Prior traumatic brain injury is a risk factor for in-hospital mortality in moderate to severe traumatic brain injury: a TRACK-TBI cohort study.

OBJECTIVES: An estimated 14-23% of patients with traumatic brain injury (TBI) incur multiple lifetime TBIs. The relationship between prior TBI and outcomes in patients with moderate to severe TBI (msTBI) is not well delineated. We examined the associations between prior TBI, in-hospital mortality, and outcomes up to 12 months after injury in a prospective US msTBI cohort. METHODS: Data from hospitalized subjects with Glasgow Coma Scale score of 3-12 were extracted from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (enrollment period: 2014-2019). Prior TBI with amnesia or alteration of consciousness was assessed using the Ohio State University TBI Identification Method. Competing risk regressions adjusting for age, sex, psychiatric history, cranial injury and extracranial injury severity examined the associations between prior TBI and in-hospital mortality, with hospital discharged alive as the competing risk. Adjusted HRs (aHR (95% CI)) were reported. Multivariable logistic regressions assessed the associations between prior TBI, mortality, and unfavorable outcome (Glasgow Outcome Scale-Extended score 1-3 (vs. 4-8)) at 3, 6, and 12 months after injury. RESULTS: Of 405 acute msTBI subjects, 21.5% had prior TBI, which was associated with male sex (87.4% vs. 77.0%, p=0.037) and psychiatric history (34.5% vs. 20.7%, p=0.010). In-hospital mortality was 10.1% (prior TBI: 17.2%, no prior TBI: 8.2%, p=0.025). Competing risk regressions indicated that prior TBI was associated with likelihood of in-hospital mortality (aHR=2.06 (1.01-4.22)), but not with hospital discharged alive. Prior TBI was not associated with mortality or unfavorable outcomes at 3, 6, and 12 months. CONCLUSIONS: After acute msTBI, prior TBI history is independently associated with in-hospital mortality but not with mortality or unfavorable outcomes within 12 months after injury. This selective association underscores the importance of collecting standardized prior TBI history data early after acute hospitalization to inform risk stratification. Prospective validation studies are needed. LEVEL OF EVIDENCE: IV. TRIAL REGISTRATION NUMBER: NCT02119182

Competition in California's Medi-Cal Managed Care Market Assessed by Herfindahl-Hirschman Index.

Evaluating market competition is an important practice to assess how the forces and components at play in a select market interact. Healthcare markets are similar to any other market present in the world, where competition can be present or absent in the exchange of goods and services. Applying a standard measure of assessing market competition, the Herfindahl-Hirschman Index, to California's Medi-Cal managed care marketplace, it is found that there is no competition present in all of California's counties as defined by the common interpretation of the Herfindahl-Hirschman Index. A distinctive trend in markets is that when less competition is present, the cost of goods and services increases to reflect the principles of supply and demand. California Medi-Cal markets follow this trend of less competitive markets being associated with increased adult midpoint costs. These findings help further to elucidate California's Medi-Cal marketplace on a county-by county level

Current trends in mild traumatic brain injury

In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed

Virtual Neurosurgery Education for Medical Students without Home Residency Programs: A Survey of 2020 Virtual Neurosurgery Training Camp Attendees

OBJECTIVE: To examine the perceived effectiveness of the virtual neurosurgery training camps (VNTC) among medical students with (HP) and without (NHP) home neurosurgery residency programs. METHODS: A survey assessing demographics, baseline interests, and ratings of usefulness and interest of programming was sent to attendees after the VNTC. Ratings were quantified on modified 7-point Likert scales. Ratings were compared between attendees HP and NHP neurosurgery residency programs using Wilcoxon sum-rank or χ RESULTS: There were 119 respondents, with 80 (67.2%) HP and 39 (32.8%) NHP students. Differences were observed between the groups for medical school type (P = 0.002), highest degree achieved (P = 0.030), previous participation in a Medical Student Neurosurgery Training Center event (P = 0.004), having a neurosurgery interest group (P \u3c 0.001), and primary reason for VNTC attendance (P = 0.028). Increased interest in peripheral nerve neurosurgery was greater for the NHP (P = 0.047) but not neurosurgery or other subspecialties. A significant difference in usefulness of the different VNTC sessions was observed (P = 0.002), whereas none was seen in willingness to pursue neurosurgery (P = 0.33), likelihood of taking a year off (P = 0.44), and preparedness for subinternships (P = 0.57) or applications (P = 0.77). CONCLUSIONS: The 2020 VNTC benefited both HPO and NHP medical students, but there were differences in perceived usefulness of virtual education. Future initiatives should continue to be tailored toward disadvantaged students

Using Interprofessional Education as a Means to Enhance Personal and Professional Development

The ACPE 2016 standards have increased emphasis on Interprofessional Education (IPE) and skills in the affective domain such as personal and professional development. The Wegmans School of Pharmacy (WSOP) at St. John Fisher College has prepared for the transition to the new standards by incorporating IPE into the pre-APPE (Advanced Pharmacy Practice Experience) curriculum so that students improve their communication skills, plan for their professional development, and learn to deal effectively with other healthcare providers. WSOP has incorporated TeamSTEPPS® training into its curriculum. TeamSTEPPS® is an evidence-based teamwork system designed to improve communication and teamwork skills among healthcare professionals. Training is comprised of preparatory work, a 4-hour workshop, and learning scenarios in groups. Both nursing and pharmacy faculty co-present modules using the TeamSTEPPS® slides followed by an online post-work assessment and course evaluation surveys. WSOP students also experience several thorough and unique exercises during their Introduction to Pharmacy Practice Experiences (IPPE) III and IV. The IPPE-III course places students in a long-term care facility, each paired with a patient. Students spend over 10 hours on-site interviewing the patient, working up a comprehensive medication plan, and interacting with members of the healthcare team. 15 hours of IPPE-III classroom time supplement this training through lectures offered by different members of the health care team sharing their roles and perspectives. The IPPE-IV class offers additional classroom instruction focused on the skills needed to succeed on advanced rotations. This course requires an additional 30 hours onsite, working closely with the WSOP clinical faculty

Using Interprofessional Education as a Means to Enhance Personal and Professional Development

The ACPE 2016 standards have increased emphasis on Interprofessional Education (IPE) and skills in the affective domain such as personal and professional development. The Wegmans School of Pharmacy (WSOP) at St. John Fisher College has prepared for the transition to the new standards by incorporating IPE into the pre-APPE (Advanced Pharmacy Practice Experience) curriculum so that students improve their communication skills, plan for their professional development, and learn to deal effectively with other healthcare providers. WSOP has incorporated TeamSTEPPS® training into its curriculum. TeamSTEPPS® is an evidence-based teamwork system designed to improve communication and teamwork skills among healthcare professionals. Training is comprised of preparatory work, a 4-hour workshop, and learning scenarios in groups. Both nursing and pharmacy faculty co-present modules using the TeamSTEPPS® slides followed by an online post-work assessment and course evaluation surveys. WSOP students also experience several thorough and unique exercises during their Introduction to Pharmacy Practice Experiences (IPPE) III and IV. The IPPE-III course places students in a long-term care facility, each paired with a patient. Students spend over 10 hours on-site interviewing the patient, working up a comprehensive medication plan, and interacting with members of the healthcare team. 15 hours of IPPE-III classroom time supplement this training through lectures offered by different members of the health care team sharing their roles and perspectives. The IPPE-IV class offers additional classroom instruction focused on the skills needed to succeed on advanced rotations. This course requires an additional 30 hours onsite, working closely with the WSOP clinical faculty

Employment and Economic Outcomes of Participants With Mild Traumatic Brain Injury in the TRACK-TBI Study.

IMPORTANCE: Mild traumatic brain injury (mTBI) may impair the ability to work. Strategies to facilitate return to work are understudied. OBJECTIVE: To assess employment and economic outcomes for employed, working-age adults with mTBI in the 12 months after injury and the association between return to work and employer assistance. DESIGN, SETTING, AND PARTICIPANTS: Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a cohort study of patients with mTBI presenting to emergency departments of 11 level I US trauma centers was performed. Patients with mTBI enrolled in the TRACK-TBI cohort study from February 26, 2014, to May 4, 2016, were followed up at 2 weeks and 3, 6, and 12 months after injury. Work status and income decline of participants were documented in the first year after injury. Associations between work status, injury characteristics, and offer of employer assistance and associations between follow-up care and employer assistance were investigated. Results were adjusted for unobserved outcomes using inverse probability weighting. Data were extracted July 12, 2020; analyses were completed March 24, 2021. Analyses included 435 participants aged 18 to 64 years who were working before the injury, had a Glasgow Coma Scale score of 13 to 15, and completed all postinjury follow-up surveys. MAIN OUTCOMES AND MEASURES: Primary outcomes were work status (working or not working) at each study follow-up milestone. Employer assistance included sick leave, reduced hours, modified schedule, transfer to different tasks, assistive technology, and coaching offered during the first 3 months after injury. RESULTS: Of 435 participants (147 [34%] female; 320 [74%] White; mean [SD] age 37.3 [12.9] years), 258 (59%) reported not working at 2 weeks after injury and 74 (17%) reported not working at 12 months after injury. More than one-fifth (92 [21%]) experienced a decline in annual income. Work status at 12 months was significantly associated with postconcussion symptoms experienced at 3 months after injury (73% of patients with 3 or more symptoms reported working at 12 months after injury vs 89% of patients with 2 or fewer symptoms; P \u3c .001) but not with other injury characteristics. Participants offered employer assistance in the first 3 months after injury were more likely to report working after injury than those not offered such assistance (at 6 months: 88% vs 78%; P = .02; at 12 months: 86% vs 72%; P = .005). CONCLUSIONS AND RELEVANCE: In this cohort study, mTBI was associated with substantial employment and economic consequences for some patients. Clinicians should systematically follow up with patients with mTBI and coordinate with employers to promote successful return to work

Perioperative Anesthesia Lean Implementation Is Associated With Increased Operative Efficiency in Posterior Cervical Surgeries at a HighVolume Spine Center.

OBJECTIVE:Lean management strategies aim to increase efficiency by eliminating waste or by improving processes to optimize value. The operating room (OR) is an arena where these strategies can be implemented. We assessed changes in OR efficiency after the application of lean methodology on perioperative anesthesia associated with posterior cervical spine surgeries. METHODS:We utilized pre- and post-lean study design to identify inefficiencies during the perioperative anesthesia process and implemented strategies to improve the process. Patient characteristics were recorded to assess for differences between the 2 groups (group 1, prelean; group 2, post-lean). In the pre-lean period, key steps in the perioperative anesthesia process were identified that were amenable to lean implementation. The time required for each identified key step was recorded by an independent study coordinator. The times for each step were then compared between the groups utilizing univariate analyses. RESULTS:After lean implementation, there was a significant decrease in overall perioperative anesthesia process time (88.4 ± 4.7 minutes vs. 76.2 ± 3.2 minutes, p = 0.04). This was driven by significant decreases in the steps: transport and setup (10.4 ± 0.8 minutes vs. 8.0 ± 0.7 minutes, p = 0.03) and positioning (20.8 ± 2.1 minutes vs. 15.7 ± 1.3 minutes, p = 0.046). Of note, the total time spent in the OR was lower for group 2 (270.1 ± 14.6 minutes vs. 252.8 ± 14.1 minutes) but the result was not statistically significant, even when adjusting for number of operated levels. CONCLUSION:Lean methodology may be successfully applied to posterior cervical spine surgery whereby improvements in the perioperative anesthetic process are associated with significantly increased OR efficiency