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Background: Excessive opioid prescribing has resulted in opioid diversion and misuse. In July 2018, Michigan's Public Act 251 established a state-wide policy limiting opioid prescriptions for acute pain to a 7-day supply. Traumatic injury increases the risk for new persistent opioid use, yet the impact of prescribing policy in trauma patients remains unknown. To determine the relationship between policy enactment and prescribing in trauma patients, we compared oral morphine equivalents prescribed at discharge before and after implementation of Public Act 251., Methods: In this cross-sectional study, adult patients who received any oral opioids at discharge from a Level 1 trauma center between January 1, 2016, and June 30, 2021, were identified. The exposure was patients admitted starting July 1, 2018. Inpatient oral morphine equivalents per day 48 hours before discharge and discharge prescription oral morphine equivalents per day were calculated. Student's t test and an interrupted time series analysis were performed to compare mean oral morphine equivalents per day pre- and post-policy. Multivariable risk adjustment accounted for patient/injury factors and inpatient oral morphine equivalent use., Results: A total of 3,748 patients were included in the study (pre-policy n = 1,685; post-policy n = 2,063). Implementation of the prescribing policy was associated with a significant decrease in mean discharge oral morphine equivalents per day (34.8 ± 49.5 vs 16.7 ± 32.3, P < .001). After risk adjustment, post-policy discharge prescriptions differed by -19.2 oral morphine equivalents per day (95% CI -21.7 to -16.8, P < .001). The proportion of patients obtaining a refill prescription 30 days post-discharge did not increase after implementation (0.38 ± 0.48 vs 0.37 ± 0.48, P = .7)., Conclusion: Discharge prescription amounts for opioids in trauma patients decreased by approximately one-half after the implementation of opioid prescribing policies, and there was no compensatory increase in subsequent refill prescriptions. Future work is needed to evaluate the effect of these policies on the adequacy of pain management and functional recovery after injury., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Meaningful reporting of quality metrics relies on detecting a statistical difference when a true difference in performance exists. Larger cohorts and longer time frames can produce higher rates of statistical differences. However, older data are less relevant when attempting to enact change in the clinical setting. The selection of time frames must reflect a balance between being too small (type II errors) and too long (stale data). We explored the use of power analysis to optimize time frame selection for trauma quality reporting., Methods: Using data from 22 Level III trauma centers, we tested for differences in 4 outcomes within 4 cohorts of patients. With bootstrapping, we calculated the power for rejecting the null hypothesis that no difference exists amongst the centers for different time frames. From the entire sample for each site, we simulated randomly generated datasets. Each simulated dataset was tested for whether a difference was observed from the average. Power was calculated as the percentage of simulated datasets where a difference was observed. This process was repeated for each outcome., Results: The power calculations for the 4 cohorts revealed that the optimal time frame for Level III trauma centers to assess whether a single site's outcomes are different from the overall average was 2 years based on an 80% cutoff., Conclusion: Power analysis with simulated datasets allows testing of different time frames to assess outcome differences. This type of analysis allows selection of an optimal time frame for benchmarking of Level III trauma center data., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Open long-bone fractures represent a complex injury within the trauma system. Guidelines recommend antibiotics be given within 60 minutes of patient arrival to the emergency department. We sought to measure and improve the timeliness of antibiotic administration at the patient, hospital, and population level within a collaborative quality initiative., Methods: Trauma collaborative quality initiative data (January 2017 to December 2020) were analyzed from 34 American College of Surgeons Committee on Trauma verified level 1 and level 2 trauma centers. Inclusion criteria were adult patients (≥16 years), injury severity score ≥5, and open tibia or femur fracture. After the baseline year, hospitals were scored annually on a pay-for-performance metric based on patients receiving antibiotics within 120 minutes of emergency department arrival. Univariate tests examined the differences between baseline and subsequent year(s) performance. A multivariable logistic regression assessed the factors associated with meeting this target time., Results: There were 2,624 patients with an open long-bone fracture. In the baseline year (2017), 76.9% of patients received antibiotics in ≤120 minutes, with a mean time of 57.9 ± 63.3 minutes. After implementing collaborative quality initiative-wide targets, performance significantly improved in subsequent years (2018, 2019, 2020). The collaborative quality initiative achieved their goal of ≥85% of patients receiving antibiotics in ≤120 minutes in 2019 (87.9%) and 2020 (88.5%), with a mean time of 43.3 ± 54.8 minutes (P < .05 vs 2017)., Conclusion: A pay-for-performance process measure within a statewide trauma collaborative quality initiative improved the timely administration of antibiotics to patients with open fractures. Work remains to align compliance with the guideline target of <60 minutes and to identify factors involved in the delay of administration., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Hospital-level variation has been found to influence outcomes in emergency general surgery. However, whether the individual surgeon plays a role in this variation is unknown., Methods: We performed an analysis of the Florida State Inpatient Database (2010-2014), which is linked to the American Hospital Association's Annual Survey Database, including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multilevel random effects modeling to quantify the amount of variation in mortality, complications, and 30-day readmissions attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a forward stepwise fashion, and the percent of the variation attributable to surgeons was derived., Results: Our study included 2,149 surgeons across 224 hospitals, with a total of 569,767 emergency general surgery cases. The overall unadjusted mortality rate was 3.8%, and the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality, explaining 32.77% of the overall variability in mortality risk compared with 0.08% and 2.28% for complications and readmissions, respectively. Peptic ulcer disease operations were most susceptible to surgeon-level variation in mortality and readmissions, whereas appendectomies and cholecystectomies were least susceptible to surgeon-level variation for all outcomes., Conclusions: Surgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in emergency general surgery should address reducing variability in practice with attention to high-risk, low-frequency procedures., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Five billion people lack access to safe, affordable, and timely surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting is commonly implemented to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical, obstetric, and anesthetic task shifting is lacking in the literature. We aimed to document the use of task shifting worldwide with a systematic review of the literature., Methods: We performed a systematic review of 10 health literature databases. We included journal articles published between January 1, 1995, and February 17, 2017, documenting the provision of surgical or anesthetic care by associate clinicians (any non-physician clinician). We extracted data for health cadres performing task shifting, types of tasks performed, training programs, and levels of supervision, and compared these across regions and income groups., Results: We identified 55 relevant studies, with data for 52 countries for surgery and 147 countries for anesthesia. Surgical task shifting was documented in 19 of 52 countries and anesthetic task shifting in 119 of 147. Task shifting was documented across all World Bank income groups. No associate clinicians were found to perform surgical procedures unsupervised in high-income countries (0 of 3 countries with data). Independent anesthesia care by associate clinicians was noted in 3 of 19 countries with data. In low-income countries, associate clinicians performed surgical procedures independently in 2 of 3 countries and independent anesthesia care in 17 of 17 countries with data., Conclusion: Task shifting is used to augment the global surgical, obstetric, and anesthetic workforce across all geographic regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce. Further research is required to assess outcomes, especially in low-income and middle-income countries where documented supervision is less robust., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The unacceptably high rate of death and disability due to injury in Sub-Saharan Africa is alarming. The objective of this work was to compare mortality rates between severely injured trauma patients at a high-volume trauma center in South Africa with matched patients in the United States., Methods: Clinical databases from the Groote Schuur Hospital for patients treated in Cape Town, South Africa and the American College of Surgeon's National Trauma Databank for patients treated at large academic trauma centers in the United States were used. Coarsened exact matching identified the most comparable patient populations based on sex, age, intent, injury type, injury mechanism, Injury Severity Score, Glasgow Coma Score, and systolic blood pressure. Conditional logistic regression generated odds ratios for mortality among the entire sample and clinically relevant subgroups., Results: Coarsened exact matching matched 97.9% of the Groote Schuur Hospital patient sample, resulting in 3,206 matched-pairs between the Groote Schuur Hospital and National Trauma Databank cohorts. Conditional logistic regression revealed an odds ratio of mortality of 1.67 (95% confidence interval, 1.10-2.52) for patients at Groote Schuur Hospital compared with matched patients from the National Trauma Databank. Subset analyses revealed significantly increased odds of mortality among patients with blunt injuries (odds ratio 3.40, 95% confidence interval, 1.68-6.88) and patients with a Glasgow Coma Score of 8 or lower (odds ratio 4.33, 95% confidence interval, 2.10-8.95). No statistically significant difference was identified among patients with penetrating injuries or with a Glasgow Coma Score >8 (P value .90 and .39, respectively)., Conclusion: International comparisons of interhospital variation in risk-adjusted outcomes following trauma can identify opportunities for quality improvement and have the potential to measure the impact of any corrective strategy implemented., (Copyright © 2017. Published by Elsevier Inc.)

Background: The Affordable Care Act has the potential to significantly affect access to care for previously uninsured patients in need of emergency general surgical care. Our objective was to determine the relationship between insurance status and disease complexity at presentation among a national sample of emergency general surgical patients., Methods: Data from the National Emergency Department Sample from 2006-2009 were queried to identify all patients aged 18-64 years old admitted through the emergency department with a primary diagnosis of appendicitis, diverticulitis, inguinal hernia, or bowel obstruction. Primary outcome of complex presentation was defined as also presenting with generalized peritonitis, intra-abdominal abscess, perforated bowel, intestinal gangrene, or other disease-specific measures of complexity. We used multivariable logistic regression to determine the independent association between insurance status and complex presentation. Models accounted for patient- and hospital-level covariates. Counterfactual models were used to estimate the risk of complex presentation attributable to lack of insurance., Results: A total of 1,373,659 patients were included, with an overall uninsured rate of 12.3%. Uninsured patients had significantly higher, unadjusted rates of complex presentation, and uninsured payer status was independently associated with complex presentation (odds ratio 1.38, 95% confidence interval: 1.34-1.42). Counterfactual models suggest that having insurance would result in a 22.37% (95% confidence interval: 22.35-22.39%) relative decline in risk of complex emergency general surgical presentation among the uninsured population., Conclusion: Insurance status is independently associated with severity of disease at presentation among emergency general surgical conditions nationally. In light of recently reaffirmed Affordable Care Act insurance expansion provisions, these results anticipate increased timely access to operative care for newly insured patients and a corresponding decline in complex, emergency general surgical presentations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Emergency operations are associated with worse outcomes than elective operations. If not repaired electively, ventral hernias are at risk of strangulating and requiring emergency repair. We sought to identify patient- and hospital-level factors associated with emergency ventral hernia repair in a nationally representative, United States sample., Methods: We abstracted data from the 2003-2011 Nationwide Inpatient Sample for adults (≥18 years) who underwent inpatient ventral hernia repair. Our primary outcome was emergency repair. We assessed differences in patient- and hospital-level factors as possible predictors of emergency repair using multivariable logistic regression. We examined secondary outcomes (mortality, total hospital cost, duration of stay) using multivariable logistic and generalized linear (family gamma; link log) regression., Results: After weighting to the United States population, we included 453,161 adults (39.5% emergency). Independent predictors of emergency repair included payer status (uninsured: odds ratio 3.50, [3.10, 3.96]; Medicaid: 1.29 [1.20, 1.39] compared with private insurance), race/ethnicity (black: 1.77 [1.64, 1.92]; Hispanic: 1.44 [1.28, 1.61] compared with white), age (≥85 years: 2.23 [2.00, 2.47] compared with <45 years), and comorbidities (Charlson Comorbidity Index ≥3: 1.68 [1.56, 1.80] compared with 0). After risk-adjustment, emergency repair was associated with greater odds of in-hospital death, greater costs, and longer hospital stay., Conclusion: Inpatient ventral hernia repairs are frequently performed emergently, with worse outcomes in this group. Independent predictors of emergency repair include factors that may limit access to and/or selection for an elective operation. These predictors provide targets for interventions to improve access to elective care and inform patient selection with the goal of improving patient outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Differences in perforated appendix admission rates (PAAR) are an ambulatory-sensitive measure of access to care. While pediatric studies report disparities in PAAR, initial adult investigations suggest a lack of racial/ethnic inequity. The objectives of this study were to (1) assess for risk-adjusted, racial/ethnic differences in PAAR among adults on a national scale, (2) consider the extent to which variations (or lack thereof) are explained by age, insurance, and income, and (3) compare results within the United States population to a national segment of the population who are completely insured., Methods: According to the Agency for Healthcare Research and Quality definition of PAAR, adults (aged 18-64 years) in the 2006-2010 Nationwide Inpatient Sample were queried for the occurrence and perforation of acute appendicitis. Risk-adjusted differences were compared by race/ethnicity over 5-year age increments using logistic regression with reweighted estimating equations. Noting disparate outcomes between younger (aged 18-34 years) versus older (aged 35-64 years) adults, age-stratified variations were further considered. Results were compared relative to differences among national military/civilian-dependent patients with universal insurance and were assessed for the extent to which disparities could be explained by variations in insurance and income., Results: A total of 129,257 (weighted: 638,452) patients were included. Despite a lack of differences overall, significantly worse outcomes among younger (odds ratio point-estimates ranged from 1.11-1.32) and better outcomes among older (0.78-0.93) minority patients were found. This observation contrasted a lack of differences among completely insured military/civilian-dependent patients (n = 12,154). A total of 22.4% (non-Hispanic black versus non-Hispanic white) and 39.0% (Hispanic versus non-Hispanic white) of younger adult differences were explained by insurance-12.2% and 13.6% by income, 29.8% and 44.0% combined., Conclusion: This national assessment of differences in access to care among adults with acute appendicitis demonstrated the existence of racial/ethnic disparities in PAAR that varied with age and were partially, although incompletely, explained by variations in insurance and income., (Copyright © 2016 Elsevier Inc. All rights reserved.)