survey of facial injuries part 1: aetiology and
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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6.
7.
8.
9.
10.
11.
12.
the association with alcohol consumption. Br J Oral Maxillofac Surg 1998;36:3–13. Murphy DA. Substance use and facial injury. Oral Maxillofac Surg Clin North Am 2010;22:231–8. Soares-Carneiro SCA, Vasconcelos BC, Matos da-Silva GS, de-Barros-Caldas LC, Porto GG, Leal JF, Catunda I. Alcohol abusive use increases facial trauma? Med Oral Patol Oral Cir Bucal 2016;21:e547–53. Furr AM, Schweinfurth JM, May WL. Factors associated with long-term complications after repair of mandibular fractures. Laryngoscope 2006;116:427–30. El-Maaytah M, Smith SF, Jerjes W, Upile T, Petrie A, Kalavrezos N, Ayliffe P, Newman L, Hopper C, Lloyd T. The effect of the new ‘‘24 hour alcohol licensing law’’ on the incidence of facial trauma in London. Br J Oral Maxillofac Surg 2008;46:460–3. Menendez P, Kypri K, Weatherburn D. The effect of liquor licensing restrictions on assault: a quasi-experimental study in Sydney, Australia. Addiction 2017;112:261–8. Chopra S, van der Rijt RG, Ngo Q, Clarke FK, Southwell-Keely JP, Robledo K, Moisidis E. A comparison of maxillofacial trauma before and after implementation of lockout laws in Sydney. Aust J Plast Surg 2018;1:75–84. Cohen SM, Rosett BE, Shifrin DA. An analysis of independent variables affecting surgical outcomes in patients undergoing repair of maxillofacial trauma: an American College of Surgeons National Surgical Quality Improvement Program Study. J Craniofac Surg 2017;28:596–9.
13. Haider AH, Bilimoria KY, Kibbe MR. A checklist to elevate the science of surgical database research. JAMA Surg 2018;153:505–7. 14. Hashmi ZG, Kaji AH, Nathens AB. Practical guide to surgical data sets: National Trauma Data Bank (NTDB). JAMA Surg 2018;153:852–3. 15. Haider AH, Hashmi ZG, Zafar SN, Castillo R, Haut ER, Schneider EB, Cornwell EE, Mackenzie EJ, Efron DT. Developing best practices to study trauma outcomes in large databases: an evidence-based approach to determine the best mortality risk adjustment model. J Trauma Acute Care Surg 2014;76:1061–9. 16. Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell EE, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg 2012;214:756–68. 17. Kardooni S, Haut ER, Chang DC, Pierce CA, Efron DT, Haider AH, Pronovost PJ, Cornwell EE. Hazards of benchmarking complications with the National Trauma Data Bank: numerators in search of denominators. J Trauma 2008;64:273–7. discussion 277–279. 18. Haider AH, Chang DC, Haut ER, Cornwell 3rd EE, Efron DT. Mechanism of injury predicts patient mortality and impairment after blunt trauma. J Surg Res 2009;153:138–42. 19. Stata Statistical Software. Release 14.2 [computer program]. College Station, TX: StataCorp LP; 2019.
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20. American College of Surgeons. National Trauma Data Bank 2016 annual report. American College of Surgeons; 2016. 21. Duailibi S, Ponicki W, Grube J, Pinsky I, Laranjeira R, Raw M. The effect of restricting opening hours on alcohol-related violence. Am J Public Health 2007;97:2276–80. 22. Walton MA, Chermack ST, Shope JT, Bingham RC, Zimmerman MA, Blow FC, Cunningham RM. Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: a randomized controlled trial. JAMA 2010;304:527–35. 23. Webster KLW, Owodunni OP, Haut ER. Addressing clinical significance. JAMA Surg 2019;154:188–9. 24. Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003;61:713–8. 25. McAllister P, Jenner S, Laverick S. Toxicology screening in oral and maxillofacial trauma patients. Br J Oral Maxillofac Surg 2013;51:773–8.
Address: Ekta Paw Johns Hopkins University Bloomberg School of Public Health Department of Health Policy and Management Baltimore MD USA E-mail: [email protected]
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx https://doi.org/10.1016/j.ijom.2020.01.016, available online at https://www.sciencedirect.com
Research Paper Trauma
The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank
E. Paw1, J. K. Canner2, E. R. Haut1,2,3, M. Manukyan2 1
Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Baltimore, MD, USA; 2Johns Hopkins Department of Surgery, Division of Acute Care Surgery, Trauma, Emergency Surgery, and Critical Care, Baltimore, MD, USA; 3Johns Hopkins Department of Anesthesiology and Critical Care Medicine, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA
E. Paw, J. K. Canner, E. R. Haut, M. Manukyan: The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank. Int. J. Oral Maxillofac. Surg. 2019; xxx: xxx–xxx. ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Maxillofacial trauma costs emergency departments approximately one billion dollars annually. Facial trauma has increased since 2000 and has been attributed to both increased use of computed tomography and interpersonal violence. Alcohol, male sex, and age 18–35 years are significant risk factors for interpersonal violence. This study is novel in using a large database to look at the effect of alcohol on clinical outcomes in facial trauma. A data analysis was performed in Stata/MP 14.2 using variables coded from the National Trauma Data Bank (NTDB); logistic regression was applied. A total 580,313 patient records were analyzed. Operations for facial fractures were performed in 20.19% of cases (n = 117,139). A positive alcohol test reduced the odds of requiring operative fixation in both the unadjusted (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.79–0.82, P < 0.001) and adjusted (OR 0.67, 95% CI 0.66–0.68, P < 0.001) models. Age and being struck (adjusted OR 1.99, 95% CI 1.91–2.07, P < 0.001) or shot (adjusted OR 1.95, 95% CI 1.84–2.06, P < 0.001) had a significant effect on operative fixation. Injury mechanisms related to interpersonal violence appeared to have higher operative fixation rates. This study did not find a correlation between acute intoxication and the need for an operative intervention. This further demonstrates the multifactorial nature of facial trauma and stresses the importance of injury and violence prevention on clinical outcomes.
Maxillofacial trauma in the United States causes significant morbidity and costs emergency departments approximately one billion dollars annually1. While trends showed a decrease in fractures from the 1990s until the year 2000, there has been 0901-5027/000001+09
an increase in the diagnosis of facial fractures since 20002. A significant proportion of this increase in diagnosis is likely related to the increased use of radiographic imaging with computed tomography; however there also appears to
Key words: trauma; facial fracture; alcohol. Accepted for publication 21 January 2020
have been a change in the etiology of maxillofacial trauma3,4. The increased use of seatbelts and restraints has led to a decrease in motor vehicle-related facial fractures, but the increase in interpersonal violence is thought to be a significant
ã 2020 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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contributor to the latest upward trend in facial-related trauma3,4. One of the most prominently identified etiological factors in facial trauma is alcohol use associated with interpersonal violence5–7. Intoxication at the time of injury may increase the severity of fractures, in addition to complications such as infection and non-union8. While there are innumerable studies of single-center experiences with alcohol and interpersonal violence, there is a paucity of literature focusing on the effect alcohol has on patient-related factors such as surgical site infection, airway compromise, and disposition upon discharge. These are important factors to examine, as they assist clinicians in determining the most appropriate treatment approach, as well as in anticipating potential complications. From a policy perspective, there has been a push in both the United Kingdom and Australia to restrict alcohol sales in certain areas, with a particular focus on reducing facial and head injuries associated with interpersonal violence. Institutional experiences post implementation of these laws has seen a reduction in this type of presentation, therefore demonstrating the positive effect that these laws can have from a public health perspective9–11. The laws in the United Kingdom were implemented in the early 2000s, but the laws in Australia have been implemented quite recently, and an assessment of the incidence of facial fractures in one of the major centers was published in early 201811. Chopra et al. demonstrated a significant decrease in assault and treatment of facial fractures after the implementation of the laws, particularly in the cities targeted by these alcohol sale restrictions11. All of the studies looking at
the implications for these laws were single-institution experiences, rather than looking at large trauma databases. In the United States, published studies examining facial fractures and alcohol have typically been institutional experiences, with very few utilizing large databases or looking across time periods. There was one study using the American College of Surgeons National Surgical Quality Improvement Program database, which looked specifically at the risks of wound infection and determined that chronic alcohol use was a risk factor for this12. The use of a large database such as the American College of Surgeons National Trauma Data Bank (NTDB) would enable the examination of the effects across heterogeneous populations to examine the strength of association between intoxication on admission and clinical outcomes of interest. The NTDB comprises prospectively collected data and allows for analysis across a number of potential confounders. Alcohol use upon presentation may have an effect on the outcomes of patients, which is relevant from a clinician perspective, but also potentially for public health interventions. With this in mind, the objective of the present study was to determine whether there is any effect of alcohol on facial fracture outcomes, in particular the likelihood of requiring operative fixation and airway complications such as unplanned intubation.
Materials and methods
Institutional Review Board approval was sought and provided for this project via the Johns Hopkins Surgical Outcome Research Group.
Data from The American College of Surgeons NTDB were utilized, drawing from years 2007 to 2016 and including all patients with any facial fracture code in any of their diagnosis codes (i.e., not just the primary diagnosis). This method follows the recommendations for large database research and use of the NTDB, as published previously13–16. Patients aged less than 18 years were excluded from this study, as were those who died on arrival or in the emergency department, as this would likely skew the data on procedural outcomes. Patients with missing data regarding alcohol status and sex were also excluded, and patients who were over the age of 100 years were consolidated into a single age group to protect patient privacy. A total of 580,313 observations were used in the final dataset for analysis after 179,460 records were excluded. Of the excluded records, 86,993 had missing data regarding alcohol status on admission or sex. See Fig. 1 for a flowchart of the patient selection process. Coding of variables
The International Statistical Classification of Diseases and Related Health Problems Ninth Revision (ICD-9) and Tenth Revision (ICD-10) diagnosis codes relating to facial fracture were collated and then used to determine a new set of dichotomous variables defining the fracture subtypes broadly as nasal bone, mandibular, malar/maxillary, orbital, other facial bones, and more than one fracture type. The majority of the data were coded as ICD-9 codes, as ICD-10 only came into use in this dataset after 2015. This affected the granularity of the available data; therefore the variables were coded as broader
Fig. 1. Flowchart of patient selection.
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The effect of alcohol on facial trauma outcomes categories rather than utilizing a score such as the Facial Injury Severity Score (FISS), which can only be determined from ICD-10 codes. The outcome of operative fixation was coded as a dichotomous variable after identifying all ICD-9 and ICD-10 codes relevant to facial fracture operations. The use of protective devices was coded from the NTDB variable determining which protective device was used and whether the airbag had deployed or not. Only the use of eye protection, helmets, and deployed airbags was examined. The NTDB also codes for various comorbidities, acknowledging that these may not have been completely filled out, particularly given the acute nature of trauma. These were used to code a dichotomous variable for a history of smoking. Complication data present in the NTDB were used to code dichotomous variables for unplanned intubation and for surgical site infection. These complication data are more reliable for the period studied here when compared to early versions of the NTDB17. The other variables examined including age, sex, race, injury intent, mechanism, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score in the emergency department, and hospital trauma level were all used in the analysis in the same format as they were coded in the NTDB. Statistical analysis
The differences between the alcohol and no alcohol groups were first tested with the Pearson x2 test to determine whether there were any significant differences in the baseline characteristics between the two groups. Due to the observational nature of the data, there were differences in the baseline characteristics; hence these were adjusted for as covariates in the final model. A comparative analysis of the effect of alcohol on discharge disposition and fracture subtype was also performed using the Pearson x2 test. Four major outcomes were analyzed: operative fixation of the facial fracture, mechanical ventilation, unplanned intubation, and surgical site infection. Clinical outcomes were coded as dichotomous variables; therefore logistic regression was used for analysis. Univariable and multivariable logistic regression analysis was used to determine which variables had the most significant clinical and statistical effect on the four major outcomes. Forward selection and tests for covariance were used to determine the final model selection. Variance inflation factor testing
and correlation matrices were used to determine variables that were highly collinear. Variables that were collinear were removed; for example, a variable coding blunt and penetrating trauma was collinear with mechanism and therefore was removed, keeping the more granular mechanism data18. Subsequently all variance inflation factors were lower than five. The major independent variables examined were age, sex, race, region, alcohol test on presentation, injury intent, mechanism of injury, and ISS category (score 1–8, 9–15, 16–24, or 25–75). Additional variables were analyzed for confounding effect as noted in Table 1. The analysis was conducted using Stata/ MP 14.219, and a P-value of <0.05 was considered significant when evaluating covariates for inclusion in the multivariable model. Results
Patient characteristics are summarized in Table S1 (see Supplementary Material). The majority of patients were male (75.24%) and in the 18–24 and 25–34 years age groups (38.11%). In regard to the mechanism descriptions, the term ‘struck-by’ is used by the NTDB to describe any injury caused by collision with an object or body part. This classification was further characterized by examining the intent recorded within each category, and 73.84% of the struck-by injuries were characterized as intentional assaults. A fifth of the patients (20.19%, n = 117,139) underwent operative fixation of their facial fracture. The results of these analyses are seen in Fig. 2, with further detail given in Table S2
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(see Supplementary Material). A positive alcohol test reduced the odds of operative fixation in both the unadjusted (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.79–0.82, P < 0.001) and adjusted (OR 0.67, 95% CI 0.66–0.68, P < 0.001) models. The variables with the greatest adjusted effect on the odds ratio (OR) were age, alcohol, injury intent, injury mechanism, ISS, and hospital trauma center level as determined by the American College of Surgeons criteria (level I–IV, with I being the highest level). Being in a younger age group significantly doubled the odds of operative management in comparison to being in the 55–64 years age group (OR 0.50, 95% CI 0.48–0.52, P < 0.001). When adjusting for other factors, the factor that gave the greatest increase in the odds of requiring operative fixation was the mechanism of injury (Fig. 2). In terms of injury mechanism, being struck (adjusted OR 1.99, 95% CI 1.91–2.07, P < 0.001) or shot (adjusted OR 1.95, 95% CI 1.84–2.06, P < 0.001) had a significant effect on operative fixation. Increased hospital trauma acuity significantly increased the odds of operative fixation. In regard to the second outcome, 30.52% of patients required more than 1 day of mechanical ventilation at any point throughout their admission. Fig. 3 and Table S3 (see Supplementary Material) detail the adjusted comparisons for the same variables as investigated for the operative fixation outcome. Similar to the outcome of operative fixation, the odds of requiring mechanical ventilation following a gunshot wound were significantly more than four times the odds of requiring mechanical ventilation for a fall
Table 1. Potential confounding variables. Patient factors
Injury factors
Smoking status
ISS (1–8, 9–15, 16–24, 25–75)
Race
Protection (none, eye, helmet, airbag)
Psychiatric history
Penetrating or blunt injury
History of drug dependence
Intent of injury (assault, self-inflicted, undetermined, unintentional, other) Mechanism of injury (stab, fall, GSW, MVC, pedestrian, struck-by, other)
GCS on arrival in the ED Hospital factors
Time and location
American College of Surgeons Trauma Level Year of admission (2007–2016) (I, II, III, IV) Region (Midwest, Northeast, South, West, not available) ED, emergency department; GCS, Glasgow Coma Scale; GSW, gunshot wound; ISS, Injury Severity Score; MVC, motor vehicle crash.
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Fig. 2. Log odds ratio of operative fixation in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 2white race; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
Fig. 3. Log odds ratio of mechanical ventilation in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 2white race; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
(adjusted OR 4.34, 95% CI 4.06–4.64, P < 0.001). Stab (adjusted OR 1.46, 95% CI 1.33–1.61, P < 0.001) and motor vehicle crash (adjusted OR 1.47, 95% CI
1.42–1.51, P < 0.001) also had significantly higher odds of mechanical ventilation. An increase in the overall ISS significantly increased the odds of
mechanical ventilation, doubling and quadrupling it in the highest injury categories, when adjusted for other variables. As would be expected, each point increase
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The effect of alcohol on facial trauma outcomes in GCS score on presentation to the emergency department decreased the odds of mechanical ventilation significantly. Each increase in hospital trauma center level (with level I being the highest) was associated with increased odds of mechanical ventilation. As seen in Fig. 4 and detailed in Table S4 (see Supplementary Material), the odds of the third outcome of unplanned intubation did increase for patients with positive alcohol (unadjusted OR 1.07, 95% CI 1.01–1.13, P < 0.02; adjusted OR 1.25, 95% CI 1.16–1.36, P < 0.001). Age 55 and older increased the odds of unplanned intubation three to four times in the adjusted and unadjusted analyses (age 55–65 years, adjusted OR 2.98, 95% CI 2.60– 3.42, P < 0.001). While injury intent did increase the odds of unplanned intubation, when other factors were adjusted for, assault and undetermined intent had the greatest odds of unplanned intubation. The mechanism of injury played a lesser role in unplanned intubation when compared to the other outcomes. The odds of unplanned intubation increased manyfold with increasing ISS and with lower GCS score on presentation. Smoking also
almost doubled the odds of unplanned intubation. Finally, the outcome of surgical site infection showed a positive association with alcohol (Fig. 5; Supplementary Material, Table S5) (unadjusted OR 1.16, 95% CI 1.08–1.25, P < 0.001; adjusted OR 1.10, 95% CI 1.00–1.21, P = 0.06). When adjusted for other factors, the effect of injury intent on the odds of surgical site infection were reduced. However, the mechanisms of motor vehicle crash (adjusted OR 2.26, 95% CI 1.92– 2.66, P < 0.001) and gunshot wound (adjusted OR 3.59, 95% CI 2.62–4.93, P < 0.001) still increased the odds of surgical site infection two to three times. With regard to the ISS, the odds of surgical site infection increased up to nine times for the highest category. Figs 2–5 more clearly visualize the noted effects of the variables on the adjusted log OR of the four outcomes. Figure 6 demonstrates the effect of alcohol on discharge disposition (P < 0.01); of note more patients with alcohol were discharged home without services or discharged themselves against medical advice. Patients who presented and were
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not intoxicated were more likely to be discharged under an organized home health service, for inpatient rehabilitation, or to a skilled nursing facility. The breakdown of fracture subtypes is demonstrated in Fig. 7 (P < 0.01), and alcohol was associated with both nasal bone fractures and an increased frequency of multiple fracture subtypes. Discussion
The primary focus of this study was to determine whether a positive alcohol test increases the need for operative fixation and is associated with increased complication rates in facial-related trauma. Of note, 15% of patients in the 2015 NTDB tested positive for alcohol, as opposed to 31.45% seen in this patient population20. The study results showed that a positive alcohol test had a negative effect on the likelihood of requiring operative fixation of facial fractures. However, if the injury intent was assault or if the mechanism was a struck-by, which is frequently associated with assault, it appeared that there was a significantly higher rate of operative fixation. Patients with the lowest ISS had the
Fig. 4. Log odds ratio of unplanned intubation in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 2white race; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016
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Fig. 5. Log odds ratio of surgical site infection in facial fracture patients after maxillofacial trauma in the National Trauma Data Bank (NTDB). Comparators: 1age 18–24 years; 3assault; 4fall; 5score <9; 6GCS 3; 7level I trauma center. GSW: gunshot wound; MVC: motor vehicle crash.
highest odds of operative fixation, perhaps due to those with higher scores having more life-threatening injuries. For the other outcomes examining complications of hospital stay (need for mechanical ventilation, unplanned intubation, and surgical site infection), alcohol did increase the odds of these occurring. These results somewhat contradict those of previously published studies. This is likely due to the nature of those studies being single-center studies and largely looking at simple associations without controlling for other factors. The present study controlled for other hospital, patient, injury, and temporal factors that could affect clinical outcomes. This was made possible by utilizing a large database, the NTDB. The results showed that intoxicated patients were less likely to require operative fixation and this raises an interesting question of whether the patient’s alcohol level is a relevant measure. Interpersonal violence appeared to be associated with higher levels of operative fixation. It is possible that other additional exacerbating social factors in the situation of interpersonal violence would be more important to measure, such as the alcohol level of the perpetrators. The published
literature also notes a strong association between alcohol and violence, and investigating this may be valuable in further ascertaining the role alcohol plays in facial-related trauma7,10,21,22. It is possible that variations by country exist, as many of the prior studies were not based in the United States, from where the NTDB derives the majority of its patients. Patients who were seen at higher trauma level hospitals (with level I being highest) were significantly more likely to have operative fixation. This could be related to the availability of surgical specialties. It is possible that lower acuity trauma centers may need to transfer patients to higher acuity centers for operative fixation. This relationship may be because there are generally patients with more acute injuries at these centers; however, a higher ISS appeared to be negatively correlated with the odds of operative fixation. In regard to the effect of these clinical outcomes, a costs analysis could help guide the value of potential preventative interventions in this instance. Specific interventions targeted at changing alcohol sales, such as those instituted in other countries, could potentially be less cost-effective than interventions aimed at reducing interpersonal violence.
Mechanical ventilation and unplanned intubation were the second and third outcome measures, and both saw an increase in odds with intoxication on presentation (adjusted OR 1.35 for mechanical ventilation and 1.25 for unplanned intubation). It was interesting to note that while the unadjusted odds of mechanical ventilation showed a decrease with age, once other factors were adjusted for this variability almost disappeared. It is unlikely that these changes were clinically significant, since the change in ORs represents a maximum of a 4% change in the probability of mechanical ventilation. Gunshot wounds carried much higher odds of mechanical ventilation when compared to the other mechanisms, but this did not apply for unplanned intubation. Increase in ISS and decrease in GCS scores were associated with both airway outcomes. This would be expected, as patients with more injuries are more likely to be unstable and therefore require airway support during their admission. Being in a higher acuity trauma center increased the odds of airway complications, likely because patients with more severe or complex injuries are more likely to be treated at these centers.
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Fig. 6. Histogram of discharge destination by alcohol on presentation after maxillofacial trauma in the National Trauma Data Bank (NTDB). 1, died; 2, discharged home with no home services; 3, discharged to home or self-care (routine discharge); 4, discharged/transferred to long-term care hospital; 5, discharged/transferred to skilled nursing facility; 6, discharged/transferred to a short-term general hospital for inpatient care; 7, discharged/transferred to an intermediate care facility (ICF); 8, discharged/transferred to another acute care hospital using emergency medical services; 9, discharged/transferred to another type of rehabilitation or long-term care; 10, discharged/transferred to court/law enforcement; 11, discharged/transferred to home under care of organized home health service; 12, discharged/transferred to hospice care; 13, discharged/transferred to inpatient rehabilitation or designated unit; 14, discharged/transferred to a psychiatric hospital or psychiatric facility; 15, left against medical advice or discontinued care; 16, not admitted to hospital.
Surgical site infection as the final outcome also increased with positive alcohol; however when adjusted, the confidence interval encompassed no effect. Mechanisms of motor vehicle crash and gunshot wound are typically associated with debris in the wounds, which is a likely contributor to their effect on surgical site infection. In regard to the discharge destination, shown in Fig. 6, far fewer intoxicated patients appeared to be discharged with services and they appeared to be at greater risk of discharging themselves against medical advice. Also, the pattern of fractures in intoxicated patients, as demonstrated in Fig. 7, was different to that in non-intoxicated patients, and it is useful for clinicians to note the increased likelihood of multiple fracture subtypes in the former group of patients. There are a number of limitations to a large database analysis. It is not possible to infer causality as the data are
observational in nature. A large number of missing values could potentially skew the results, therefore observations with missing values in the variables of interest were excluded. Variables that are drawn from pre-existing diagnoses have the potential for inaccuracy due to the data not having been recorded. However, due to the size of the dataset, a small number of missing values is unlikely to impact the overall conclusions. Having a large dataset could contribute to statistically significant values that may not be of clinical significance, and so the interpretation of these results has focused on those variables that have the greatest effect on the clinical outcomes23. Of note in this dataset, across each year of the NTDB examined, there was a slight decrease in the odds of operative fixation, ranging from 0.8 to 1; while this was not thought to be a clinically significant fluctuation over time, it may represent a change in trauma care across this period.
The next step with this dataset is to look with granularity at patients with fractures resulting from interpersonal violence. Specifically, this would be to examine whether there is a difference in type of mechanism by sex, for example a greater likelihood of interpersonal violence related to domestic violence in females. This could be analyzed using E codes if sufficient information has been recorded. Also, while there was some information on drug utilization available in this study, a closer look at the use of other substances where they could be better characterized with more granular data would be useful. A number of other studies have investigated the link between illicit drug use and facial trauma as single-center studies24,25. A second analysis of interest would be a comparison of geriatric and non-geriatric patients to assist with identifying risk factors. These are likely to become more important as the population continues to age.
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Fig. 7. Histogram of fracture type by alcohol on presentation after maxillofacial trauma in the National Trauma Data Bank (NTDB). 1, nasal bone; 2, mandible; 3, malar/maxillary bones; 4, orbital; 5, other facial bones; 6, more than one fracture type.
In conclusion, despite this study’s focus on alcohol as an independent variable in facial trauma, it appears that the effects of alcohol are not consistent across this patient population. However, injuries related to interpersonal violence do appear to increase the severity of facial fracture as measured by the odds of requiring operative fixation and also appear to be associated with complications. This in itself has interesting clinical and public health implications in regard to injury and violence prevention. Interpersonal violence may not only increase the occurrence of facial fractures, but also potentially leads to worse clinical outcomes. Further research into the factors leading to interpersonal violence to guide injury prevention programs would benefit these patients.
Funding
None.
Competing interests
None.
Ethical approval
Johns Hopkins Medicine IRB Approval #IRB00053752.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.ijom.2020. 01.016.
Patient consent
Not required as only de-identified data were used.
Disclosures
Dr Haut was the paid author of a paper commissioned by the National Academies of Medicine titled ‘‘Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making’’ which was used to support the report titled ‘‘A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.’’
Acknowledgements. This project was part of the Johns Hopkins Center for Surgical Outcomes Research (JSCOR) Program.
References 1. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg 2011;69:2613–8. 2. VandeGriend ZP, Hashemi A, Shkoukani M. Changing trends in adult facial trauma epidemiology. J Craniofac Surg 2015;26:108–12. 3. Shapiro AJ, Michael Johnson R, Miller SF, McCarthy MC. Facial fractures in a level I trauma centre: the importance of protective devices and alcohol abuse. Injury 2001;32:353–6. 4. Adkinson JM, Murphy Jr RX. Impact of automobile restraint device utilization on facial fractures and fiscal implications for plastic surgeons. Ann Plast Surg 2011;66:472–5. 5. Hutchison IL, Magennis P, Shepherd JP, Brown AE. The BAOMS United Kingdom survey of facial injuries part 1: aetiology and
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6.
7.
8.
9.
10.
11.
12.
the association with alcohol consumption. Br J Oral Maxillofac Surg 1998;36:3–13. Murphy DA. Substance use and facial injury. Oral Maxillofac Surg Clin North Am 2010;22:231–8. Soares-Carneiro SCA, Vasconcelos BC, Matos da-Silva GS, de-Barros-Caldas LC, Porto GG, Leal JF, Catunda I. Alcohol abusive use increases facial trauma? Med Oral Patol Oral Cir Bucal 2016;21:e547–53. Furr AM, Schweinfurth JM, May WL. Factors associated with long-term complications after repair of mandibular fractures. Laryngoscope 2006;116:427–30. El-Maaytah M, Smith SF, Jerjes W, Upile T, Petrie A, Kalavrezos N, Ayliffe P, Newman L, Hopper C, Lloyd T. The effect of the new ‘‘24 hour alcohol licensing law’’ on the incidence of facial trauma in London. Br J Oral Maxillofac Surg 2008;46:460–3. Menendez P, Kypri K, Weatherburn D. The effect of liquor licensing restrictions on assault: a quasi-experimental study in Sydney, Australia. Addiction 2017;112:261–8. Chopra S, van der Rijt RG, Ngo Q, Clarke FK, Southwell-Keely JP, Robledo K, Moisidis E. A comparison of maxillofacial trauma before and after implementation of lockout laws in Sydney. Aust J Plast Surg 2018;1:75–84. Cohen SM, Rosett BE, Shifrin DA. An analysis of independent variables affecting surgical outcomes in patients undergoing repair of maxillofacial trauma: an American College of Surgeons National Surgical Quality Improvement Program Study. J Craniofac Surg 2017;28:596–9.
13. Haider AH, Bilimoria KY, Kibbe MR. A checklist to elevate the science of surgical database research. JAMA Surg 2018;153:505–7. 14. Hashmi ZG, Kaji AH, Nathens AB. Practical guide to surgical data sets: National Trauma Data Bank (NTDB). JAMA Surg 2018;153:852–3. 15. Haider AH, Hashmi ZG, Zafar SN, Castillo R, Haut ER, Schneider EB, Cornwell EE, Mackenzie EJ, Efron DT. Developing best practices to study trauma outcomes in large databases: an evidence-based approach to determine the best mortality risk adjustment model. J Trauma Acute Care Surg 2014;76:1061–9. 16. Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell EE, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg 2012;214:756–68. 17. Kardooni S, Haut ER, Chang DC, Pierce CA, Efron DT, Haider AH, Pronovost PJ, Cornwell EE. Hazards of benchmarking complications with the National Trauma Data Bank: numerators in search of denominators. J Trauma 2008;64:273–7. discussion 277–279. 18. Haider AH, Chang DC, Haut ER, Cornwell 3rd EE, Efron DT. Mechanism of injury predicts patient mortality and impairment after blunt trauma. J Surg Res 2009;153:138–42. 19. Stata Statistical Software. Release 14.2 [computer program]. College Station, TX: StataCorp LP; 2019.
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20. American College of Surgeons. National Trauma Data Bank 2016 annual report. American College of Surgeons; 2016. 21. Duailibi S, Ponicki W, Grube J, Pinsky I, Laranjeira R, Raw M. The effect of restricting opening hours on alcohol-related violence. Am J Public Health 2007;97:2276–80. 22. Walton MA, Chermack ST, Shope JT, Bingham RC, Zimmerman MA, Blow FC, Cunningham RM. Effects of a brief intervention for reducing violence and alcohol misuse among adolescents: a randomized controlled trial. JAMA 2010;304:527–35. 23. Webster KLW, Owodunni OP, Haut ER. Addressing clinical significance. JAMA Surg 2019;154:188–9. 24. Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003;61:713–8. 25. McAllister P, Jenner S, Laverick S. Toxicology screening in oral and maxillofacial trauma patients. Br J Oral Maxillofac Surg 2013;51:773–8.
Address: Ekta Paw Johns Hopkins University Bloomberg School of Public Health Department of Health Policy and Management Baltimore MD USA E-mail: [email protected]
Please cite this article in press as: Paw E, et al. The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank, Int J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.ijom.2020.01.016