Data, Data Everywhere: But Not a Drop to Analyze

Heena Santry, M.D., M.S. will discuss the challenges she faced as a researcher in converting two decades worth of trauma registry data into usable form for analysis. Dr. Santry is Assistant Professor of Surgery and Quantitative Health Sciences where she also serves as Director of Trauma Outcomes Research and Quality Assessment. She is also a UMass Clinical Research Scholar funded through the CTSA

2010 K12 Awardees: Overview of Research Projects

Two UMCCTS Clinical Research Scholars (K awardees) describe their research projects and professional growth as junior faculty: - Sarah Cutrona on Electronic Transmission of Health Information across Networks - Heena Santry on Career Development for an Academic Acute Care Surgeon and Acute Care Surgery Practice Patterns: A Tale of Two Complexitie

Does Aeromedical Transport Increase Anything Else Besides The Cost Of Care For Trauma Patients?

INTRODUCTION: Unlike many other interventions for trauma, the utilization of transport services are directly impacted by environmental factors such as geography and weather. The previous literature on aeromedical transport for trauma patients has not accounted for the variability in patient selection based on these factors. Furthermore, travel distances for aeromedical transport are rarely accounted for when trying to address this controversial topic. We undertook this study to determine whether helicopter transport imparted a survival benefit. METHODS: Our institution’s trauma registry was queried from January 1, 2000 to December 31, 2010 for adult patients (≥15yrs of age) transported directly from the scene of injury to our level one trauma center in central New England. Cohorts were designated ‘AIR’ if transported by helicopter and ‘GROUND’ if by ground EMS vehicles. A multivariable logistic regression model for mortality was constructed. In order to account for the travel time a patient would have been subject to if transported by ground, we included a co-variate for network bands in our model. Network bands were generated by 5-min increments, using Maptitude geographic information systems software that measure predicted time of travel based on available roadways and traffic patterns, as shown in figure 1. RESULTS: There were 3,615 patients who met inclusion criteria on these days. 1,281 (35%) were assigned to the AIR cohort and 2,334 (65%) were assigned to the GROUND cohort. Multivariable analyses of mortality showed that neither mode of transport nor the distance traveled were independent predictors of mortality. However, intubation status, presence of abnormal systolic blood pressure at the time of presentation to the trauma center, age, ISS, AIS and RTS were all independent predictors of mortality. CONCLUSION: There was no survival benefit for patients transported by helicopter in this study

Gastrointestinal Perforations: Examining the Overlooked Unintentional Consequences of Our Nation’s Epidemic of Antibiotic Exposure

Objective: More than 266 million courses of antibiotics are dispensed to outpatients annually in the US, with the rising elderly population consuming a substantial number of antibiotics. At least 30% of these antibiotics prescribed are unnecessary. Alterations in gut microbiome are known to cause stomach and small intestine (SSI) perforations. However, the impact of antibiotic exposure outcomes of SSI perforations among the elderly has not been studied. We examined the relationship between antibiotic exposure, as a proxy for microbiome modulation, and SSI perforation outcomes in a nationwide sample of elderly patients. Methods: A 5% random sample of Medicare beneficiaries (2009-2011) was queried to identify patients with SSI perforations. Previous outpatient antibiotic exposure (0-30, 31-60, 61-90 days prior to admission) was assessed. Clinical characteristics were compared between no previous antibiotic exposure (NPA) and previous antibiotic exposure (PA) patients. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay and 30-day readmission. Univariate and multivariable regression analyses were performed. Results: Overall, 401 patients ≥ 65 years had SSI perforations (68.3% with NPA and 31.7 % with PA). Mean age (± SD) was 80 years (± 8). Overall in-hospital mortality was 13%. There was a significant difference in the rates of mortality (12% in NPA vs. 18 % in 0-30 days PA, 17% 31-60 days PA, and 8% 61-90 days PA, P= 0.002). After adjustment of other factors, a trend toward increased in-hospital mortality was observed among patients in 0-30 days PA (odds ratio [OR] 2.0, 95% confidence interval [CI] (0.9, 4.7) and was significantly associated with ICU admission (OR 4.3, 95% CI (1.8, 10.2). Conclusion: Recent antibiotic use increases illness severity and may increase mortality among elderly patients with SSI perforations. Exposure to antibiotics, one of the most modifiable determinants of microbiota, should be minimized in the outpatient setting

Utilization and Outcomes of Patients with Colorectal Cancer Liver Metastases in the Medicare Population

Aggressive treatment of colorectal liver metastases (CRLM) after colectomy is increasing in the last two decades with reports of improved survival. Multiple treatment options are available for CRLM but their use and utility remains unknown. Methods: Using SEER-Medicare linked database (1991-2005), we identified 7131 patients who had undergone colectomy with CRLM. Demographic, clinical and tumor factors were examined as determinants of therapy. Treatment options consisted of surgery (resection, ablation) or chemotherapy. Univariate and multivariate analyses were performed to determine predictors of overall survival after colectomy. Results:635 patients (8.9%) underwent liver directed surgery defined as either a liver resection (n=495), ablation (n=216) or both (n=76) for CRLM. 322 patients (51%) were female and 313 (49%) were male. 147 patients (23%) were SES 1, 230 patients (36%) were SES 2, and 258 (41%) were SES 3. There was a survival advantage to receiving liver surgery or chemotherapy in selected patients with CRLM (p Conclusion: In the Medicare population, patients with CRLM who receive potentially curative therapy such as resection, ablation or chemotherapy experience a substantial survival advantage; despite this only 8.9% of patients received directed therapy for their metastasis. Barriers to treatment and its underutilization must be identified to improve survival in patients diagnosed with CRLM after colectomy

Contemporary Analysis of Malignancies in Women of Child-Bearing Age: An NSQIP Analysis

Background: Recent evidence suggests that cancer incidence among pregnant women is increasing. The pattern of malignancies in pregnant women and how these compare to their nonpregnant counterparts has not been explored. Here we describe the differences in the proportion of resected malignancies in this population. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify women aged 18-49 who underwent an operation for malignancy from 2007-2012. Age-adjusted distribution of specific surgical interventions for malignancy based on ICD-9 codes were compared among pregnant and non-pregnant women using logistic regression analysis. Results: 42,732 subjects with malignancies surgically treated during child-bearing age were identified. 0.33% (n=143) were pregnant. The most common tumors requiring resection were breast (51%), thyroid (17%), and colorectal (9%). The distribution for most cancers was similar between groups. The age-adjusted proportion was significantly increased in breast, major salivary gland and oropharyngeal malignancies (p\u3c0.05). The proportion of resected colorectal cancers was significantly lower in pregnant women (p\u3c0.05; Table 1). Conclusion: This study serves as the first comprehensive and contemporary overview of malignancies resected in women of childbearing age. This study demonstrates that the proportion of resections among pregnant women was significantly greater in breast, major salivary gland and oropharyngeal cancers and lower for colorectal cancers. While these data might represent true differences in cancer incidence, further work is necessary to demonstrate if these are true differences in incidence versus differences in detection and treatment of the pregnant patient

Endemic Gallbladder Cancer: Is There a Role for Prophylactic Cholecystectomy?

Background: Gallbladder cancer (GBC) is an often lethal malignancy with variable distribution. Incidence in the United States is low. However, in areas of Central/South America, Central Europe, Japan, and the Indian subcontinent, GBC is a major cause of cancer death. Cholecystectomy is safe and commonly performed worldwide. Thus, prophylactic cholecystectomy (PCCY) has been proposed in regions with endemic GBC. We developed a simple decision model to assist caregivers in determining the optimal strategy for managing GBC based on local incidence and technological capabilities. Methods: Rates of disease and outcomes were derived from a review of the literature. Using TreeAge-Pro software, a decision model was created to simulate expected health outcomes for populations with high GBC incidence, following 3 treatment strategies: no early intervention, one-time screening ultrasound (US), or PCCY. Lifetime cancer-specific survival was the outcome of interest. Sensitivity analyses were performed to determine threshold values. Results: Based on our model, populations where lifetime risk of GBC exceeds 0.4% may benefit from early intervention by US or PCCY. Two-way sensitivity analysis shows that over a relatively narrow range of disease incidence, US may be favored if sensitivity exceeds 50%. In many cases where lifetime risk exceeds 1%, PCCY may improve survival. Conclusions: GBC varies in incidence, but affects many individuals in some populations in the Americas. The lethality of GBC may justify aggressive public health intervention including screening or prophylactic cholecystectomy. Decision analysis models using best-available evidence may help determine the optimal treatment of individuals at risk for GBC

Impact of Pre-Injury Warfarin Use Among Medicare Beneficiaries With Head Trauma

Introduction: The effect of warfarin on outcomes of head injured patients remains controversial. Yet more than 2 million Americans, many of them elderly, are started on warfarin annually. Meanwhile, with the aging US population, elderly Americans are becoming an increasingly large proportion of head injured patients. We studied a national cohort of Medicare beneficiaries with head injuries to determine the effects of pre-injury warfarin on outcomes. Methods: A retrospective review of a 5% random sample of Medicare claims data (2009-2010) was performed for enrollees with at least 1 year of Medicare eligibility. Head injury cases were identified using ICD-9 codes for intracranial hemorrhage with or without accompanying skull fractures. Using Part D prescription drug claims, warfarin exposure was defined as \u3e2 warfarin prescriptions filled within 60 days prior to injury. Characteristics and outcomes (mortality, length of stay (LOS), ICU LOS) between warfarin users and patients not on warfarin (non-users) were compared using univariate tests of association. Multivariable models adjusting for patient characteristics, concomitant torso injuries/long-bone fractures, and need for ICU care were conducted to measure the independent effect of warfarin on in-hospital mortality. Results: We identified 3,420 head injured patients,6.6% of whom were treated with warfarin. Warfarin users were more likely to be female (74.2%vs.65.6%, p Conclusion: Anticoagulation with warfarin increases risk of mortality after head injury nearly two fold in Medicare beneficiaries even after adjusting for other risk factors. As new, more difficult to reverse, agents are introduced for chronic anticoagulation this problem may be exacerbated. Physicians should exercise caution when initiating chronic anticoagulation in patients over the age of 65

The Rose-Colored Glasses of Geriatric Fall Patients: Inconsistencies Between Knowledge of Risk Factors for and Actual Causes of Falls

Background: Falls are the leading cause of fatal injury, and most common cause of non-fatal trauma, among older adults. We sought to elicit older patient\u27s perspectives on fall risks for the general population as well as contributions to any personal falls to identify opportunities to improve fall education. Methods: Ten patients with a history of falls from inpatient trauma and outpatient geriatric services were interviewed. Transcripts were analyzed independently by five individuals using triangulation and constant comparison (NVivo11, QSR International) to compare fall risks to fall causes. Results: All patients reported that either they (9/10 participants) or someone they knew (8/10) had fallen. Despite this, only two personally worried about falling. Patient perceptions of fall risks fell into seven major themes: physiologic decline (8/10); underestimating limitations (7/10); environmental hazards (7/10), lack of awareness/rushing (4/10), misuse/lack of walking aids (3/10); positional transitions (2/10), and improper footwear (1/10). In contrast, the most commonly reported causes of personal falls were lack of awareness/rushing (7/10), environmental hazards (3/10), misuse/lack of walking aids (2/10), improper footwear (2/10), physiologic decline (2/10), underestimating limitations (1/10) and positional transitions (1/10). In general tended to attribute their own falls to their surroundings and were less likely to attribute physical or psychological limitations. Conclusion: Despite participants identifying falls as a serious problem, they were unlikely to worry about falling themselves. Participants were able to identify common fall risks. However, when speaking about personal experience, they were more likely to blame environmental hazards or rushing, and minimized the role of physiologic decline and personal limitations

Rates of Insurance for Injured Patients before and after Health Care Reform in Massachusetts: Another Case of Double Jeopardy?

Background: As a result of healthcare reform (HCR), insurance rates among Massachusetts (MA) residents increased from 86.6% (2006) to 94.4% (2010) and conferred a 7.6% higher probability of being insured compared to neighboring states. The effect of an individual mandate on insurance rates among trauma patients is unknown. Methods: This was retrospective analysis of adult (18-64yrs) trauma patients from MA and surrounding states (NH, RI, CT, NY, VT) treated at our level 1 trauma center in central MA before (2004-2005) and after (2009-2010) MA-HCR. We estimated changes in insurance rates across time-periods and state-residence. Results: Before MA-HCR, 76.7% (1647/2,148) of injured MA residents had insurance compared to 84.3% (2088/2477) post-HCR (p Conclusions: In this single center study, time rather than HCR resulted in modest increases in insurance rates. However, MA-HCR was ineffectual at increasing insurance among trauma patients to levels comparable to the general public, suggesting certain factors may place certain subgroups in “double jeopardy” by simultaneously increasing risk of injury and precluding compliance with an individual mandate