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Summary: Background: Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri‐operative frailty with mortality, 30‐day readmission and days at home after non‐cardiac surgical procedures of different physiological stress. Methods: This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee‐for‐service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non‐cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims‐based frailty index (robust, < 0.15; pre‐frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate‐to‐severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all‐cause mortality at 30 days and 365 days after the surgical procedure. Results: In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate‐to‐severe frailty vs. robust ranged from 1.59–3.91) and at 365 days (hazard ratio 1.30–4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category. Conclusions: These results emphasise routine frailty screening before major and minor non‐cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision‐making with older adults with frailty. [ABSTRACT FROM AUTHOR]

Background: To assess performance of the American College of Surgeons Geriatric Surgery Verification (GSV) Program preoperative communication standards in older patients undergoing high risk spine surgery. Methods: We performed an external validation of a natural language processing (NLP) method for identifying documentation meeting GSV communication standards. We then applied this method to a retrospective cohort of patients aged 65 and older who underwent spinal fusion procedures between January 2018–December 2020 in a large healthcare system in Massachusetts. Our primary outcome of interest was fulfillment of GSV communication domains: overall health goals, treatment goals, and patient‐centered outcomes. Factors associated with the fulfillment of at least one domain were assessed using Poisson regression to adjust for confounding. Results: External validation of the NLP method had a sensitivity of 88.6% and specificity of 99.0%. Our study population included 1294 patients, of whom only 0.8% (n = 10) patients contained documentation of all three GSV domains, and 33.7% (n = 436) had documentation fulfilling at least one GSV domain. The GSV domain with lowest frequency of documentation was overall health goals, with only 35 (2.7%) of patients meeting this requirement. Adjusted analysis suggested that patients with a Charlson comorbidity score of one or more had higher fulfillment of GSV criteria (CCI 1–3: prevalence rate ratio (PRR) 1.8, 95% confidence interval (CI) 1.5–2.1; CCI >3: PRR 1.5, 95% CI 1.2–1.9). Conclusion: A paucity of geriatric patients undergoing spine surgery had preoperative documentation consistent with GSV standards. Given that spine surgery is one of the highest risk surgeries in older adults and GSV standards are relevant to all surgical specialties, wider promulgation of these standards is warranted. [ABSTRACT FROM AUTHOR]

Palliative surgical procedures are operations that aim to alleviate symptoms in a patient with serious, life-limiting illness. They are common, particularly within the field of surgical oncology. However, few high-quality studies have attempted to measure the durability of improvements in symptoms and quality of life after palliative surgery. Furthermore, many of the studies that do exist are outdated and employ highly inconsistent definitions of palliative surgery. Consequently, the paucity of robust and reliable evidence on the benefits, risks, and trade-offs of palliative surgery hampers clinical decision-making for patients and their surgeons. The evidence for palliative surgery suggests that, with effective communication about goals of care and careful patient selection, palliative surgery can provide symptomatic relief and reduce healthcare burdens for certain seriously ill patients. Despite its prevalence, palliative surgery has not been clearly defined in the existing literature. Research exploring the benefits and trade-offs of operations performed with palliative intent is needed to determine which patients benefit from palliative surgery. [ABSTRACT FROM AUTHOR]

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI. [ABSTRACT FROM AUTHOR]

Background: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. Methods: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. Results: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. Conclusions: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Background: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. Methods: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Results: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. Conclusions: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies. [ABSTRACT FROM AUTHOR]

Introduction: Serious illness is a life‐limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes. Methods: Using Health and Retirement Study data (2008–2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES‐D < 3, or yes, CES‐D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in‐hospital outcomes, including hospital days (days admitted between discharge date and one‐year post‐discharge), in‐hospital complications (no or yes), and discharge destination (home or non‐home). Results: Of the 1343 patients, 55.0% were female and 81.6% were non‐Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre‐admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non‐home discharge (OR 1.6, 95% CI 1.2–2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in‐hospital or post‐acute outcomes in multivariable analysis. Conclusions: Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter. [ABSTRACT FROM AUTHOR]

Introduction: Increasing numbers of individuals admitted to hospitals for trauma are older adults, many of whom also have underlying serious illnesses. Older adults with serious illness benefit from palliative care, but the palliative care needs of seriously ill older adults with trauma have not been elucidated. We hypothesize that older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours before trauma admission. Methods: Using Health and Retirement Study data (2008–2018) linked to Medicare claims, we identified patients 66 years or older who met an established definition of serious illness in surgery and were admitted with trauma. Descriptive analyses were performed for baseline patient characteristics, pre‐admission pain (dichotomized as none/mild vs. moderate/severe), depression (dichotomized as no, Center for Epidemiologic Studies Depression scale [CES‐D] < 3 vs. yes, CES‐D ≥ 3), and unpaid caregiving hours (dichotomized as low (<30 h/month), high (≥30 h/month)). Results: We identified 1741 patients, 67.4% were female and 86.8% White. Mean age was 83 (SD 7.5), and 60.3% had ≥4 comorbidities. The majority (62.9%) were admitted due to falls, 33.5% had isolated hip fracture. The prevalence of baseline moderate/severe pain and depression were 38.1% and 42.6%, respectively. Among the cohort, 42.2% had unpaid caregiving, of those 27.7% had ≥30 h/week of unpaid caregiving hours. Conclusions: Prior to trauma admission, older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours. These findings may inform targeted palliative care interventions to reduce symptom burden and post‐discharge healthcare utilization. [ABSTRACT FROM AUTHOR]

Background: Elder abuse is a major cause of injury, morbidity, and death. We aimed to identify the factors associated with interventions against suspected physical abuse in older adults. Methods: Analysis of the 2017–2018 ACS TQIP. All trauma patients ≥60 years with an abuse report for suspected physical abuse were included. Patients with missing information on abuse interventions were excluded. Outcomes were rates of abuse investigation initiation following an abuse report and change of caregiver at discharge among survivors with an abuse investigation initiated. Multivariable regression analyses were performed. Results: Of 727,975 patients, 1405 (0.2%) had an abuse report. Patients with an abuse report were younger (mean, 72 vs 75, p < 0.001), and more likely to be females (57% vs 53%, p = 0.007), Hispanic (11% vs 6%, p < 0.001), Black (15% vs 7%, p < 0.001), suffer from dementia (18% vs 11%, p < 0.001), functional disability (19% vs 15%, p < 0.001), have a positive admission drug screen (9% vs 5%, p < 0.001) and had a higher ISS (median [IQR], 9 [4–16] vs 6 [3–10], p < 0.001). Perpetrators were members of the immediate/step/extended family in 91% of cases. Among patients with an abuse report, 1060 (75%) had abuse investigations initiated. Of these, 227 (23%) resulted in a change of caregiver at discharge. On multivariate analysis for abuse investigation initiation, male gender, private insurance, and management at non‐level I trauma centers were associated with lower adjusted odds (p < 0.05), while Hispanic ethnicity, positive admission drug screen, and penetrating injury were associated with higher adjusted odds (p < 0.05). On multivariate analysis for change of caregiver, male gender, and private insurance were associated with lower adjusted odds (p < 0.05), while functional disability and dementia were associated with higher adjusted odds (p < 0.05). Conclusions: Significant gender, ethnic, and socioeconomic disparities exist in the management of physical abuse of older adults. Further studies are warranted to expand on and address the contributing factors underlying these disparities. Level of Evidence: III. Study Type: Therapeutic/Care Management. [ABSTRACT FROM AUTHOR]

Background: The American College of Surgeons Geriatric Surgery Verification Program outlines best practices for surgical care in older adults. These recommendations have guided institutions to create workflows to better support needs specific to older surgical patients. This qualitative study explored clinician experiences to understand influences on implementation of frailty screening and an interdisciplinary care pathway in older elective colorectal surgery and neurosurgery patients. Study Design: Semi‐structured in‐person and video‐based interviews were conducted from July 2021 to March 2022 with clinicians caring for patients ≥70 years on the colorectal surgery and neurosurgery services. Interviews addressed familiarity with and beliefs about the intervention, intervention alignment with routine workflow and workflow adaptations, and barriers and facilitators to performing the intervention. Interviews were analyzed using the consolidated framework for implementation research (CFIR) to find themes related to ongoing implementation. Results: Thirty‐two clinicians participated (56.3% female, 58.8% White). Fifteen relevant CFIR constructs were identified. Key themes to implementation success included strong participant belief in effectiveness of the intervention and its advantage over standard care; the importance of training, reference materials, and champions; and the need for institution‐level investment in resources to amplify the impact of the intervention on patients and expand the capacity to address their needs. Conclusion: Systematic evaluation found implementation of frailty screening and an interdisciplinary care pathway in elective colorectal surgery and neurosurgery patients to be supported by participating clinicians, yet sustainability of the intervention and further adoption across surgical services to better meet the needs of older patients would necessitate organizational resource allocation. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to examine the relationship between duration of surgical intervention and postoperative complications in radical cystectomy (RC). We hypothesized that the complication rate increases with longer operative time. Methods: We analyzed the National Surgical Quality Improvement Program database 2011–2017 to identify all patients who underwent RC. Clinicodemographic characteristics, operative time, and perioperative complications using the Clavien-Dindo Classification (CDC) were abstracted. We fit a generalized linear model with linear splines for operative time to analyze if the relationship between operative time and probability of complication changed over time. Results: A total of 10,520 RC patients were identified with a mean operative time of 5.5 h (standard deviation 2.03). In 55% and 18.2%, any complication and major complications (CDC ≥3) occurred within 30 days postoperatively, respectively. The spline regression model for any complication showed an almost linear relationship between the complication rate and operative time, ranging from 55% at 2.5 h to 82% at 10 h. For major complications, the model revealed the inflection point (knot) at 4.5 h, which corresponds to the lowest complication rate with 15%. Operative times at the extremes of the distribution had higher complication rates: 17.5% if <2.5 h and 28% if >10 h. Discussion/Conclusion: Operative time of RC is associated with postoperative complications. Though many factors impact the duration of surgery, surgeries that lasted between 4 and 5 h had trend toward the lowest complication rates. Attention to factors impacting operative time may allow surgeons to identify strategies for optimizing surgical care and reducing complications after RC. [ABSTRACT FROM AUTHOR]

Background: Despite the well-established benefits of palliative care, little is known about the use of palliative interventions among patients with advanced gastrointestinal (GI) cancer near the end of life (EOL). Methods: A national cohort study analyzed 142,304 patients with advanced GI cancers (stage 3 or 4) near EOL (death within 1 year of diagnosis) in the National Cancer Database (2004–2014) who received palliative interventions (defined as treatment to relieve symptoms: surgery, radiation, chemotherapy, and/or pain management). The study used multivariable hierarchical regression evaluate the association between the use of palliative interventions, temporal trends, and patient and hospital factors. Results: Overall, 16.5% of the patients were treated with a palliative intervention, and use increased over time (13.4% in 2004 vs 19.8% in 2014; trend test, p < 0.001). Palliative interventions were used most frequently for esophageal cancer (20.6%) and least frequently for gallbladder cancer (13.3%). Palliative interventions were associated with younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98–0.99), recent diagnosis year (OR, 1.05; 95% CI, 1.04–1.06), black race (white [ref]; OR, 1.07; 95% CI, 1.01-1.12), insurance status (no insurance [ref]; private: OR, 0.92; 95% CI ,0.95–0.99), hospital type (community cancer program [ref]; integrated network cancer programs: OR, 1.37; 95% CI ,1.07–1.75), and stage 4 disease (OR, 2.17; 95% CI, 2.07–2.27). Patients in southern and western regions were less likely to receive palliative intervention (Northeast [ref]; OR, 0.76; 95% CI, 0.62–0.94 and OR 0.46; 95% CI, 0.37–0.57, respectively). Conclusion: Increased palliative intervention use over time suggests ongoing changes in how care is delivered to GI cancer patients toward EOL. However, sociodemographic and geographic variation suggests opportunities to address barriers to optimal EOL care. [ABSTRACT FROM AUTHOR]

Background: Patients with Alzheimer's Disease and Related Dementias (ADRD) undergoing inpatient procedures represent a population at elevated risk for adverse outcomes including postoperative complications, mortality, and discharge to a higher level of care. Outcomes may be particularly poor in patients with ADRD undergoing high‐risk procedures. We sought to determine traditional (e.g., 30‐day mortality) and patient‐centered (e.g., discharge disposition) outcomes in patients with ADRD undergoing high‐risk inpatient procedures. Methods: This retrospective cohort study analyzed electronic health records linked to fee‐for‐service Medicare claims data at a tertiary care academic health system. All patients from a large multi‐hospital health system undergoing high‐risk inpatient procedures from October 1, 2015 to September 30, 2017 with continuous Medicare Parts A and B enrollment in the 12 months prior to and 90 days following the procedure were included. Results: This study included 6779 patients. 536 (7.9%) had ADRD. A multivariable analysis of outcomes demonstrated higher risks for postoperative complications (OR 1.49, 95% CI 1.23–1.81) and 90‐day mortality (OR 1.44 [95% CI 1.09–1.91]) in patients with ADRD compared to those without. Patients with ADRD were more likely to be discharged to a higher level of care (OR 1.70, 95% CI 1.32–2.18) and only 37.3% of patients admitted from home were discharged to home. Conclusions: Compared to those without ADRD, patients living with ADRD undergoing high‐risk procedures have poor traditional and patient‐centered outcomes including increased risks for 90‐day mortality, postoperative complications, longer hospital lengths of stay, and discharge to a higher level of care. These data may be used by patients, their surrogates, and their physicians to help align surgical decision‐making with health care goals. [ABSTRACT FROM AUTHOR]

Background: Older adults often prioritize independence and time spent at home when making major treatment decisions. Identifying preoperative predictors of non-home discharge (i.e., requiring institutional discharge rather than home), among adults undergoing elective diverticulitis surgery, can support surgical decision-making and expectation management. This study aims to (1) examine rates of non-home discharge after elective surgery for diverticulitis and (2) identify predictors of non-home discharge.Methods: This is a multi-institutional cohort study of National Surgical Quality Improvement Program Database. Patients over 18 years who underwent colon resection with diagnosis of diverticulitis were included. Clinical and demographic information were collected by trained nurse reviewers. Emergency operations were excluded. Patients with home versus non-home discharge were compared and predictors identified using multivariable regression.Results: Between 2016 and 2019, 40,912 patients were identified. Mean age was 58.5 years (SD = 12.58) with 48.5% 60 + years and 17.7% of patients 70 + years old. The majority (55.9%) were female and "White" race (83.5%). Most patients underwent colectomy without ostomy (88.4%). Nine percent of patients over age 60 had non-home discharge. Functional dependence preoperatively was strongly associated with non-home discharge. On multivariable analysis, significant predictors of non-home discharge were preoperative functional dependence (OR 28.2; 95% CI 9.8-81.7), advancing chronologic age (age 80 + : OR 22.4; 95% CI 18.6-26.9), and preoperative albumin < 3.0 (OR 4.0; 95% CI 3.4-4.6).Conclusions: Nearly one in ten patients over 60 years was not discharged home after elective diverticulitis surgery. Preoperative functional status predicts non-home discharge. Future studies need to assess potentially modifiable causes of non-home discharge, such as social support. [ABSTRACT FROM AUTHOR]

Background: Educational resources and decision aids help patients, their care partners and health care providers prepare for and confidently engage in Advance Care Planning (ACP). Incorporating ACP resources as part of a self-management approach may lead to fuller engagement with ACP beyond identifying a surrogate decision-maker, towards supporting a person to identify their values and goals and to communicate them with their care partners and health care providers. Objective: To examine the use of educational resources and decision aids to support self-management of ACP in 11 health systems across the US. Methods: This study was a qualitative interview study examining barriers and facilitators to ACP. Guided by interpretative description and the chronic care model, we sought to describe how health care stakeholders (clinicians and administrators) and patients use ACP resources to support engagement with ACP. Results: 274 health care stakeholders were interviewed, and 7 patient focus groups were conducted across 11 health systems. The majority of participants reported using resources to support completion of preference documentation, with fewer participants using resources that promote more engagement in ACP. ACP resources were reported as valuable in preparing for and complementing a complex, interpersonal, and interprofessional process. Barriers to using resources included a lack of a defined workflow and time. Conclusion: Our data suggest that ACP resources that promote engagement are valued but under-utilized in practice. The use of ACP resources with an inter-professional team and a self-management approach is a promising strategy to mitigate the barriers of ACP implementation while improving engagement in ACP. [ABSTRACT FROM AUTHOR]

Background: Older adults comprise an increasing proportion of emergency general surgery (EGS) admissions and face high morbidity and mortality. We created a geriatric surgical service with geriatric and palliative expertise to mitigate risks of hospitalization most hazardous to older patients. We sought to identify geriatric surgical service interventions most relevant to EGS patients. Methods: We prospectively identified patients ≥75 years admitted to the EGS service at an urban tertiary care hospital from January 2020–March 2021 who screened positive for frailty (FRAIL score ≥3 [scale 0–5, higher being worse]) or with cognitive impairment. A pilot geriatric surgical service, led by a dually‐board certified geriatric and palliative care specialist, conducted a comprehensive geriatric assessment and modified Rockwood Frailty Index calculation for each eligible patient. Patient, hospital admission, and geriatric consultation characteristics were collected via chart review. Results: Fifty consecutive patients (median age 82 years [IQR 78–90], 56% female) received geriatric consultation (median time 3 days [IQR 1–6] from admission). The most common admission diagnosis was bowel obstruction (32%). Sixty‐four percent of patients underwent ≥1 surgical procedure. Using the Frailty Index, 64% were moderately or severely frail. Interventions most frequently performed by the geriatric team included delirium prevention and management (66%), consideration of swallowing function (52%), individualized pain management (50%), and facilitation of serious illness conversations (58%). Conclusions: Geriatric service involvement addresses a high burden of both geriatric and palliative care needs in older EGS patients. Geriatric recommendations may direct interventions for surgical education in fundamental geriatric and palliative care knowledge to maximize geriatric resources for the most high‐risk patients. [ABSTRACT FROM AUTHOR]

Objective: Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1–2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care. Data sources: Adult MHS beneficiaries, aged 18–64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly‐aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal‐year 2016–2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database. Study design: Retrospective cohort. Data collection: Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in‐hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in‐hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care. Principal findings: A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed‐to‐expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active‐duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each). Conclusions: Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health‐policy planning based on evidence‐based evaluation and the need to consider the consequential downstream effects caused by changes in access to care. [ABSTRACT FROM AUTHOR]

Background: The long-term consequences of musculoskeletal trauma can be profound and can extend beyond the post-injury period. The surveillance of long-term expenditures among individuals who sustain orthopaedic trauma has been limited in prior work. We sought to compare the health-care requirements of active-duty individuals who sustained orthopaedic injuries in combat and non-combat (United States) environments using TRICARE claims data.Methods: We identified service members who sustained combat or non-combat musculoskeletal injuries between 2007 and 2011. Combat-injured personnel were matched to those in the non-combat-injured cohort on a 1:1 basis using biologic sex, year of the injury, Injury Severity Score (ISS), and age at the index hospitalization. Health-care utilization was surveyed through 2018. The total health-care expenditures over the post-injury period were the primary outcome. These were assessed as a total overall cost and then as costs adjusted per year of follow-up. We used negative binomial regression to identify the independent association between risk factors and health-care expenditures.Results: We identified 2,119 individuals who sustained combat-related orthopaedic trauma and 2,119 individuals who sustained non-combat injuries. The most common mechanism of injury within the combat-injured cohort was blast-related trauma (59%), and 418 individuals (20%) sustained an amputation. The total costs were $156,886 for the combat-injured group compared with $55,873 for the non-combat-injured group (p < 0.001). Combat-related orthopaedic injuries were associated with a 43% increase in health-care expenditures (incidence rate ratio, 1.43 [95% confidence interval, 1.19 to 1.73]). Severe ISS at presentation, ≥2 comorbidities, and amputations were also significantly associated with health-care utilization, as was junior enlisted rank, our proxy for socioeconomic status.Conclusions: Health-care requirements and associated costs are substantial among service members sustaining combat and non-combat orthopaedic trauma. Given the sociodemographic characteristics of our cohort, we believe that these results are translatable to civilians who sustain similar types of musculoskeletal trauma. [ABSTRACT FROM AUTHOR]