Do outcomes in emergency general surgery vary for minority patients based on surgeons\u27 racial/ethnic case mix?

Background: We hypothesized that Black and Hispanic patients undergoing Emergency General Surgery (EGS) with surgeons who treat higher proportions of minority patients will experience better outcomes.Methods: Using the Florida State Inpatient Database (2010-2014), we performed multivariable regression to assess complications in patients undergoing EGS as a function of patient race and the proportion of Black, Hispanic, or White patients treated by the surgeon during the study period. Analyses were clustered by hospital and adjusted for patient age, comorbidities, sex, insurance, and hospital-level variables.Results: 5471 surgeons were distributed across 204 hospitals. Of the 520,024 patients included, 67% were White, 16.5% were Black, and 14.2% were Hispanic. For non-White patients undergoing EGS, the increased likelihood of sustaining a complication relative to White patients (OR 1.09, 95% confidence interval [CI] 1.07-1.11) decreased when treated by surgeons whose caseload consisted of higher proportions of Black/Hispanic patients (aOR 0.88, 95% CI 0.78-0.99).Conclusion: Black patients undergoing EGS are at higher risk for experiencing complications when treated by surgeons whose caseload consists of higher proportions of White patients

Trends in the Surgical Management and Outcomes of Complicated Peptic Ulcer Disease

Background: Older data indicate that less patients undergo surgery for complicated peptic ulcer disease (PUD). We evaluated contemporary trends in the surgical management and outcomes of patients with complicated PUD. Methods: The National Inpatient Sample (2005-2014) was queried for patients with complicated PUD (hemorrhage, perforation, or obstruction). Trend analyses were used to evaluate changes in management and outcomes. Results: There were 1 570 696 admissions for complicated PUD during the study period. Majority (87.0%) presented with hemorrhage, 10.6% presented with perforation, and 2.4% had an obstruction. The average age was 67 years. Overall, admissions with complicated PUD decreased from 180 054 in 2005 to 150 335 in 2014. The proportion of patients managed operatively decreased from 2.5% to 1.9% in the hemorrhage group, 75.0% to 67.4% in the perforation group, and 26.0% to 20.2% in the obstruction group (all P-trend \u3c .05). Overall, among patients managed operatively, the use of acid-reducing procedures decreased from 25.9% to 13.9%, mortality decreased from 11.9% to 9.4% (both P-trend \u3c .001), while complications remained stable (10.4% to 10.3%, P-trend = .830). Conclusions: There are fewer admissions with complicated PUD and more patients are treated nonoperatively. Despite subtle improvements, significant proportions of patients still die from complicated PUD indicating the need for improved preoperative optimization and postoperative care among these patients

Mechanism of injury independently predicts mortality and functional outcomes in blunt trauma patients

Background: While performing trauma outcomes research, the standard with regard to the cause of injury has been to control for the “type” of trauma, that is penetrating vs. blunt. Most injury assessment schemes do not control for the “mechanism” by which a patient suffers their injury (e.g. falls, motor vehicle crashes, pedestrian struck by motor vehicle, etc). The independent relationship between mechanism of injury (MOI) and trauma outcomes is unknown. We hypothesized that patients who suffer otherwise similar and equivalent injuries demonstrate different outcomes solely due to the mechanism by which they sustained their injury. Objective: To determine the independent relationship between mechanism of injury (MOI) and mortality and functional outcomes after blunt trauma.Methods: Review of patients (ages 15 and above) included in the National Trauma Data Bank (NTDB) between 2001- 2005 who suffered moderate/ severe blunt trauma (New Injury Severity Score (NISS) \u3e 9). ICD version 9, E-Codes were used to categorize patients in to one of six MOI groups. Patients with burns and penetrating trauma were excluded. Outcome measures were mortality and presence or absence of a functional deficit at discharge in three domains: Speech, Walking and Feeding. Multiple logistic regression was utilized to determine outcome differences between each MOI group and motor vehicle crash which was selected as the reference group. Patients were adjusted for age, gender, anatomic injury severity (using the NISS), physiologic injury severity upon admission (using the Revised Trauma Score), head injury (using the Relative Head Injury Severity Score), extremity injury (using the Abbreviated Injury Scale), race, insurance status, and injury intent (intentional vs. unintentional). Results: of the 1.4 million patients included in the NTDB over the study period, 515,464 patients met our inclusion criteria. Mean age was 39 years, 65% were males and mean NISS for patients was 19. Crude mortality was 5.96% and 63% of patients had at least one functional deficit at discharge (52% had impaired walking, 16% had impaired feeding and 9% had a speech deficit). The table demonstrates how MOI independently influences outcomes after blunt trauma. Pedestrians struck by motor vehicle had worse outcomes, whereas patients who fell on the same level had better outcomes than the reference group controlling for injury severity and other known variables that influence outcomes

Systematically Tabulated Outcomes Research Matrix (STORM): A methodology to generate research hypotheses

Background: Here we describe the Systematically Tabulated Outcomes Research Matrix (STORM) method to generate research questions from pre-existing databases with the aim of improving patient outcomes.Materials and methods: STORM can be applied to a database by tabulating its variables into a matrix of independent variables (y-axis) and dependent variables (x-axis) and then applying each unique pairing of an independent and dependent variable to a patient population to generate potentially meaningful research questions.Results: To demonstrate this methodology and establish proof-of-principle, STORM was applied on a small scale to the National Trauma Data Bank and generated at least seven clinically meaningful research questions.Conclusion: When coupled with rigorous clinical judgment, the STORM approach complements the traditional method of hypothesis formation and can be generalized to outcomes research using registry databases across different medical specialties