Racial and Ethnic Disparities Among Minority Geriatric Trauma Patients in the United States: An Analysis of Data From a National Sample Using the Trauma Quality Improvement Program Database

For this dissertation, I completed three manuscripts with the common overall aim of assessing health disparities among geriatric trauma patients in the U.S. The first manuscript reports on a structured narrative review of the literature comprised of three approaches that ensure comprehensive and targeted research: a scoping review, an exploratory search, and a citation review. The second manuscript is a descriptive analysis of one-year (2016) of data from the American College of Surgeon’s Trauma Quality Improvement Program (ACS-TQIP) with a focus on older adults aged 65 and older who have had an injury. The population was stratified into four groups: Non-Hispanic Whites (NHWs), African Americans, Hispanics, and Other races. For each group, I conducted a simple univariate tabulation for key demographic characteristics and injury-related variables. I also assessed comorbidities, insurance type, and regional differences. Finally, in manuscript three, I performed a one-year analysis of the ACS-TQIP dataset and included all adult trauma patients aged 65 and older who were admitted in 2016. My primary aim was to understand health disparities regarding in-hospital health measures, such as in-hospital mortality, length of stay (LOS), and in-hospital complications. I conducted multivariable regression analysis controlling for age, gender, injury severity, comorbidities, insurance status, calendar year, and type of trauma center. I argue that racial/ethnic disparity exists for GTPs in terms of in-hospital mortality, in-hospital complications, and LOS. Type of injury, severity of injury, and age group are critical predictors of different health outcomes among minority GTPs. Minimizing disparities in GTPs care is crucial to reducing morbidity and mortality. More focused primary research is needed to expand our knowledge of racial/ethnic disparities among GTPs. It is critical that future research stratify each minority group by differences in injury type, injury severity, and age group.Release after 07/16/202

Factors influencing performance by contracted non-state providers implementing a basic package of health services in Afghanistan

Abstract Background In 2002 Afghanistan’s Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan. Methods The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis. Results While some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other. Conclusion Three sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan’s example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries

Developing a National Trauma Research Action Plan (NTRAP): Results from the Geriatric Research Gap Delphi Survey.

BACKGROUND: Treating older trauma patients requires a focus on the confluence of age-related physiological changes and the impact of the injury itself. Therefore, the primary way to improve the care of geriatric trauma patients is through the development of universal, systematic multidisciplinary research. To achieve this, the Coalition for National Trauma Research has developed the National Trauma Research Action Plan that has generated a comprehensive research agenda spanning the continuum of geriatric trauma care from prehospital to rehabilitation. METHODS: Experts in geriatric trauma care and research were recruited to identify current gaps in clinical geriatric research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines ensuring heterogeneity and generalizability. On subsequent surveys, participants were asked to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. The consensus was defined as \u3e60% of panelists agreeing on the priority category. RESULTS: A total of 24 subject matter experts generated questions in 109 key topic areas. After editing for duplication, 514 questions were included in the priority ranking. By Round three, 362 questions (70%) reached 60% consensus. Of these, 161 (44%) were High, 198 (55%) Medium, and 3 (1%) Low priority. CONCLUSIONS: Among the questions prioritized as high priority, questions related to three types of injuries (i.e., rib fracture, traumatic brain injury, and lower extremity injury) occurred with the greatest frequency.Among the 25 highest priority questions, the key topics with the highest frequency were pain management, frailty, and anticoagulation-related interventions. The most common types of research proposed were interventional clinical trials and comparative effectiveness studies, outcome research, and healthcare systems research. LEVEL OF EVIDENCE: IVType of StudyExpert consensus

Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial.

BACKGROUND: The frailty index is a known predictor of adverse outcomes in geriatric patients. Trauma-Specific Frailty Index (TSFI) was created and validated at a single center to accurately identify frailty and reliably predict worse outcomes among geriatric trauma patients. This study aims to prospectively validate the TSFI in a multi-institutional cohort of geriatric trauma patients. METHODS: This is a prospective, observational, multi-institutional trial across 17 American College of Surgeons Levels I, II, and III trauma centers. All geriatric trauma patients (65 years and older) presenting during a 3-year period were included. Frailty status was measured within 24 hours of admission using the TSFI (15 variables), and patients were stratified into nonfrail (TSFI, ≤0.12), prefrail (TSFI, 0.13-0.25), and frail (TSFI, \u3e0.25) groups. Outcome measures included index admission mortality, discharge to rehabilitation centers or skilled nursing facilities (rehab/SNFs), and 3-month postdischarge readmissions, fall recurrences, complications, and mortality among survivors of index admission. RESULTS: A total of 1,321 geriatric trauma patients were identified and enrolled for validation of TSFI (nonfrail, 435 [33%]; prefrail, 392 [30%]; frail, 494 [37%]). The mean ± SD age was 77 ± 8 years; the median (interquartile range) Injury Severity Score was 9 (5-13). Overall, 179 patients (14%) had a major complication, 554 (42%) were discharged to rehab/SNFs, and 63 (5%) died during the index admission. Compared with nonfrail patients, frail patients had significantly higher odds of mortality (adjusted odds ratio [aOR], 1.93; p = 0.018), major complications (aOR, 3.55; p \u3c 0.001), and discharge to rehab/SNFs (aOR, 1.98; p \u3c 0.001). In addition, frailty was significantly associated with higher adjusted odds of mortality, major complications, readmissions, and fall recurrence at 3 months postdischarge ( p \u3c 0.05). CONCLUSION: External applicability of the TSFI (15 variables) was evident at a multicenter cohort of 17 American College of Surgeons trauma centers in geriatric trauma patients. The TSFI emerged as an independent predictor of worse outcomes, both in the short-term and 3-month postdischarge. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III