Traumatic injury in the United States: In-patient epidemiology 2000–2011

Background Trauma is a leading cause of death and disability in the United States (US). This analysis describes trends and annual changes in in-hospital trauma morbidity and mortality; evaluates changes in age and gender specific outcomes, diagnoses, causes of injury, injury severity and surgical procedures performed; and examines the role of teaching hospitals and Level 1 trauma centres in the care of severely injured patients. Methods We conducted a retrospective descriptive and analytic epidemiologic study of an inpatient database representing 20,659,684 traumatic injury discharges from US hospitals between 2000 and 2011. The main outcomes and measures were survey-adjusted counts, proportions, means, standard errors, and 95% confidence intervals. We plotted time series of yearly data with overlying loess smoothing, created tables of proportions of common injuries and surgical procedures, and conducted survey-adjusted logistic regression analysis for the effect of year on the odds of in-hospital death with control variables for age, gender, weekday vs. weekend admission, trauma-centre status, teaching-hospital status, injury severity and Charlson index score. Results The mean age of a person discharged from a US hospital with a trauma diagnosis increased from 54.08 (s.e. = 0.71) in 2000 to 59.58 (s.e. = 0.79) in 2011. Persons age 45–64 were the only age group to experience increasing rates of hospital discharges for trauma. The proportion of trauma discharges with a Charlson Comorbidity Index score greater than or equal to 3 nearly tripled from 0.048 (s.e. = 0.0015) of all traumatic injury discharges in 2000 to 0.139 (s.e. = 0.005) in 2011. The proportion of patients with traumatic injury classified as severe increased from 22% of all trauma discharges in 2000 (95% CI 21, 24) to 28% in 2011 (95% CI 26, 30). Level 1 trauma centres accounted for approximately 3.3% of hospitals. The proportion of severely injured trauma discharges from Level 1 trauma centres was 39.4% (95% CI 36.8, 42.1). Falls, followed by motor-vehicle crashes, were the most common causes of all injuries. The total cost of trauma-related inpatient care between 2001 and 2011 in the US was $240.7 billion (95$12.0 billion (95% CI 10.5, 13.4) in 2001 to 29.1 billion (95% CI 25.2, 32.9) in 2011. Conclusions Trauma, which has traditionally been viewed as a predicament of the young, is increasingly a disease of the old. The strain of managing the progressively complex and costly care associated with this shift rests with a small number of trauma centres. Optimal care of injured patients requires a reappraisal of the resources required to effectively provide it given a mounting burden

The changing face of major trauma in the UK

Aim Major trauma (MT) has traditionally been viewed as a disease of young men caused by high-energy transfer mechanisms of injury, which has been reflected in the configuration of MT services. With ageing populations in Western societies, it is anticipated that the elderly will comprise an increasing proportion of the MT workload. The aim of this study was to describe changes in the demographics of MT in a developed Western health system over the last 20 years. Methods The Trauma Audit Research Network (TARN) database was interrogated to identify all cases of MT (injury severity score >15) between 1990 and the end of 2013. Age at presentation, gender, mechanism of injury and use of CT were recorded. For convenience, cases were categorised by age groups of 25 years and by common mechanisms of injury. Longitudinal changes each year were recorded. Results Profound changes in the demographics of recorded MT were observed. In 1990, the mean age of MT patients within the TARN database was 36.1, the largest age group suffering MT was 0–24 years (39.3%), the most common causative mechanism was road traffic collision (59.1%), 72.7% were male and 33.6% underwent CT. By 2013, mean age had increased to 53.8 years, the single largest age group was 25–50 years (27.1%), closely followed by those >75 years (26.9%), the most common mechanism was low falls (39.1%), 68.3% were male and 86.8% underwent CT. Conclusions This study suggests that the MT population identified in the UK is becoming more elderly, and the predominant mechanism that precipitates MT is a fall from <2 m. Significant improvements in outcomes from MT may be expected if services targeting the specific needs of the elderly are developed within MT centres

Trauma Care Beyond the Hospital Doors: Lessons from Stroke Center Certification

Thesis (Master's)--University of Washington, 2012CONTEXT: Discharge to skilled nursing facilities (SNF) has been associated with increased long-term mortality. Currently, discharge disposition is not evaluated in trauma center verification but is a performance measure in primary stroke center (PSC) certification. OBJECTIVES: To determine trends in trauma and stroke patient discharges and examine the effect of PSC certification requirements on discharge disposition. Design, Setting, and Patients: Retrospective cohort study of adult trauma and stroke patients discharged from January 2003 to December 2009. The National Trauma Data Bank and Healthcare Cost and Utilization Project Nationwide Inpatient Sample were used to study trauma and stroke patients respectively. The Joint Commission PSC program was implemented December 2003. MAIN OUTCOME MEASURE: Relative risk of discharge to SNFs and inpatient rehabilitation facilities (IRF), over time. RESULTS: Over the period of the study, the proportion of trauma patients age ≥65 years increased from 23% (95% confidence interval [CI], 20.2%-25.8%) to 30% (CI, 25.6%-34.6%). In-hospital mortality decreased from 4.5% [CI, 2.0%-6.9%] in 2003, to 3.2% [CI, 2.8%-3.5%] in 2009. The majority of patients who survived hospitalization were discharged home (64.6% [CI, 61.3%-67.9%]). On average, stroke patients were 71.9 (SD, 0.01) years old and 72.6% (CI, 72.5%-72.6%) were age ≥65 years. In-hospital mortality was 6.1% (CI, 6.0%-6.1%). Less than half (45.7% [CI, 45.7%-45.8%]) of patients who survived hospitalization were discharged home. In 2009, trauma patients were 34% (adjusted RR 1.34 [CI, 1.15-1.57]) more likely to be discharged to SNF, compared to 2003, but 36% (adjusted RR 0.64 [CI, 0.48-0.85]) less likely to be discharged to IRF. However, stroke patients were 78% (adjusted RR 1.78 [CI, 1.74-1.82]) more likely to be discharged to IRF. The largest absolute increase (2.1% [CI, 2.1%-2.1%]) in stroke patient discharges to IRF occurred in the year following PSC implementation. CONCLUSIONS: After adjusting for confounding factors, there was a significant increase in trauma center discharges to SNF and a decrease in discharges to IRF. However, during the same period and especially after implementation of the PSC program, stroke patients were more likely to be discharged to IRF. Trauma centers should evaluate discharge disposition as a part of the verification process

Effect of Ezetimibe Added to High-intensity Statin Therapy in Patients with Hypercholesterolemia: A Meta-Analysis

Background: It is unknown whether the conclusion of the IMPROVE-IT trial can be extrapolated into patients taking high intensity statin plus ezetimibe. Therefore, a meta-analysis was performed to evaluate the impact of ezetimibe combined with high intensity statin on low-density lipoprotein cholesterol (LDL-C) levels in patients with hypercholesterolemia. Methods: A systematic literature search was performed using PubMed and EMBASE and restricted to randomized controlled trials (RCTs) in patients with hypercholesterolemia. The outcome of this analysis was mean difference in LDL-C reduction in patients treated with high intensity statin plus ezetimibe compared to corresponding high intensity statin. Results: Of the 404 citations, six RCTs involving 714 patients were included. Compared to the high intensity statin group, overall the mean difference in LDL-C reduction with high intensity statin plus ezetimibe was -12.07% (95% CI: -2.16 to -21.97; p=0.02). The results were associated with substantial heterogeneity (I2=84%, p\u3c0.00001). Notably, the mean difference in LDL-C reduction was decreased to -8.6% (95% CI: -4.22 to -12.98; p=0.0001) with non-significant heterogeneity (p=0.27, I2=22%) when the Robinson 2014 study was omitted. Conclusion: Among patients with hypercholesterolemia, adding ezetimibe to high intensity statin led to a mild but significant additional reduction in LDL-C levels compared to high intensity statin monotherapy

Causes of death differ between elderly and adult falls

As the population ages, mortality from falls will soon exceed that from all other forms of injury. Tremendous resources are focused on this problem, but how these patients die is unclear. To fill this gap, we tested the hypothesis that falls among the elderly are related to patient, rather than to injury factors when compared with falls among younger adults. From January 2002 to December 2012, 7,293 fall admissions were reviewed. Data are reported as mean ± SD if normally distributed or median (interquartile range) if not. In 2002 to 2007, 25% of all falls were in elderly patients (≥65 years), but in 2008 to 2012, this proportion increased to 30% (p < 0.001). When comparing adult (n = 5,216) with elderly (n = 2,077) admissions, characteristics were as follow: Injury Severity Score (ISS) of 8 (4-13) versus 9 (5-17), length of stay (in days) of 3 (1-7) versus 6 (2-11), and mortality of 3.8% versus 13.7% (all p < 0.001). After controlling for variables associated with mortality using multiple logistic regression, elderly age was the strongest independent predictor of mortality (odds ratio, 8.18; confidence interval, 4.88-13.71). When comparing adult (n = 198) with elderly (n = 285) fatalities, ground-level falls occurred in 31% versus 91%, ISS was 27 (25-41) versus 25 (16-36), and length of stay (in days) was 2 (0-6) versus 4 (1-11) (all p < 0.001). Death occurred directly from fall in 82% versus 63%, from complications in 10% versus 20%, and from a fatal event preceding the fall in 8% vs. 17% (all p < 0.001). The proportion of fall admissions in the elderly is growing in this trauma system. Elderly age is the strongest independent predictor of mortality following a fall. In those who die, death is less likely a direct effect of the fall. Epidemiologic study, level III

The Effect of Sharrows, Painted Bicycle Lanes and Physically Protected Paths on the Severity of Bicycle Injuries Caused by Motor Vehicles

We conducted individual and ecologic analyses of prospectively collected data from 839 injured bicyclists who collided with motorized vehicles and presented to Bellevue Hospital, an urban Level-1 trauma center in New York City, from December 2008 to August 2014. Variables included demographics, scene information, rider behaviors, bicycle route availability, and whether the collision occurred before the road segment was converted to a bicycle route. We used negative binomial modeling to assess the risk of injury occurrence following bicycle path or lane implementation. We dichotomized U.S. National Trauma Data Bank Injury Severity Scores (ISS) into none/mild (0–8) versus moderate, severe, or critical (&gt;8) and used adjusted multivariable logistic regression to model the association of ISS with collision proximity to sharrows (i.e., bicycle lanes designated for sharing with cars), painted bicycle lanes, or physically protected paths. Negative binomial modeling of monthly counts, while adjusting for pedestrian activity, revealed that physically protected paths were associated with 23% fewer injuries. Painted bicycle lanes reduced injury risk by nearly 90% (IDR 0.09, 95% CI 0.02–0.33). Holding all else equal, compared to no bicycle route, a bicycle injury nearby sharrows was nearly twice as likely to be moderate, severe, or critical (adjusted odds ratio 1.94; 95% confidence interval (CI) 0.91–4.15). Painted bicycle lanes and physically protected paths were 1.52 (95% CI 0.85–2.71) and 1.66 (95% CI 0.85–3.22) times as likely to be associated with more than mild injury respectively