j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 3 ) 1 e6
Available online at www.sciencedirect.com
journal homepage: www.JournalofSurgicalResearch.com
Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury Melissa Hazlitt, MA,a J. Bradford Hill, MD,b Oliver L. Gunter, MD,c and Oscar D. Guillamondegui, MD, MPHc,* a
Division of Trauma, Department of Surgery, Meharry Medical College, Nashville, Tennessee Division of Trauma, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee c Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee b
article info
abstract
Article history:
Background: This piece aims to examine the relationships between hollow viscus injury
Received 23 February 2013
(HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury
Received in revised form
patterns with complex postoperative convalescence and morbidity, representing an ideal
6 May 2013
focus for identifying potential disparities among a homogeneous injury population.
Accepted 10 May 2013
Materials and methods: A retrospective review included patients admitted to a level I trauma
Available online xxx
center with HVI from 2000e2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury
Keywords:
were excluded. US Census (2000) median household income by zip code was used as
Trauma
socioeconomic proxy. Demographic and injury-related variables were also included.
Critical care
Endpoints were mortality and outcomes associated with HVI morbidity.
Healthcare disparities
Results: A total of 933 patients with HVI were identified and 256 met inclusion criteria. There
Hollow viscus injury
were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer
Payer status
source. However, lower median household income was significantly associated with longer
Blunt trauma
intervals to ostomy takedown (P ¼ 0.032). Additionally, private payers had significantly lower
Penetrating trauma
rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P ¼ 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P ¼ 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P ¼ 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P ¼ 0.036). Conclusions: Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source. ª 2013 Elsevier Inc. All rights reserved.
1.
Introduction
There is mounting evidence that nonclinical factors such as socioeconomic and insurance status impact health outcomes.
For example, disparity has been described with respect to race and cardiac revascularization [1], prevention and early detection of colorectal cancer [2], and rejection incidence following renal transplant [3]. Socioeconomic factors and, in
* Corresponding author. Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21st Ave South, 404 Medical Arts Building, Nashville, TN 37212. Tel.: þ1 615 936 0189; fax: þ1 615 936 0185. E-mail address: [email protected] (O.D. Guillamondegui). 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.05.052
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 3 ) 1 e6
Fig. 1 e Exclusion criteria for patients with severe concomitant solid organ or vasculature injury and parameters for intervention.
particular, insurance status have been described to impact outcomes across medical conditions, perhaps more profoundly than race or income [4,5]. However, these factors may have a diminished effect on traumatic injury outcomes, particularly in the short term due to the emergent, standardized, and egalitarian nature of acute care. As Greene [6] notes, “Trauma care is one of the most protocolized and standardized systems of care.” Thus, the behavior of surgeons and allied health professionals may not be impacted by variations in socioeconomic status (SES) indicators within the limited timeline of standardized care that defines trauma acute care. Yet, recent large retrospective studies have shown that nonclinical factors may indeed impact mortality and postoperative morbidity in complex ways, especially when acute stabilization is completed and more long-term management is underway [7e10]. Although these studies indicate relationships between outcomes and SES, the extent and variability of socioeconomic correlation with morbidity and mortality remains unclear. There is also inherent confounding that complicates much of the literature, as many studies include large populations with heterogeneous injury patterns. Thus, this study was designed to characterize relationships among the homogenous population of abdominal hollow viscus injuries (HVI). HVI represent an injury pattern marked by early intervention and complex, yet well-characterized, convalescence and morbidity [11]. It is therefore an ideal focus for independently examining the impact of socioeconomic and nonclinical factors on both mortality and morbidity. The authors hypothesize that there is no difference between outcomes in trauma with isolated HVI based upon demographic or socioeconomic variables.
2.
Materials and methods
Institutional review board approval was obtained for this study. A retrospective review included all patients admitted to Vanderbilt University Medical Center, a level I trauma center, with HVI from the years 2000e2009, as identified in the Trauma Registry of the American College of Surgeons database. We
excluded patients with a concomitant significant solid organ or vascular injury, based upon abbreviated injury scales (AIS > 2) and ICD-9 codes of “severe,” and patients with initial surgical intervention beyond 48 h of admission. Cases were then stratified by small or large bowel injury, presence of an anastomosis, and diversion method. United States Census (2000) median household income was culled by zip code. Included were 112 known zip codes with a population clustering within the Vanderbilt level I catchment area. Additional demographic and injury-related variables were included, such as race, gender, age, payer source, blunt versus penetrating trauma, injury severity scale, intensive care unit (ICU) days, total hospital length of stay, “severe” or “nonsevere” HVI (ICD-9 code), and discharge disposition. Payer source was defined as self-pay (uninsured), government pay (including Medicare and Medicaid programs), and private pay (third-party commercial insurance). Low median outcome is defined as the lowest quartile. The primary endpoint was mortality, and secondary outcomes represented common endpoints associated with HVI morbidity, including ventral hernia, abscess, soft tissue infection, anastomotic leak, fascial dehiscence, and unplanned readmission. The interval to closure was recorded for patients with an open abdomen following their initial laparotomy, and the interval to ostomy takedown was recorded for patients with either ileostomy or colostomy. c2 test, Spearman rank correlation, and logistic regression analyses were utilized to identify relationships between SES and mortality/morbidities. Variables investigated with logistic regression include ICU days, hospital days, ISS, and median household income plotted against death. Analysis of variance was used to assess the differences among our groups with statistical significance with P values below 0.05. All analyses were performed within SPSS Statistics version 19 (IBM Corporation, Chicago, IL).
3.
Results
A total of 933 total patients with abdominal injury including HVI were identified from 2000e2009. Of these patients, 648
3
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 3 ) 1 e6
Table 1 e Population demographics. Variable
Total (n ¼ 256)
Private pay (n ¼ 73)
Gov’t pay (n ¼ 77)
Self-pay (n ¼ 100)
35.6 220 (86%) 125 (49%) 86 (34%) 40 (15.6)
36.8
37.8z
33.3y
52 (71%)y,z 14 (19%)z 4 (5.5%)y
35 (46%)* 16 (21%)z 25 (33%)*,z
35 (35%)* 53 (53%)*,y 11 (11%)y
$37,543
$39,983y,z
$36,342*
$36,918*
Demographic Age, y, mean Male, n (%) White, n (%) Black, n (%) Hispanic, n (%) Socioeconomic Median household income, mean y
P 0.101
Available online at www.sciencedirect.com
journal homepage: www.JournalofSurgicalResearch.com
Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury Melissa Hazlitt, MA,a J. Bradford Hill, MD,b Oliver L. Gunter, MD,c and Oscar D. Guillamondegui, MD, MPHc,* a
Division of Trauma, Department of Surgery, Meharry Medical College, Nashville, Tennessee Division of Trauma, Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee c Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee b
article info
abstract
Article history:
Background: This piece aims to examine the relationships between hollow viscus injury
Received 23 February 2013
(HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury
Received in revised form
patterns with complex postoperative convalescence and morbidity, representing an ideal
6 May 2013
focus for identifying potential disparities among a homogeneous injury population.
Accepted 10 May 2013
Materials and methods: A retrospective review included patients admitted to a level I trauma
Available online xxx
center with HVI from 2000e2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury
Keywords:
were excluded. US Census (2000) median household income by zip code was used as
Trauma
socioeconomic proxy. Demographic and injury-related variables were also included.
Critical care
Endpoints were mortality and outcomes associated with HVI morbidity.
Healthcare disparities
Results: A total of 933 patients with HVI were identified and 256 met inclusion criteria. There
Hollow viscus injury
were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer
Payer status
source. However, lower median household income was significantly associated with longer
Blunt trauma
intervals to ostomy takedown (P ¼ 0.032). Additionally, private payers had significantly lower
Penetrating trauma
rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P ¼ 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P ¼ 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P ¼ 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P ¼ 0.036). Conclusions: Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source. ª 2013 Elsevier Inc. All rights reserved.
1.
Introduction
There is mounting evidence that nonclinical factors such as socioeconomic and insurance status impact health outcomes.
For example, disparity has been described with respect to race and cardiac revascularization [1], prevention and early detection of colorectal cancer [2], and rejection incidence following renal transplant [3]. Socioeconomic factors and, in
* Corresponding author. Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, 1211 21st Ave South, 404 Medical Arts Building, Nashville, TN 37212. Tel.: þ1 615 936 0189; fax: þ1 615 936 0185. E-mail address: [email protected] (O.D. Guillamondegui). 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.05.052
2
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 3 ) 1 e6
Fig. 1 e Exclusion criteria for patients with severe concomitant solid organ or vasculature injury and parameters for intervention.
particular, insurance status have been described to impact outcomes across medical conditions, perhaps more profoundly than race or income [4,5]. However, these factors may have a diminished effect on traumatic injury outcomes, particularly in the short term due to the emergent, standardized, and egalitarian nature of acute care. As Greene [6] notes, “Trauma care is one of the most protocolized and standardized systems of care.” Thus, the behavior of surgeons and allied health professionals may not be impacted by variations in socioeconomic status (SES) indicators within the limited timeline of standardized care that defines trauma acute care. Yet, recent large retrospective studies have shown that nonclinical factors may indeed impact mortality and postoperative morbidity in complex ways, especially when acute stabilization is completed and more long-term management is underway [7e10]. Although these studies indicate relationships between outcomes and SES, the extent and variability of socioeconomic correlation with morbidity and mortality remains unclear. There is also inherent confounding that complicates much of the literature, as many studies include large populations with heterogeneous injury patterns. Thus, this study was designed to characterize relationships among the homogenous population of abdominal hollow viscus injuries (HVI). HVI represent an injury pattern marked by early intervention and complex, yet well-characterized, convalescence and morbidity [11]. It is therefore an ideal focus for independently examining the impact of socioeconomic and nonclinical factors on both mortality and morbidity. The authors hypothesize that there is no difference between outcomes in trauma with isolated HVI based upon demographic or socioeconomic variables.
2.
Materials and methods
Institutional review board approval was obtained for this study. A retrospective review included all patients admitted to Vanderbilt University Medical Center, a level I trauma center, with HVI from the years 2000e2009, as identified in the Trauma Registry of the American College of Surgeons database. We
excluded patients with a concomitant significant solid organ or vascular injury, based upon abbreviated injury scales (AIS > 2) and ICD-9 codes of “severe,” and patients with initial surgical intervention beyond 48 h of admission. Cases were then stratified by small or large bowel injury, presence of an anastomosis, and diversion method. United States Census (2000) median household income was culled by zip code. Included were 112 known zip codes with a population clustering within the Vanderbilt level I catchment area. Additional demographic and injury-related variables were included, such as race, gender, age, payer source, blunt versus penetrating trauma, injury severity scale, intensive care unit (ICU) days, total hospital length of stay, “severe” or “nonsevere” HVI (ICD-9 code), and discharge disposition. Payer source was defined as self-pay (uninsured), government pay (including Medicare and Medicaid programs), and private pay (third-party commercial insurance). Low median outcome is defined as the lowest quartile. The primary endpoint was mortality, and secondary outcomes represented common endpoints associated with HVI morbidity, including ventral hernia, abscess, soft tissue infection, anastomotic leak, fascial dehiscence, and unplanned readmission. The interval to closure was recorded for patients with an open abdomen following their initial laparotomy, and the interval to ostomy takedown was recorded for patients with either ileostomy or colostomy. c2 test, Spearman rank correlation, and logistic regression analyses were utilized to identify relationships between SES and mortality/morbidities. Variables investigated with logistic regression include ICU days, hospital days, ISS, and median household income plotted against death. Analysis of variance was used to assess the differences among our groups with statistical significance with P values below 0.05. All analyses were performed within SPSS Statistics version 19 (IBM Corporation, Chicago, IL).
3.
Results
A total of 933 total patients with abdominal injury including HVI were identified from 2000e2009. Of these patients, 648
3
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 3 ) 1 e6
Table 1 e Population demographics. Variable
Total (n ¼ 256)
Private pay (n ¼ 73)
Gov’t pay (n ¼ 77)
Self-pay (n ¼ 100)
35.6 220 (86%) 125 (49%) 86 (34%) 40 (15.6)
36.8
37.8z
33.3y
52 (71%)y,z 14 (19%)z 4 (5.5%)y
35 (46%)* 16 (21%)z 25 (33%)*,z
35 (35%)* 53 (53%)*,y 11 (11%)y
$37,543
$39,983y,z
$36,342*
$36,918*
Demographic Age, y, mean Male, n (%) White, n (%) Black, n (%) Hispanic, n (%) Socioeconomic Median household income, mean y
P 0.101
