Morgan Madison E, Bradburn Eric H, Vernon Tawnya M, Gross Brian, Jammula Shreya, Cook Alan D, Covaci Andrea, Rogers Frederick B
428406 Trauma Services, Penn Medicine Lancaster General Health, Lancaster, PA, USA.
2092 Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA.
Am Surg. 2020 May;86(5):486-492. doi: 10.1177/0003134820919723.
Extended hospital length of stay (LOS) is widely associated with significant healthcare costs. Since LOS is a known surrogate for cost, we sought to evaluate outliers. We hypothesized that particular characteristics are likely predictive of trauma high resource consumers (THRC) and can be used to more effectively manage care of this population.
The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003-2017 for all adult (age ≥15) trauma patients admitted to accredited trauma centers in Pennsylvania. THRC were defined as patients with hospital LOS two standard deviations above the population mean or ≥22 days (p<0.05). Patient demographics, comorbid conditions and clinical variables were compared between THRC and non-THRC to identify potential predictor variables. A multilevel mixed-effects logistic regression model controlling for age, gender, injury severity, admission Glasgow coma score, systolic blood pressure, and injury year assessed the adjusted impact of clinical factors in predicting THRC status. The National Trauma Data Bank (NTDB) was retrospectively queried from 2014-2016 for all adult (age ≥15) trauma patients admitted to state-accredited trauma centers and likewise were assessed for factors associated with THRC.
A total of 465,601 patients met inclusion criteria [THRC: 16,818 (3.6%); non-THRC 448,783 (96.4%)]. Compared to non-THRC counterparts, THRC patients were significantly more severely injured (median ISS: 9 vs. 22, p<0.001). In adjusted analysis, gunshot wound (GSW) to the abdomen, undergoing major surgery and reintubation along with injury to the spine, upper or lower extremities were significantly associated with THRC. From the NTDB, 2 323 945 patients met inclusion criteria. In adjusted analysis, GSW to the abdomen was significantly associated with THRC. Penetrating injury overall was associated with decreased risk of being a THRC in the NTDB dataset. Those who had either GSW to abdomen, surgery, or reintubation required significantly longer LOS (p<0.001).
Reintubation, major surgery, gunshot wound to abdomen, along with injury to the spine, upper or lower extremities are all strongly predictive of THRC. Understanding the profile of the THRC will allow clinicians and case management to proactively put processes in place to streamline care and potentially reduce costs and LOS.
住院时间延长（LOS）与高额医疗费用广泛相关。由于住院时间是已知的费用替代指标，我们试图评估异常值。我们假设特定特征可能是创伤高资源消耗者（THRC）的预测指标，可用于更有效地管理该人群的护理。
回顾性查询2003 - 2017年宾夕法尼亚创伤结果研究数据库，纳入宾夕法尼亚州经认可的创伤中心收治的所有成年（年龄≥15岁）创伤患者。THRC定义为住院时间比人群均值高出两个标准差或≥22天的患者（p<0.05）。比较THRC和非THRC患者的人口统计学、合并症及临床变量，以确定潜在预测变量。采用多水平混合效应逻辑回归模型，控制年龄、性别、损伤严重程度、入院格拉斯哥昏迷评分、收缩压和损伤年份，评估临床因素对预测THRC状态的校正影响。回顾性查询2014 - 2016年国家创伤数据库（NTDB），纳入所有成年（年龄≥15岁）且入住州认可创伤中心的创伤患者，并同样评估与THRC相关的因素。
共有465,601例患者符合纳入标准[THRC：16,818例（3.6%）；非THRC：448,783例（96.4%）]。与非THRC患者相比，THRC患者的损伤明显更严重（中位损伤严重度评分：9 vs. 22，p<0.001）。校正分析显示，腹部枪伤（GSW）、接受大手术、再次插管以及脊柱、上肢或下肢损伤与THRC显著相关。从NTDB纳入的2,323,945例患者中，校正分析显示腹部GSW与THRC显著相关。在NTDB数据集中，总体穿透伤与成为THRC的风险降低相关。腹部GSW、手术或再次插管的患者住院时间显著更长（p<0.001）。
再次插管、大手术、腹部枪伤以及脊柱、上肢或下肢损伤均强烈提示为THRC。了解THRC的特征将使临床医生和病例管理人员能够主动采取措施简化护理流程，并可能降低成本和缩短住院时间。
