Ogola G.O.,Baylor Scott and White Health |
Gale S.C.,East Texas Medical Center |
Haider A.,Brigham and Women's Hospital |
Shafi S.,Baylor Scott and White Health
Journal of Trauma and Acute Care Surgery | Year: 2015
BACKGROUND Adoption of the acute care surgery model has led to increasing volumes of emergency general surgery (EGS) patients at trauma centers. However, the financial burden of EGS services on trauma centers is unknown. This study estimates the current and future costs associated with EGS hospitalization nationwide. METHODS We applied the American Association for the Surgery of Trauma's DRG International Classification of Diseases - 9th Rev. criteria for defining EGS to the 2010 National Inpatient Sample (NIS) data and identified adult EGS patients. Cost of hospitalization was obtained by converting reported charges to cost using the 2010 all-payer inpatient cost-to-charge ratio for all hospitals in the NIS database. Cost was modeled via a log-gamma model in a generalized linear mixed model to account for potential correlation in cost within states and hospitals in the NIS database. Patients' characteristics and hospital factors were included in the model as fixed effects, while state and hospital were included as random effects. The national incidence of EGS was calculated from NIS data, and the US Census Bureau population projections were used to estimate incidence for 2010 to 2060. Nationwide costs were obtained by multiplying projected incidences by estimated costs and reported in year 2010 US dollar value. RESULTS Nationwide, there were 2,640,725 adult EGS hospitalizations in 2010. The national average adjusted cost per EGS hospitalization was $10,744 (95% confidence interval [CI], $10,615-$10,874); applying these cost data to the national EGS hospitalizations gave a total estimated cost of $28.37 billion (95% CI, $28.03-$28.72 billion). Older age groups accounted for greater proportions of the cost ($8.03 billion for age ≥ 75 years, compared with $1.08 billion for age 18-24 years). As the US population continues to both grow and age, EGS costs are projected to increase by 45% to $41.20 billion (95% CI, $40.70-$41.7 billion) by 2060. CONCLUSION EGS constitutes a significant portion of US health care costs and is expected to rise with the demographic changes in the population. Trauma centers should conduct careful financial analyses of their EGS services, based on their unique case mix and payer mix. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Keilani Z.M.,Ochsner Clinic Foundation |
Berne J.D.,East Texas Medical Center |
Agko M.,University of Toledo
Journal of Vascular Surgery | Year: 2010
Blunt cerebrovascular injuries, defined as blunt injuries to the internal carotid or vertebral arteries, are uncommon and usually occur in victims of high-speed deceleration motor vehicle crashes. A blunt cerebrovascular injury after an equestrian accident is an extremely unusual presentation. In recent years, advances in screening and treatment with pharmacologic anticoagulation before the onset of neurologic symptoms have improved outcomes for these patients. Endovascular stenting and embolization, although unproven, offer a new potential approach for these complex injuries. We present a unique case of four-vessel blunt cerebrovascular injuries after a horse-riding injury that required multidisciplinary management. Copyright © 2010 Published by Elsevier Inc.
Nouri K.H.,University of Houston |
Brish E.L.,East Texas Medical Center
Pain Medicine | Year: 2011
Objective. We report a case of malignancy-related testicular pain successfully treated by placement of spinal cord stimulator electrodes. Effective analgesia was provided by epidural lead placement over the dorsal columns. The rationale for our technique was based on contemporary understanding of spinal cord stimulation mechanism in conjunction with analysis of our patient's anatomical lesion location. Case Report. A 57-year-old man with a history of prostate carcinoma status post a radical retropubic prostatectomy presented to our clinic with a 2-year history of progressive burning and stabbing left scrotal and inguinal pain. Given his inability to tolerate opioid analgesics, he underwent ilioinguinal, iliohypogastric, and ganglion impar nerve blocks, which relieved his inguinal pain. His testicular pain nevertheless persisted, and he therefore underwent a successful dual-lead trial of spinal cord stimulation prompting a permanent implant. Outcome Measures. Patient's responses to the visual analog scale (VAS) were collected at 10 time points over the course of 2 years under two conditions: no stimulation and dual-lead stimulation. Results. Our patient's VAS questionnaire responses indicate a sustained 80% decrease of pain at 6 weeks status post-permanent spinal cord stimulator implant with self-reported increase of function at work and complete weaning off oral analgesics. Conclusions. Testicular pain may be difficult to treat particularly in patients unable to tolerate opioid analgesics. In cases that have failed conservative therapy, a trial of spinal cord stimulation should be explored. Wiley Periodicals, Inc.
Berne J.D.,East Texas Medical Center |
Cook A.,East Texas Medical Center |
Rowe S.A.,East Texas Medical Center |
Norwood S.H.,East Texas Medical Center
Journal of Vascular Surgery | Year: 2010
Introduction: The diagnosis of blunt cerebrovascular injuries (BCVI) has improved with widespread adaptation of screening protocols and more accurate multi-detector computed tomography (MDCT-A) angiography. The population at risk and for whom screening is indicated is still controversial. To help determine which blunt trauma patients would best benefit from screening we performed a comprehensive analysis of risk factors associated with BCVI. Methods: All patients with BCVI from June 12, 2000 (the date at which our institution began screening for these injuries) to June 30, 2009 were identified by the primary author (JDB) and recorded in a prospective database. Associated injuries were identified retrospectively by International Classification of Diseases, Ninth Revision (ICD-9) code and compared with similar patients without BCVI. Demographic information was also compared from data obtained from the trauma registry. Univariate analyses exploring associations between individual risk factors and BCVI were performed using Fisher's exact test for dichotomous variables and Student's t test for continuous variables. Additionally, relative risk (RR) was calculated for dichotomous variables to describe the strength of the relationship between the categorical risk factors and BCVI. Multivariate logistic regression models for BCVI, BCAI (blunt internal carotid artery injury), and BVAI (blunt vertebral artery injury) were developed to explore the relative contributions of the various risk factors. Results: One hundred two patients with BCVI were identified out of 9935 blunt trauma patients admitted during this time period (1.03% incidence). Fifty-nine patients (0.59% incidence) had a BVAI and 43 patients (0.43% incidence) had a BCAI. Univariate analysis found cervical spine fracture (CSI) (RR = 10.4), basilar skull fracture (RR = 3.60), and mandible fracture (RR = 2.51) to be most predictive of the presence of BCVI (P < .005). Independent predictors of BCVI on multivariate logistic regression were CSI (OR = 7.46), mandible fracture (OR = 2.59), basilar skull fracture (OR = 1.76), injury severity score (ISS) (OR = 1.05), and emergency department Glasgow Coma Scale (ED-GCS) (OR = 0.93): all P < .05. Conclusions: Blunt trauma patients with a high risk mechanism and a low GCS, high injury severity score, mandible fracture, basilar skull fracture, or cervical spine injury are at high risk for BCVI should be screened with MDCT-A. © 2010 Society for Vascular Surgery.
Cook A.,East Texas Medical Center |
Norwood S.,East Texas Medical Center |
Berne J.,East Texas Medical Center
Journal of Trauma - Injury, Infection and Critical Care | Year: 2010
Background: Ventilator-associated pneumonia (VAP) incidence is used as a quality measure. We hypothesized that patient and provider factors accounted for the higher incidence of VAP in trauma patients compared with other critically ill patients. Methods: We conducted a 2-year study of all intubated adult patients at our Trauma Center. VAP was identified according to the Centers for Disease Control and Prevention definition. Groups were compared for the incidence of VAP and outcomes. Results: The cohort of 2,591 patients included 511 trauma patients and 2,080 nontrauma patients. VAP occurred in 161 patients and more frequently in trauma patients (17.8% vs. 3.4%, p < 0.001). The overall death rate (17.4% vs. 9.8%, p < 0.001) and the death rate for VAP patients (31.4% vs. 11%, p = 0.002) was higher in the nontrauma group. Bronchoalveolar lavage was performed more frequently in the trauma patient group (22.1% vs. 8.9%, p < 0.001), and gram-negative organisms were isolated more commonly in trauma patients (65.9% vs. 30%, p < 0.001), respectively. VAP occurred earlier among the trauma group (mean 8.9 days vs. 14.1 days, p < 0.001). Trauma represented an odds ratio of 3.9 (95% confidence interval 2.4-6.3, p < 0.001) for the development of VAP. Conclusion: The incidence of VAP is greatest among trauma patients at our institution. The increased use of bronchoalveolar lavage, the earlier onset of VAP, and the higher incidence of gram-negative pneumonias suggest that both patient and provider factors may influence this phenomenon. VAP was associated with increased mortality in the nontrauma group only. These factors should be considered before VAP is applied as a quality indicator. Copyright © 2010 by Lippincott Williams & Wilkins.
Klein S.M.,Gundersen Lutheran Hospital |
Badman B.L.,AP and S Clinic |
Keating C.J.,Foundation for Orthopaedic Research and Education |
Devinney D.S.,East Texas Medical Center |
And 2 more authors.
Journal of Shoulder and Elbow Surgery | Year: 2010
Hypothesis: Delayed surgical treatment of unstable distal clavicle fractures is associated with a higher complication rate. Materials and methods: Between 1998 and 2008, a retrospective study of 38 patients (average age, 42.9 year) with Neer type II clavicular fractures was performed. Fractures were treated with a hook-plate (22 patients) or with superior locked plate with suture augmentation (16 patients). Patients were divided into acute (27 patients) or delayed (11 patients) treatment groups based on the timing of surgical intervention before or after 4 weeks. All had clinical and radiographic follow-up for 1 year or until fracture union. Results: Union was achieved in 36 of 38 patients (94.7%). The acute treatment group had an average American Shoulder and Elbow Surgeons score of 77.9 compared with 65.0 in the delayed group. Six complications occurred (15.8%) including 2 infections (5.3%), 1 hardware failure (2.6%), and 3 peri-implant fractures (7.9%). The complication rate was 36.4% in the delayed group vs 7.4% in the acutely treated group (P = .047). Discussion: A high rate of union was observed in all cases regardless of timing or method of fixation. Despite a high rate of union, the results of treatment in the delayed group were more problematic. Patients treated with a hook-plate in a delayed fashion had more complications than those treated in an acute fashion (P = .039). Peri-implant fractures occurred only in patients treated with hook-plates. Conclusion: Surgical timing played a critical role in the outcome and complication rate in treatment of unstable distal third clavicle fractures. © 2010.
Walker J.P.,East Texas Medical Center |
Morrison R.L.,East Texas Medical Center
Journal of the American College of Surgeons | Year: 2011
Background: Several thousand snakebites occur annually in the US, but fewer than 10 deaths occur. Most deaths are from envenomations by rattlesnakes (Crotalus species), but deaths from copperhead and water moccasin (Agkistrodon species) are rare. Study Design: All snakebites presented to East Texas Medical Center, Crockett, a level III trauma center, from 1995 to 2010 were reviewed. A total of 142 snakebites were treated. Ninety-four were of the Agkistrodon species-contortrix contortrix (copperhead) or piscivorus leukostoma (water moccasin). Three were rattlesnakes, and 3 were from the Texas coral snake (Micrurus fulvius tener). Forty-two were unidentified pit vipers. The following results are of the 88 copperhead bites. Results: The most common presenting symptoms were pain and swelling. Eighty-five percent were of grade 1 envenomations. Ten patients had laboratory abnormalities secondary to the snakebite. Forty-four were admitted for observation. The average length of stay for patients admitted was 2 days. No patients received antivenom, and no patients required surgical intervention. There were no deaths. One patient had edema and ecchymosis that persisted for more than 1 month. Conclusions: Accurate identification of the pit viper species involved in snakebites is essential. Although envenomation by a rattlesnake (Crotalus species) may require antivenom and uncommonly surgery, a bite by a copperhead (Agkistrodon contortrix) rarely requires any intervention other than observation. The unnecessary use of antivenom should be discouraged. © 2011 American College of Surgeons.
Gale S.C.,East Texas Medical Center |
Shafi S.,Baylor Research Institute |
Dombrovskiy V.Y.,Rutgers Robert Wood Johnson Medical School |
Arumugam D.,Rutgers Robert Wood Johnson Medical School |
Crystal J.S.,Rutgers Robert Wood Johnson Medical School
Journal of Trauma and Acute Care Surgery | Year: 2014
BACKGROUND: Emergency general surgery (EGS) represents illnesses of very diverse pathology related only by their urgent nature. The growth of acute care surgery has emphasized this public health problem, yet the true "burden of disease" remains unknown. Building on efforts by the American Association for the Surgery of Trauma to standardize an EGS definition, we sought to describe the burden of disease for EGS in the United States. We hypothesize that EGS patients represent a large, diverse, and challenging cohort and that the burden is increasing. METHODS: The study population was selected from the Nationwide Inpatient Sample, 2001 to 2010, using the AAST EGS DRG International Classification of Diseases - 9th Rev. codes, selecting all EGS patients 18 years or older with urgent/emergent admission status. Rates for operations, mortality, and sepsis were compiled along with hospital type, length of stay, insurance, and demographic data. The χ test, the t test, and the Cochran-Armitage trend test were used; p < 0.05 was significant. RESULTS: From 2001 to 2010, there were 27,668,807 EGS admissions, 7.1% of all hospitalizations. The population-adjusted case rate for 2010 was 1,290 admissions per 100,000 people (95% confidence interval, 1,288.9-1,291.8). The mean age was 58.7 years; most had comorbidities. A total of 7,979,578 patients (28.8%) required surgery. During 10 years, admissions increased by 27.5%; operations, by 32.3%; and sepsis cases, by 15% (p < 0.0001). Mortality and length of stay both decreased (p < 0.0001). Medicaid and uninsured rates increased by a combined 38.1% (p < 0.0001). Nearly 85% were treated in urban hospitals, and nearly 40% were treated in teaching hospitals; both increased over time (p < 0.0001). CONCLUSION: The EGS burden of disease is substantial and is increasing. The annual case rate (1,290 of 100,000) is higher than the sum of all new cancer diagnoses (all ages/types): 650 per 100,000 (95% confidence interval, 370.1-371.7), yet the public health implications remain largely unstudied. These data can be used to guide future research into improved access to care, resource allocation, and quality improvement efforts. LEVEL OF EVIDENCE: Epidemiologic study, level III. © 2014 Lippincott Williams & Wilkins.
Shankar S.,Ochsner Clinic Foundation |
Rowe S.,East Texas Medical Center
Ochsner Journal | Year: 2011
Background: Splenic injury as a result of colonoscopy is rare but may be underreported and cases may remain undetected. Methods: Review of the literature and analysis of 93 cases, including a new case report. Results: Neither a history of abdominal surgery nor performance of a biopsy seems related to an increased incidence of splenic injury. However, a number of colonoscopy-related factors, such as difficulty intubating, looping of the instrument, and traction on the splenocolic ligament, lead to capsular avulsions and lacerations of the spleen. In addition, excess external pressure on the left hypochondrium can simulate blunt trauma, and other maneuvers can increase traction at the splenic flexure. In the majority of cases, symptoms develop within 24 hours of the colonoscopy. Computed tomography scan provides the most sensitive and specific method of diagnosis. Conclusion: The number of colonoscopies continues to increase with the aging population, increasing the potential number of associated splenic injuries. The physician needs to have a high index of suspicion when a patient presents after colonoscopy with abdominal pain associated with hemody-namic instability. Abdominal pain within 24 hours is the most reliable indicator and requires further workup and monitoring. Persistent hemodynamic instability mandates operative management. © Academic Division of Ochsner Clinic Foundation.
Matsushima K.,Pennsylvania State University |
Cook A.,East Texas Medical Center |
Tollack L.,University of Texas Southwestern Medical Center |
Shafi S.,Baylor University |
Frankel H.,Pennsylvania State University
Journal of Surgical Research | Year: 2011
Background: The impact by integration of emergency general surgery (EGS) with trauma in an acute care surgery model on the timeliness and quality of care in patients of each type at a high volume level I trauma center is still indeterminate. We hypothesized that trauma and EGS can be successfully integrated in an academic institution. Methods: Retrospective review of prospectively collected trauma/EGS database was conducted at a high-volume, urban academic level I trauma center. Patients admitted to or requested consultation from trauma and EGS services were included. We explored the covariates affecting time to operating room (TOR), morbidity and in-hospital mortality rate. Results: There were 1794 trauma patients and 1565 EGS patients identified over a 6-month period. Linear regression models failed to demonstrate a correlation between TOR and surgical team workload (WL), injury severity score (ISS), and caseload for the operating room staff and facility. While lower TOR, Glasgow coma scale, ISS and age were associated with an increased likelihood of complications, WL did not correlate with the occurrence of complications. TOR and surgical team WL had no association with death in trauma patients. The occurrence of complications was associated with a nearly 8-fold increase in the risk of death (odds ratio 7.56, 95% confidence interval [CI] 1.49-39.32, P = 0.02). Conclusion: Increased workload during combined trauma/EGS call in an acute care surgery model did not affect the TOR nor worsen patient outcome. Implementation of a trauma/EGS model is justified even in high-volume academic institutions, if appropriately staffed and resourced. © 2011 Elsevier Inc. All rights reserved.