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Background: Necrotizing fasciitis (NF) is a rapidly progressive disease that requires urgent surgical debridement for survival. Interhospital transfer (IT) may be associated with delay to operation, which could increase mortality. We hypothesized that mortality would be higher in patients undergoing surgical debridement for necrotizing fasciitis after IT compared to Emergency Department (ED) admission. Methods: We performed a retrospective cohort analysis from 2000–2006 using the Nationwide Inpatient Sample. Inclusion criteria were age >18 years, primary diagnosis of NF, and surgical therapy within 72 hours of admission. Logistic regression was used to assess the relationship between admission source, patient and hospital variables, and mortality. Results: We identified 9,958 cases over the study period. Patients in the ED group were more likely to be nonwhite and of lower income when compared with patients in the IT group. Unadjusted mortality was higher in the IT group than ED group (15.5% vs 8.7%, P < .001). After adjusting for potential confounders, odds of mortality were still greater in the IT (OR 2.04, CI 95% 1.60–2.59, P < .001). Conclusion: Interhospital transfer is associated with increased risk of in-hospital mortality after surgical therapy for NF, a finding which persists after controlling for patient and hospital level variables. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether mortality and clinical outcomes vary for injured patients in a mature trauma system on weeknights and weekends compared with weekdays. Design: Retrospective cohort study. Setting: Pennsylvania trauma system. Patients: A total of 90 461 patients over 5 years. Intervention: Treatment at a level I, II, or III trauma center. Main Outcome Measures: In-hospital mortality, time to procedures, and length of stay. Results: In adjusted analyses, patients presenting on weeknights were no more likely to die than patients presenting during weekdays, and patients presenting on weekends were less likely to die than patients presenting on weekdays (odds ratio=0.89; 95% confidence interval, 0.81-0.97). Presenting on weeknights was associated with longer intensive care unit stay (incidence rate ratio=1.06; 95% confidence interval, 1.02-1.10) and longer hospital stay (incidence rate ratio=1.02; 95% confidence interval, 1.00-1.04). Presenting on weekends was associated with longer intensive care unit stay (incidence rate ratio=1.04; 95% confidence interval, 1.02- 1.10) but not longer hospital stay. Delays to laparotomy or craniotomy were not seen in either group. Conclusions: We demonstrate comparable mortality among injured patients presenting on weeknights vs weekdays and lower mortality among injured patients on weekends vs weekdays. Systems-based solutions of the trauma model are protective against the weekend effect and inform care for other emergency care-sensitive conditions. [ABSTRACT FROM AUTHOR]

Background: More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients. Objectives: The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma. Methods: The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome. Results: Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean (± standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2 ± 17.5; for EMS, 10.1 ± 14.5; p < 0.001), and 16.6% of the subjects died (PD, 21.4 ± 0.41%; EMS, 14.8 ± 0.36%; p < 0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR = 1.6, 95% CI = 1.2 to 2.0; p < 0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR = 1.01, 95% CI = 0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p = 0.159). Conclusions: Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued. [ABSTRACT FROM AUTHOR]

Rapid access to emergency care can be life-saving, and geography is an important determinant of access to care. In this article, the authors review the organization of emergency care in the United States and describe the use of geographic information systems (GIS) to describe and solve health-related problems. The distribution of and access to medical resources, especially in the case of time-sensitive conditions, embodies the core concepts of geography-the relationship between place, time, and physical phenomena. The authors propose the expanded use of GIS in the development of the emergency care system and suggest that a transparent inventory of emergency care resources, coupled with an understanding of how access to appropriate care influences outcomes, can inform the creation of a regionalized, coordinated, and accountable emergency care system. ACADEMIC EMERGENCY MEDICINE 2010; 17: 1274-1278 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

The article discusses the highlights of the 11th "American Emergency Medicine" (AEM) consensus conference held in Phoenix, Arizona on June 2, 2010. The event was sponsored by the Society for Academic Emergency Medicine (SAEM) Regionalization Task Force with the American College of Emergency Physicians (ACEP) and the Emergency Department Practice Management Association (EDPMS). Conference co-chairs Ricardo Martinez and Brendan Carr framed the importance of redefining regionalization and developing a regionalization research agenda.

The 2010 Academic Emergency Medicine ( AEM) consensus conference 'Beyond Regionalization' aimed to place the design of a 21st century emergency care delivery system at the center of emergency medicine's (EM's) health policy research agenda. To examine the lessons learned from existing regional systems, consensus conference organizers convened a panel discussion made up of experts from the fields of acute care surgery, interventional cardiology, acute ischemic stroke, cardiac arrest, critical care medicine, pediatric EM, and medical toxicology. The organizers asked that each member provide insight into the barriers that slowed network creation and the solutions that allowed them to overcome barriers. For ST-segment elevation myocardial infarction (STEMI) management, the American Heart Association's (AHA's) Mission: Lifeline aims to increase compliance with existing guidelines through improvements in the chain of survival, including emergency medical services (EMS) protocols. Increasing use of therapeutic hypothermia post-cardiac arrest through a network of hospitals in Virginia has led to dramatic improvements in outcome. A regionalized network of acute stroke management in Cincinnati was discussed, in addition to the effect of pediatric referral centers on pediatric capabilities of surrounding facilities. The growing importance of telemedicine to a variety of emergencies, including trauma and critical care, was presented. Finally, the importance of establishing a robust reimbursement mechanism was illustrated by the threatened closure of poison control centers nationwide. The panel discussion added valuable insight into the possibilities of maximizing patient outcomes through regionalized systems of emergency care. A primary challenge remaining is for EM to help to integrate the existing and developing disease-based systems of care into a more comprehensive emergency care system. Academic Emergency Medicine 2010; 17:1354-1358 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

OBJECTIVE: We examined whether firearm mortality rates among children varied across US counties along a rural-urban continuum. METHODS: US vital statistics data were accessed for all pediatric (age: 0-19 years) firearm deaths from 1999 through 2006. Deaths were analyzed according to a modified rural-urban continuum code (based on population size and proximity to metropolitan areas) assigned to each county (3141 counties). RESULTS: In the 8-year study period, there were 23 649 pediatric firearm deaths (15 190 homicides, 7082 suicides, and 1377 unintentional deaths). Pediatric nonfirearm mortality rates were significantly higher in the most-rural counties (adjusted rate ratio: 1.36 [95% confidence interval [Cl]: 1.13-1.64]), compared with the most-urban counties. The most-rural counties demonstrated virtually identical pediatric firearm mortality rates (adjusted rate ratio: 0.91 [95% Cl: 0.63-1.32]), compared with the most-urban counties. The most-rural counties had higher rates of pediatric firearm suicide (adjusted rate ratio: 2.01 [95% CI: 1.43-2.831) and unintentional firearm death (adjusted rate ratio: 2.19 [95% Cl: 1.27-3.77]), compared with the most-urban counties. Pediatric firearm homicides rates were significantly higher in the mosturban counties (adjusted rate ratio: 3.69 [95% Cl: 2.00-6.801), compared with the most-rural counties. CONCLUSIONS: Children in the most-rural US counties had firearm mortality rates that were statistically indistinguishable from those for children in the most-urban counties. This finding reflects a greater homicide rate in urban counties counterbalanced by greater suicide and unintentional firearm death rates in rural counties. Nonfirearm mortality rates were significantly greater outside the most-urban US counties. [ABSTRACT FROM AUTHOR]

We sought to generate national estimates for post-cardiac arrest mortality, to assess trends, and to identify hospital factors associated with survival. We used a national sample of US hospitals to identify patients resuscitated after cardiac arrest from 2000 to 2004 to describe the association between hospital factors (teaching status, location, size) and mortality, length of stay, and hospital charges. Analyses were performed using logistic regression. A total of 109,739 patients were identified. In-hospital mortality was 70.6%. A 2% decrease in unadjusted mortality from 71.6% in 2000 to 69.6% in 2004 (OR 0.96, P < 0.001) was observed. Mortality was lower at teaching hospitals (OR 0.58, P = 0.001), urban hospitals (OR 0.63, P = 0.004), and large hospitals (OR 0.55, P < 0.001). Mortality after in-hospital cardiac arrest decreased over 5 years. Mortality was lower at urban, teaching, and large hospitals. There are implications for dissemination of best practices or regionalization of post-cardiac arrest care. [ABSTRACT FROM AUTHOR]

Summary: Aim: A growing body of evidence suggests that variability in post-cardiac arrest care contributes to differential outcomes of patients with initial return of spontaneous circulation after cardiac arrest. We examined hospital-level variation in mortality of patients admitted to United States intensive care units (ICUs) with a diagnosis of cardiac arrest. Methods: Patients with a primary ICU admission diagnosis of cardiac arrest were identified in the 2002–2005 Acute Physiology and Chronic Health Evaluation (APACHE) IV dataset, a multicenter clinical registry of ICU patients. Results: We identified 4674 patients from 39 hospitals. The median number of annual patients was 33 per hospital (range: 12–116). Mean APACHE score was 94 (±38), and overall mortality was 56.8%. Age, severity of illness (acute physiology score), and admission Glasgow Coma Scale were all associated with increased mortality (p <0.001). There was no survival difference for patients admitted from the emergency department vs. the inpatient floor. Among institutions, unadjusted in-hospital mortality ranged from 41% to 81%. After adjusting for age and severity of illness, institutional mortality ranged from 46% to 68%. Patients treated at higher volume centers were significantly less likely to die in the hospital. Conclusions: We demonstrate hospital-level variation in severity adjusted mortality among patients admitted to the ICU after cardiac arrest. We identify a volume–outcome relationship showing lower mortality among patients admitted to ICUs that treat a high volume of post-cardiac arrest patients. Prospective studies should identify hospital-level and patient care factors that contribute to post-cardiac arrest survival. [Copyright &y& Elsevier]

Objectives. The prehospital management of trauma patients remains controversial. Little is known about the time each procedure contributes to the on-scene duration, and this information would be helpful in prioritizing which procedures to perform in the prehospital setting. We sought to estimate the contribution of procedures to on-scene duration focusing on intubation and establishment of intravenous (IV) access. Methods. Data were provided by the Office of Emergency Planning and Response at the Mississippi Department of Health. Real-time prehospital patient-level data are collected by emergency medical services (EMS) providers for all 9-1-1 calls statewide. Linear regression was performed to determine the overall additional time for an average procedure and to calculate marginal increases in on-scene time associated with the establishment of IV access and with endotracheal intubation. Analyses were performed using Stata 9. Results. During 2001-2005, 192,055 prehospital runs were made for trauma patients. 121,495 (63%) included prehospital procedures. Average on-scene duration for those runs was 15:24 (minutes:seconds). On average, each procedure was associated with an addition of 1 minute to the on-scene duration (95% confidence interval [CI]: 58-62 seconds). A scene involving the establishment of IV access was 5:04 longer, while one involving tracheal intubation was 2:36 longer. Conclusions. We estimate the marginal increase in on-scene duration associated with the performance of an average procedure, establishment of IV access, and endotracheal intubation. There are policy and planning implications for the time trade-off of prehospital procedures, especially discretionary ones. [ABSTRACT FROM AUTHOR]

The article presents insights on a study of patient choice in the selection of hospitals by 9-1-1 emergency medical services providers in trauma systems. Topics discussed include the role of the patient's voice in health-seeking behavior, the discovery of the unmeasured confounder in the relationship between severity of injury and transport to a trauma center and the patients' prioritization of outcomes other than in-hospital mortality.

The 2010 Academic Emergency Medicine consensus conference on regionalization in emergency care began with an update on the Institute of Medicine (IOM) reports on the Future of Emergency Care. This was followed by two presentations from federal officials, focusing on regionalization from the perspective of the White House National Security Staff and the Emergency Care Coordination Center. This article summarizes the content of these presentations. It should be noted that this summary is the perspective of the authors and does not represent the official policy of the U.S. government. Academic Emergency Medicine 2010; 17: 1351-1353 © 2010 by the Society for Academic Emergency Medicine [ABSTRACT FROM AUTHOR]

Purpose: Group brainstorming is a technique for the elicitation of patient input that has many potential uses, however no data demonstrate concept saturation. In this study we explore concept saturation in group brainstorming performed in a single session as compared to two or three sessions. Methods: Fifty-two predominately African American adults patients with moderately to poorly controlled Diabetes Mellitus participated in three separate group brainstorming sessions as part of a PCORI-funded group concept mapping study examining comparing methods for the elicitation of patient important outcomes (PIOs). Brainstorming was unstructured, in response to a prompt designed to elicit PIOs in diabetes care. We combined similar brainstormed responses from all three sessions into a 'master list' of unique PIOs, and then compared the proportion obtained at each individual session, as well as those obtained in combinations of 2 sessions, to the master list. Results: Twenty-four participants generated 85 responses in session A, 14 participants generated 63 in session B, and 14 participants generated 47 in session C. Compared to the master list, the individual sessions contributed 87%, 76%, and 63% of PIOs. Session B added 3 unique PIOs not present in session A, and session C added 2 PIOs not present in either A or B. No single session achieved >90% saturation of the master list, but all 3 combinations of 2 sessions achieved > 90%. Conclusions: Single sessions elicited only 63-87% of the patient-important outcomes obtained across all three sessions, however all combinations of two sessions elicited over 90% of the master list, suggesting that 2 sessions are sufficient for concept saturation. Trial registration: NCT02792777. Registered 2 June 2016. [ABSTRACT FROM AUTHOR]

Background: Data are limited regarding how to effectively and efficiently identify patient priorities for research or clinical care. Our goal was to compare the comprehensiveness and efficiency of group concept mapping (GCM), a group participatory method, to interviews for identifying patient goals when seeking care.Methods: We engaged patients with moderately- to poorly-controlled diabetes mellitus in either GCM or an individual interview. The primary outcome was the comprehensiveness of GCM brainstorming (the first stage of GCM) as compared to interviews for eliciting patient-important outcomes (PIOs) related to seeking care. Secondary outcomes included 1) comprehensiveness of GCM brainstorming and interviews compared to a master list of PIOs and 2) efficiency of GCM brainstorming, the entire GCM process and interviews.Results: We engaged 89 interview participants and 52 GCM participants (across 3 iterations of GCM) to identify outcomes most important to patients when making decisions related to diabetes management. We identified 26 PIOs in interviews, 33 PIOs in the first GCM brainstorming session, and 38 PIOs across all three GCM brainstorming sessions. The initial GCM brainstorming session identified 77% (20/26) of interview PIOs, and all 3 GCM brainstorming sessions combined identified 88% (23/26). When comparing GCM brainstorming and interviews to the master list of PIOs, the initial GCM brainstorming sessions identified 80% (33/41), all 3 GCM brainstorming sessions identified 93% (38/41) and interviews identified 63% (26/41) of all PIOs. Compared to interviews, GCM brainstorming required less research team time, more patient time, and had a lowest cost. The entire GCM process still required less research team time than interviews, though required more patient time and had a higher cost than interviews.Conclusions: GCM brainstorming is a powerful tool for effectively and efficiently identifying PIOs in certain scenarios, though it does not provide the breadth and depth of individual interviews or the higher level conceptual organization of the complete process of GCM. Selection of the optimal method for patient engagement should include consideration of multiple factors including depth of patient input desired, research team expertise, resources, and the population to be engaged.Trial Registration: Registered on ClinicalTrials.gov , NCT02792777. Registration information submitted 6/2/2016, with the registration first posted on the ClinicalTrials.gov website 6/8/2016. Data collection began on 4/29/2016. [ABSTRACT FROM AUTHOR]

Objective: To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. Data Sources and Study Setting: ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010–2019); American Hospital Association Annual Survey (2009–2018). Study Design: Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non‐ECSCs. We reported marginal effects at the means. Data Collection/Extraction Methods: We examined 1,265,588 adult ED patients transferred from 187 hospitals. Principal Findings: Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5–1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were − 0.6 pp to −1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. Conclusions: Large population‐level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors. [ABSTRACT FROM AUTHOR]

Study Objective: We examine differences in inpatient mortality and hospitalization costs at trauma and nontrauma centers for injuries of minor and moderate severity.Methods: Inpatient data sets from the California Office of Statewide Health Planning and Development were analyzed for 2009 to 2011. The study population included patients younger than 85 years and admitted to general, acute care hospitals with a primary diagnosis of a minor or moderate injury. Minor injuries were defined as having a New Injury Severity Score less than 5 and moderate injuries as having a score of 5 to 15. Multivariate logistic regression and generalized linear model with log-link and γ distribution were used to estimate differences in adjusted inpatient mortality and costs.Results: A total of 126,103 admissions with minor or moderate injury were included in the study population. The unadjusted mortality rate was 6.4 per 1,000 admissions (95% confidence interval [CI] 5.9 to 6.8). There was no significant difference found in mortality between trauma and nontrauma centers in unadjusted (odds ratio 1.2; 95% CI 0.97 to 1.48) or adjusted models (odds ratio 1.1; 95% CI 0.79 to 1.57). The average cost of a hospitalization was $13,465 (95% CI $12,733 to $14,198) and, after adjustment, was 33.1% higher at trauma centers compared with nontrauma centers (95% CI 16.9% to 51.6%).Conclusion: For patients admitted to hospitals for minor and moderate injuries, hospitalization costs in this study population were higher at trauma centers than nontrauma centers, after adjustments for patient clinical-, demographic-, and hospital-level characteristics. Mortality was a rare event in the study population and did not significantly differ between trauma and nontrauma centers. [ABSTRACT FROM AUTHOR]

Study objective Reasons for recurrent emergency department (ED) visits have been examined primarily through administrative data review. Inclusion of patients’ perspectives of reasons for ED return may help inform future initiatives aimed at reducing recurrent utilization. The objective of this study is to describe the personal experiences and challenges faced by patients transitioning home after an ED discharge. Methods We performed semistructured qualitative interviews of adult patients with an unscheduled return to the ED within 9 days of an index ED discharge. Questions focused on problems with the initial discharge process, medications, outpatient care access, social support, and health care decisionmaking. Themes were identified with a modified grounded theory approach. Results Sixty interviews were performed. Most patients were satisfied with the discharge process at the index discharge, but many had complaints about the clinical care delivered, including insufficient evaluation and treatment. The primary reason for returning to the ED was fear or uncertainty about their condition. Most patients had a primary care physician, but they rarely visited a physician before returning to the ED. Patients cited convenience and more expedited evaluations as primary reasons for seeking care in the ED versus the clinic. Conclusion Postdischarge factors, including perceived inability to access timely follow-up care and uncertainty and fear about disease progression, are primary motivators for return to the ED. Many patients prefer hospital-based care because of increased convenience and timely results. Further work is needed to develop alternative pathways for patients to ask questions and seek guidance when and where they want. [ABSTRACT FROM AUTHOR]

Study objective: Two decades ago, Philadelphia began allowing police transport of patients with penetrating trauma. We conduct a large, multiyear, citywide analysis of this policy. We examine the association between mode of out-of-hospital transport (police department versus emergency medical services [EMS]) and mortality among patients with penetrating trauma in Philadelphia. Methods: This is a retrospective cohort study of trauma registry data. Patients who sustained any proximal penetrating trauma and presented to any Level I or II trauma center in Philadelphia between January 1, 2003, and December 31, 2007, were included. Analyses were conducted with logistic regression models and were adjusted for injury severity with the Trauma and Injury Severity Score and for case mix with a modified Charlson index. Results: Four thousand one hundred twenty-two subjects were identified. Overall mortality was 27.4%. In unadjusted analyses, patients transported by police were more likely to die than patients transported by ambulance (29.8% versus 26.5%; OR 1.18; 95% confidence interval [CI] 1.00 to 1.39). In adjusted models, no significant difference was observed in overall mortality between the police department and EMS groups (odds ratio [OR] 0.78; 95% CI 0.61 to 1.01). In subgroup analysis, patients with severe injury (Injury Severity Score >15) (OR 0.73; 95% CI 0.59 to 0.90), patients with gunshot wounds (OR 0.70; 95% CI 0.53 to 0.94), and patients with stab wounds (OR 0.19; 95% CI 0.08 to 0.45) were more likely to survive if transported by police. Conclusion: We found no significant overall difference in adjusted mortality between patients transported by the police department compared with EMS but found increased adjusted survival among 3 key subgroups of patients transported by police. This practice may augment traditional care. [Copyright &y& Elsevier]

Study objectives: Many US cities have experienced population reductions, often blamed on crime and interpersonal injury. Yet the overall injury risk in urban areas compared with suburban and rural areas has not been fully described. We begin to investigate this evidence gap by looking specifically at injury-related mortality risk, determining the risk of all injury death across the rural-urban continuum. Methods: A cross-sectional time-series analysis of US injury deaths from 1999 to 2006 in counties classified according to the rural-urban continuum was conducted. Negative binomial generalized estimating equations and tests for trend were completed. Total injury deaths were the primary comparator, whereas differences by mechanism and age were also explored. Results: A total of 1,295,919 injury deaths in 3,141 US counties were analyzed. Injury mortality increased with increasing rurality. Urban counties demonstrated the lowest death rates, significantly less than rural counties (mean difference=24.0 per 100,000; 95% confidence interval 16.4 to 31.6 per 100,000). After adjustment, the risk of injury death was 1.22 times higher in the most rural counties compared with the most urban (95% confidence interval 1.07 to 1.39). Conclusion: Using total injury death rate as an overall safety metric, US urban counties were safer than their rural counterparts, and injury death risk increased steadily as counties became more rural. Greater emphasis on elevated injury-related mortality risk outside of large cities, attention to locality-specific injury prevention priorities, and an increased focus on matching emergency care needs to emergency care resources are in order. [Copyright &y& Elsevier]

Background: Admission physiology predicts mortality after injury, but may be improved by resuscitation before transfer. This phenomenon, which has been termed lead-time bias, may lead to underprediction of mortality in transferred patients and inaccurate benchmarking in centers receiving large numbers of transfer patients. We sought to determine the impact of using vital signs on arrival at the referring center vs on arrival at the trauma center in mortality prediction models for transferred trauma patients.Study Design: We performed a retrospective cohort study using a state-wide trauma registry including all patients age 16 years or older, with Abbreviated Injury Scale scores ≥ 3, admitted to level I and II trauma centers in Pennsylvania, from 2011 to 2014. The primary outcomes measure was the risk-adjusted association between mortality and interhospital transfer (IHT) when adjusting for physiology (as measured by Revised Trauma Score [RTS]) using the referring hospital arrival vital signs (model 1) compared with trauma center arrival vital signs (model 2).Results: After adjusting for patient and injury factors, IHT was associated with reduced mortality (odds ratio [OR] 0.85; 95% CI 0.77 to 0.93) using the RTS from trauma center admission, but with increased mortality (OR 1.15; 95% CI 1.05 to 1.27) using RTS from the referring hospital. The greater the number of transfer patients seen by a center, the greater the difference in center-level mortality predicted by the 2 models (β -0.044; 95% CI -0.044 to -0.0043; p ≤ 0.001).Conclusions: Trauma center vital signs underestimate mortality in transfer patients and may lead to incorrect estimates of expected mortality. Where possible, benchmarking efforts should use referring hospital vital signs to risk-adjust IHT patients. [ABSTRACT FROM AUTHOR]

Racial and racialized economic residential segregation has been empirically associated with outcomes across multiple health conditions but not yet explored in relation to out-of-hospital cardiac arrest (OHCA). We sought to examine if measures of racial and economic residential segregation are associated with differences in survival to discharge after OHCA for Black and White Medicare beneficiaries. Utilizing age-eligible Medicare fee-for-service claims data from 2013 to 2015, we identified OHCA claims and determined survival to discharge. The primary predictor, residential segregation, was calculated using the index of concentration at the extremes (ICE) for the beneficiary residential ZIP code. Multilevel modified Poisson regression models were used to determine the association of OHCA outcomes and ZIP code level ICE measures. In total, 194,263 OHCA cases were identified among beneficiaries residing in 75% of US ZIP codes. Black beneficiaries exhibited 12.1% survival to discharge, compared with 12.5% of White beneficiaries. In fully adjusted models of the three ICE measures accounting for differences in treating hospital characteristics, there was as high as a 28% (RR 1.28, CI 1.23–1.26) higher relative likelihood of survival to discharge in the most segregated White ZIP codes (Q5) as compared to the most segregated Black ZIP codes (Q1). Racial residential segregation is independently associated with disparities in OHCA outcomes; among Medicare beneficiaries who generated a claim after suffering an OHCA, ICE measures of racial segregation are associated with a lower likelihood of survival to discharge for those living in the most segregated Black and lower income quintiles compared to higher quintiles. [ABSTRACT FROM AUTHOR]

The article offers information on a study which aims at describing how Accountable Care Organizations (ACOs) are prioritizing costreduction strategies related to acute unscheduled care using responses from a national survey of ACOs. It mentions that ACOs prioritize strategies to reduce emergency departments (ED) visits above reducing potentially avoidable inpatient admissions from the ED, despite significantly larger health care expenditures associated with inpatient hospitalizations.

Background: One in nine emergency department (ED) visits by Medicare beneficiaries are for ambulatory care sensitive conditions (ACSCs). This study aimed to examine the association between ACSC ED visits to hospitals with the highest proportion of ACSC visits ("high ACSC hospitals) and safety-net status.Methods: This was a cross-sectional study of ED visits by Medicare fee-for-service beneficiaries ≥ 65 years using 2013-14 claims data, Area Health Resources File data, and County Health Rankings. Logistic regression estimated the association between an ACSC ED visit to high ACSC hospitals, accounting for individual, hospital, and community factors, including whether the visit was to a safety-net hospital. Safety net status was measured by Disproportionate Share Hospital (DSH) index patient percentage; public hospital status; and proportion of dual-eligible beneficiaries. Hospital-level correlation was calculated between ACSC visits, DSH index, and dual-eligible patients. We stratified by type of ACSC visit: acute or chronic.Results: Among 5,192,729 ACSC ED visits, the odds of visiting a high ACSC hospital were higher for patients who were Black (1.37), dual-eligible (1.18), and with the highest comorbidity burden (1.26, p < 0.001 for all). ACSC visits had increased odds of being to high ACSC hospitals if the hospitals were high DSH (1.43), served the highest proportion of dual-eligible beneficiaries (2.23), and were for-profit (relative to non-profit) (1.38), and lower odds were associated with public hospitals (0.64) (p < 0.001 for all). This relationship was similar for visits to high chronic ACSC hospitals (high DSH: 1.59, high dual-eligibility: 2.60, for-profit: 1.41, public: 0.63, all p < 0.001) and to a lesser extent, high acute ACSC hospitals (high DSH: 1.02; high dual-eligibility: 1.48, for-profit: 1.17, public: 0.94, p < 0.001). The proportion of ACSC visits at all hospitals was weakly correlated with DSH proportion (0.2) and the proportion of dual-eligible patients (0.29), and this relationship was also seen for both chronic and acute ACSC visits, though stronger for the chronic ACSC visits.Conclusion: Visits to hospitals with a high proportion of acute ACSC ED visits may be less likely to be to hospitals classified as safety net hospitals than those with a high proportion of chronic ACSC visits. [ABSTRACT FROM AUTHOR]

The impact of injury extends beyond the hospital stay, but trauma center performance metrics typically focus on in-hospital mortality. We compared risk adjusted rates of in-hospital and long-term mortality among Pennsylvania trauma centers. We hypothesized that centers with low rates of in-hospital mortality would also have low rates of long-term mortality. We identified injured patients (age ≥ 65) admitted to Pennsylvania trauma centers in 2013 and 2014 using the Pennsylvania Trauma Outcomes Study, a robust, state-wide trauma registry. We matched trauma registry records to Medicare claims from the y 2013 to 2015. Matching variables included admission date and patient demographics including date of birth, zip, sex, and race and/or ethnicity. Outcomes examined were inpatient, 30-day, and 1-y mortality. Multivariable logistic regression models including presenting physiology, comorbidities, injury characteristics, and demographics were developed to calculate expected mortality rates for each trauma center at each time point. Trauma center performance was assessed using observed-to-expected ratios and ranking for in-hospital, 30-day, and 1-y mortality. Of the 15,451 patients treated at 28 centers, 8.1% died before discharge or were discharged to hospice. Another 3.4% died within 30 d, and another 14.7% died within 1 y of injury. Of patients who survived hospitalization but died within 30 d, 92.5% were injured due to fall, and 75.0% sustained head injuries. Survival at 1 y was higher in patients discharged home (88.4%), compared to those discharged to a skilled nursing facility or long-term acute care hospital (72.7% and 52.6%, respectively). Three centers were identified as outliers (two low and one high) for in-hospital mortality, none of which were outliers when the horizon was stretched to 30 d from injury. At 30 d, two different low and two different high outliers were found. Nearly one-in-three injured older adults who die within 30 d of injury dies after hospital discharge. Hospital rankings for in-hospital mortality correlate poorly with long-term outcomes. These findings underscore the importance of looking beyond survival to discharge for quality improvement and benchmarking. [ABSTRACT FROM AUTHOR]

Objective: Despite well-established treatment guidelines, diabetes is difficult to manage for many individuals. The importance of using shared decision making to optimize diabetes treatment is recognized, yet what matters most to individuals with diabetes is not well established. Our goal was to identify patients' goals and priorities for diabetes management.Methods: We engaged 141 participants through interviews and group concept mapping to identify patient-important outcomes (PIOs) for diabetes care. We generated a master list of PIOs by aggregating interview data coded to "goals" and ideas brainstormed during concept mapping, and then a patient advisory board sorted the PIOs into higher-level domains.Results: We identified 41 PIOs sorted into 7 broad domains: optimize daily self-care, optimize long term health, learn about diabetes, achieve measurable goals, manage medications, manage diet and best utilize medical / professional services.Conclusions: Most (4/7) of PIO domains focused on personal and life goals, not medically-oriented goals. Use of these PIOs and domains may facilitate more effective SDM discussions for patients with diabetes.Practice Implications: Use of PIOs from this work can enable the empowerment of patients to voice their priorities during SDM conversations, thus facilitating development of truly individualized diabetes treatment plans. [ABSTRACT FROM AUTHOR]

Objectives. To create a tool to rapidly determine where pandemic demand for critical care overwhelms county-level surge capacity and to compare public health and medical responses. Methods. In March 2020, COVID-19 cases requiring critical care were estimated using an adaptive metapopulation SEIR (susceptible-exposed-infectious-recovered) model for all 3142 US counties for future 21-day and 42-day periods from April 2, 2020, to May 13, 2020, in 4 reactive patterns of contact reduction--0%, 20%, 30%, and 40%--and 4 surge response scenarios--very low, low, medium, and high. Results. In areas with increased demand, surge response measures could avert 104 120 additional deaths--55% through high clearance of critical care beds and 45% through measures such as greater ventilator access. The percentages of lives saved from high levels of contact reduction were 1.9 to 4.2 times greater than high levels of hospital surge response. Differences in projected versus actual COVID-19 demands were reasonably small over time. Conclusions. Nonpharmaceutical public health interventions had greater impact in minimizing preventable deaths during the pandemic than did hospital critical care surge response. Ready-to-go spatiotemporal supply and demand data visualization and analytics tools should be advanced for future preparedness and all-hazards disaster response. [ABSTRACT FROM AUTHOR]

There is growing evidence on the effect of face mask use in controlling the spread of COVID-19. However, few studies have examined the effect of local face mask policies on the pandemic. In this study, we developed a dynamic compartmental model of COVID-19 transmission in New York City (NYC), which was the epicenter of the COVID-19 pandemic in the USA. We used data on daily and cumulative COVID-19 infections and deaths from the NYC Department of Health and Mental Hygiene to calibrate and validate our model. We then used the model to assess the effect of the executive order on face mask use on infections and deaths due to COVID-19 in NYC. Our results showed that the executive order on face mask use was estimated to avert 99,517 (95% CIs 72,723–126,312) COVID-19 infections and 7978 (5692–10,265) deaths in NYC. If the executive order was implemented 1 week earlier (on April 10), the averted infections and deaths would be 111,475 (81,593–141,356) and 9017 (6446–11,589), respectively. If the executive order was implemented 2 weeks earlier (on April 3 when the Centers for Disease Control and Prevention recommended face mask use), the averted infections and deaths would be 128,598 (94,373–162,824) and 10,515 (7540–13,489), respectively. Our study provides public health practitioners and policymakers with evidence on the importance of implementing face mask policies in local areas as early as possible to control the spread of COVID-19 and reduce mortality. [ABSTRACT FROM AUTHOR]

Background: A family history of diabetes and family members' experiences with diabetes may influence individuals' beliefs and expectations about their own diabetes. No qualitative studies have explored the relationship between family history and experiences and individuals' diabetes illness representations. Methods: Secondary data analysis of 89 exploratory, semi-structured interviews with adults with type 1 or type 2 diabetes seeking care in an urban health system. Participants had a recent diabetes-related ED visit/hospitalization or hemoglobin A1c > 7.5%. Interviews were conducted until thematic saturation was achieved. Demographic data were collected via self-report and electronic medical record review. Interviews were audio-recorded, transcribed, and coded using a conventional content analysis approach. References to family history and family members' experiences with diabetes were analyzed using selected domains of Leventhal's Common Sense Model of Self-Regulation. Results: Participants cited both genetic and behavioral family history as a major cause of their diabetes. Stories of relatives' diabetes complications and death figured prominently in their discussion of consequences; however, participants felt controllability over diabetes through diet, physical activity, and other self-care behaviors. Conclusions: Findings supported an important role of family diabetes history and experience in development of diabetes illness representations. Further research is needed to expand our understanding of the relationships between these perceptions, self-management behaviors, and outcomes. Family practice providers, diabetes educators and other team members should consider expanding assessment of current family structure and support to also include an exploration of family history with diabetes, including which family members had diabetes, their self-care behaviors, and their outcomes, and how this history fits into the patient's illness representations. [ABSTRACT FROM AUTHOR]

Background: The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.Objective: We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality.Methods: We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered.Results: There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score-predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p < 0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p = 0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit's percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).Conclusions: We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma. [ABSTRACT FROM AUTHOR]

Aim: International classification of disease (ICD-9) code 427.5 (cardiac arrest) is utilized to identify cohorts of patients who suffer out-of-hospital cardiac arrest (OHCA), though the use of ICD codes for this purpose has never been formally validated. We sought to validate the utility of ICD-9 code 427.5 by identifying patients admitted from the emergency department (ED) after OHCA.Methods: Adult visits to a single ED between January 2007 and July 2012 were retrospectively examined and a keyword search of the electronic medical record (EMR) was used to identify patients. Cardiac arrest was confirmed; and ICD-9 information and location of return of spontaneous circulation (ROSC) were collected. Separately, the EMR was searched for patients who received ICD-9 code 427.5. The kappa coefficient (κ) was calculated, as was the sensitivity and specificity of the code for identifying OHCA.Results: The keyword search identified 1717 patients, of which 385 suffered OHCA and 333 were assigned the code 427.5. The agreement between ICD-9 code and cardiac arrest was excellent (κ = 0.895). The ICD-9 code 427.5 was both specific (99.4%) and sensitive (86.5%). Of the 52 cardiac arrests that were not identified by ICD-9 code, 33% had ROSC before arrival to the ED. When searching independently on ICD-9 code, 347 patients with ICD-9 code 427.5 were found, of which 320 were "true" arrests. This yielded a positive predictive value of 92% for ICD-9 code 427.5 in predicting OHCA.Conclusions: ICD-9 code 427.5 is sensitive and specific for identifying ED patients who suffer OHCA with a positive predictive value of 92%. [ABSTRACT FROM AUTHOR]

Objectives: To determine how frequently patients revisit the emergency department after an initial encounter, and to describe revisit capture rates for the same hospital, health system, and geographic region.Data Sources/study Setting: Florida state data from January 1, 2010, to June 30, 2011, from the Healthcare Cost and Utilization Project.Study Design: This is a retrospective cohort study of emergency department return visits among Florida adults over an 18-month period. We evaluated pairs of index and 30-day return emergency department visits and compared capture rates for hospital, health system, and geographic units.Data Collection/extraction Methods: Data were obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project and the American Hospital Association Annual Survey Database.Principal Findings: Among 9,416,212 emergency department visits, 22.6 percent (2,124,441) were associated with a 30-day return. Seventy percent (1,477,772) of 30-day returns occurred to the same hospital. The 30-day return capture rates were highest within the same geographic area: county-level capture at 92 percent (IQR=86-96 percent) versus health system capture at 75 percent (IQR = 68-81 percent).Conclusions: Acute care utilization patterns are often independent of health system boundaries. Current population-based health care models that attribute patients to a single provider or health system may be strengthened by considering geographic patterns of acute care utilization. [ABSTRACT FROM AUTHOR]