Undertriage of older trauma patients: is this a national phenomenon?

Background: Older age is associated with high rates of morbidity and mortality after injury. Statewide studies suggest significantly injured patients aged ≥55 y are commonly undertriaged to lower level trauma centers (TCs) or nontrauma centers (NTCs). This study determines whether undertriage is a national phenomenon. Materials and methods: Using the 2011 Nationwide Emergency Department Sample, significantly injured patients aged ≥55 y were identified by diagnosis and new injury severity score (NISS) ≥9. Undertriage was defined as definitive care anywhere other than level I or II TCs. Weighted descriptive analysis compared characteristics of patients by triage status. Multivariable logistic regression determined predictors of undertriage, controlling for hospital characteristics, injury severity, and comorbidities. Results: Of 4,152,541 emergency department (ED) visits meeting inclusion criteria, 74.0% were treated at lower level TCs or NTCs. Patients at level I and II TCs more commonly had NISS ≥9 (22.2% versus 12.3%, P \u3c 0.001), but among all patients with NISS ≥9, 61.3% were undertriaged to a lower level TC or a NTC. On multivariable logistic regression, factors independently associated with higher odds of being undertriaged were increasing age, female gender, and fall-related injuries. A subgroup analysis examined urban and suburban areas only where access to a TC is more likely and found that 55.8% of patients\u27 age were undertriaged. Conclusions: There is substantial undertriage of patients aged ≥55 y nationwide. Over half of significantly injured older patients are not treated at level I or II TCs. The impact of undertriage should be determined to ensure older patients receive trauma care at the optimal sit

Rural risk: Geographic disparities in trauma mortality

Background: Barriers to trauma care for rural populations are well documented, but little is known about the magnitude of urban-rural disparities in injury mortality. This study sought to quantify differences in injury mortality comparing rural and nonrural residents with traumatic injuries.Methods: Using data from the 2009-2010 Nationwide Emergency Department Sample, multiple logistic regression analyses were conducted to estimate odds of death after traumatic injury for rural residents compared with nonrural residents, while controlling for age, sex, injury type and severity, comorbidities, trauma designation, and Census region.Results: Rural residents were 14% more likely to die after traumatic injury compared with nonrural residents (P \u3c .001). Increased odds of death for rural residents were observed at level I (odds ratio = 1.20, P \u3c .001), level II (odds ratio = 1.34, P \u3c .001), and level IV/nontrauma centers (odds ratio = 1.23, P \u3c .001). The disparity was greatest for injuries occurring in the South and Midwest (odds ratio = 1.54, P \u3c .001 and odds ratio = 2.06, P \u3c .001, respectively) and for cases with an injury severity score \u3c9 or unknown severity (odds ratio = 2.09, P \u3c .001 and odds ratio = 1.31, P \u3c .001, respectively).Conclusion: Rural residents are significantly more likely than nonrural residents to die after traumatic injury. This disparity varies by trauma center designation, injury severity, and US Census region. Distance and time to treatment likely play a role in rural injury outcomes, along with regional differences in prehospital care and trauma system organization

Temporal trends in gender-affirming surgery among transgender patients in the United States

Importance: Little is known about the incidence of gender-affirming surgical procedures for transgender patients in the United States.Objectives: To investigate the incidence and trends over time of gender-affirming surgical procedures and to analyze characteristics and payer status of transgender patients seeking these operations.Design, setting, and participants: In this descriptive observational study from 2000 to 2014, data were analyzed from the National Inpatient Sample, a representative pool of inpatient visits across the United States. The initial analyses were done from June to August 2015. Patients of interest were identified by International Classification of Diseases, Ninth Revision, diagnosis codes for transsexualism or gender identity disorder. Subanalysis focused on patients with procedure codes for surgery related to gender affirmation.Main outcomes and measures: Demographics, health insurance plan, and type of surgery for patients who sought gender-affirming surgery were compared between 2000-2005 and 2006-2011, as well as annually from 2012 to 2014.Results: This study included 37 827 encounters (median [interquartile range] patient age, 38 [26-49] years) identified by a diagnosis code of transsexualism or gender identity disorder. Of all encounters, 4118 (10.9%) involved gender-affirming surgery. The incidence of genital surgery increased over time: in 2000-2005, 72.0% of patients who underwent gender-affirming procedures had genital surgery; in 2006-2011, 83.9% of patients who underwent gender-affirming procedures had genital surgery. Most patients (2319 of 4118 [56.3%]) undergoing these procedures were not covered by any health insurance plan. The number of patients seeking these procedures who were covered by Medicare or Medicaid increased by 3-fold in 2014 (to 70) compared with 2012-2013 (from 25). No patients who underwent inpatient gender-affirming surgery died in the hospital.Conclusions and relevance: Most transgender patients in this national sample undergoing inpatient gender-affirming surgery were classified as self-pay; however, an increasing number of transgender patients are being covered by private insurance, Medicare, or Medicaid. As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them

Collecting sexual orientation and gender identity information in the emergency department : The divide between patient and provider perspectives

Background: In the USA, The Joint Commission and Institute of Medicine have called for collection of patient sexual orientation (SO) and gender identity (GI) information in healthcare. In a recent study, we reported that ED clinicians believe patients will refuse to provide this information; however, very few patients say they would refuse to provide SO/GI. As part of this study, we interviewed patients and providers regarding the importance of collecting this information. While these interviews were briefly summarised in our prior report, the qualitative data warranted a more thorough analysis and exposition to explore provider and patient views as well as risks and benefits of collecting SO/GI. Methods: A purposive sample of 79 participants was recruited for semi-structured interviews between August 2014 and January 2015. Participants included community members who had a previous ED encounter and ED providers from 3 community and 2 academic centres in a major US metropolitan area. Interviews were conducted one-on-one in person, audio-recorded and transcribed verbatim. Data were analysed using the constant comparative method. Results: Fifty-three patients and 26 ED providers participated. Patients perceived collection of SO/GI to be important in most clinical circumstances because SO/GI is relevant to their identity and allows providers to treat the whole person. However, many providers felt SO/GI was not relevant in most clinical circumstances because similar care is provided to all patients regardless of SO/GI. Patients and providers agreed there are risks associated with collecting SO/GI in the ED. Conclusions: ED clinicians do not perceive routine collection of SO/GI to be medically relevant in most circumstances. However, patients feel routine SO/GI collection allows for recognition of individual identity and improved therapeutic relationships in the ED. These discordant perspectives may be hindering patient-centred care, especially for sexual and gender minority patients

Educating the surgeon-scientist: A qualitative study evaluating challenges and barriers toward becoming an academically successful surgeon

Background: The advancement of surgical science relies on educating new generations of surgeon-scientists. Career development awards (K Awards) from the National Institutes of Health, often considered a marker of early academic success, are one way physician-scientists may foster skills through a mentored research experience. This study aimed to develop a conceptual framework to understand institutional support and other factors leading to a K Award.Methods: A national, qualitative study was conducted with academic surgeons. Participants included 15 K Awardees and 12 surgery department Chairs. Purposive sampling ensured a diverse range of experiences. Semistructured, in-depth telephone interviews were conducted. Interviews were audio recorded and transcribed verbatim, and 2 reviewers analyzed the transcripts using Grounded Theory methodology.Results: Participants described individual and institutional factors contributing to success. K Awardees cited personal factors such as perseverance and team leadership skills. Chairs described the K Awardee as an institutional investment requiring protected time for research, financial support, and mentorship. Both K Awardees and Chairs identified a number of challenges unique to the surgeon-scientist, including financial strains and competing clinical demands.Conclusion: Institutional support for surgeons pursuing K Awards is a complex investment with significant initial costs to the department. Chairs act as stewards of institutional resources and support those surgeon-scientists most likely to be successful. Although the K Award pathway is one way to develop surgeon-scientists, financial burdens and challenges may limit its usefulness. These findings, however, may better prepare young surgeons to develop career plans and identify new mechanisms for academic productivity

Risks, benefits, and importance of collecting sexual orientation and gender identity data in healthcare settings: A multi-method analysis of patient and provider perspectives

Purpose: Research suggests that LGBT populations experience barriers to healthcare. Organizations such as the Institute of Medicine recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare, to reduce LGBT disparities. We explore patient views regarding the importance of SO/GI collection, and patient and provider views on risks and benefits of routine SO/GI collection in various settings.Methods: We surveyed LGBT/non-LGBT patients and providers on their views on SO/GI collection. Weighted data were analyzed with descriptive statistics; content analysis was conducted with open-ended responses.Results: One-half of the 1516 patients and 60% of 429 providers were female; 64% of patients and 71% of providers were White. Eighty percent of providers felt that collecting SO data would offend patients, whereas only 11% of patients reported that they would be offended. Patients rated it as more important for primary care providers to know the SO of all patients compared with emergency department (ED) providers knowing the SO of all patients (41.3% vs. 31.6%; P \u3c 0.001). Patients commonly perceived individualized care as an SO/GI disclosure benefit, whereas providers perceived patient-provider interaction improvement as the main benefit. Patient comments cited bias/discrimination risk most frequently (49.7%; N = 781), whereas provider comments cited patient discomfort/offense most frequently (54.5%; N = 433).Conclusion: Patients see the importance of SO/GI more in primary care than ED settings. However, many LGBT patients seek ED care due to factors including uninsurance; therefore, the ED may represent an initial point of contact for SO/GI collection. Therefore, patient-centered approaches to collecting SO/GI are needed. Patients and providers differed in perceived risks and benefits to routine SO/GI collection. Provider training in LGBT health may address patients\u27 bias/discrimination concerns, and ultimately reduce LGBT health disparities

Risks, Benefits, and Importance of Collecting Sexual Orientation and Gender Identity Data in Healthcare Settings: A Multi-Method Analysis of Patient and Provider Perspectives

Purpose: Research suggests that LGBT populations experience barriers to healthcare. Organizations such as the Institute of Medicine recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare, to reduce LGBT disparities. We explore patient views regarding the importance of SO/GI collection, and patient and provider views on risks and benefits of routine SO/GI collection in various settings.Methods: We surveyed LGBT/non-LGBT patients and providers on their views on SO/GI collection. Weighted data were analyzed with descriptive statistics; content analysis was conducted with open-ended responses.Results: One-half of the 1516 patients and 60% of 429 providers were female; 64% of patients and 71% of providers were White. Eighty percent of providers felt that collecting SO data would offend patients, whereas only 11% of patients reported that they would be offended. Patients rated it as more important for primary care providers to know the SO of all patients compared with emergency department (ED) providers knowing the SO of all patients (41.3% vs. 31.6%; P \u3c 0.001). Patients commonly perceived individualized care as an SO/GI disclosure benefit, whereas providers perceived patient-provider interaction improvement as the main benefit. Patient comments cited bias/discrimination risk most frequently (49.7%; N = 781), whereas provider comments cited patient discomfort/offense most frequently (54.5%; N = 433).Conclusion: Patients see the importance of SO/GI more in primary care than ED settings. However, many LGBT patients seek ED care due to factors including uninsurance; therefore, the ED may represent an initial point of contact for SO/GI collection. Therefore, patient-centered approaches to collecting SO/GI are needed. Patients and providers differed in perceived risks and benefits to routine SO/GI collection. Provider training in LGBT health may address patients\u27 bias/discrimination concerns, and ultimately reduce LGBT health disparities

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma

While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23–0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference −0.64 [-1.10 to −0.18]) and face (AIS mean difference −0.49 [-0.71 to −0.27]); and facial fracture (OR 0.26 [0.15–0.46]). Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity. [Display omitted] •Full-face helmets significantly reduce traumatic brain injury.•Full-face helmets significantly reduce facial fracture.•Full-face helmets reduce severity of head, neck, and facial injury