A statewide, hospital-based analysis of frequency and outcomes in carotid endarterectomy.

BACKGROUND: For more than 40 years carotid endarterectomy (CE) has been used in the treatment of extracranial carotid disease for the prevention of stroke. Recent prospective clinical trials have confirmed the benefit of CE for both symptomatic and asymptomatic patients. Our purpose was to examine statewide trends in the numbers of CE over a 6-year time period and to evaluate outcomes. METHODS: Using data from the North Carolina Medical Database Commission (NCMDC) all CE procedures from 1988 to 1993 were identified. Numbers of CE were compared with the population and hospital admissions. Variables of length of stay, hospital charges, discharge disposition, and occurrence of stroke and death were analyzed. RESULTS: A total of 11,973 CE were performed in 6 years. Compared by admissions, population, and the proportion of elderly, the number of CE increased yearly. The stroke rate was 1.7% and the death rate 1.2% for an overall in-hospital stroke plus mortality rate of only 2.7%. CONCLUSIONS: From a diverse group of hospitals and a large number of surgeons and patients, this hospital-based study documents the acceptance and safety of CE in the treatment of extracranial carotid disease.

Management outcomes in splenic injury: a statewide trauma center review.

OBJECTIVE: Clinical pathways now highlight both observation and operation as acceptable initial therapeutic options for the management of patients with splenic injury. The purpose of this study was to evaluate treatment trends for splenic injury in all North Carolina trauma centers over a 6-year period. METHODS: Splenic injuries in adults over a 6-year period (January 1988-December 1993) were identified in the North Carolina Trauma Registry using ICD-9-CM codes. Patients were divided into four groups by method of management: 1) no spleen operation, 2) splenectomy, 3) definitive splenorrhaphy, and 4) splenorrhaphy failure followed by splenectomy. The authors examined age, mechanism of injury, admitting blood pressure, and severity of injury by trauma score and injury severity score. SUMMARY BACKGROUND DATA: Comparisons were made between adult (17-64 years of age) and geriatric (older than 65 years of age) patients and between patients with blunt and penetrating injury. Resource utilization (length of stay, hospital charges) and outcome (mortality) were compared. RESULTS: One thousand two hundred fifty-five patients were identified with splenic injury. Rate of splenic preservation increased over time and was achieved in more than 50% of patients through nonoperative management (40%) and splenorrhaphy (12%). Splenorrhaphy was not used commonly in either blunt or penetrating injury. Overall mortality was 13%. Geriatric patients had a higher mortality and resource utilization regardless of their mechanism of injury or method of management. CONCLUSIONS: Nonoperative management represents the prevailing method of splenic preservation in both the adult and geriatric population in North Carolina trauma center hospitals. Satisfactory outcomes and economic advantages accompany nonoperative management in this adult population.

Splenic salvage in adults at a level II community hospital trauma center.

Recognition of the important role of the spleen within the immune system has prompted surgeons to regularly consider splenic preservation. We studied our experience at a Level II trauma center to determine whether this trend is reflected in our management. We reviewed 81 adult blunt trauma patients with splenic injury admitted between January 1988 and December 1993. We examined age, race, and clinical data including mechanism of injury, trauma and injury severity scores, organ injury scale (OIS) grade, admitting blood pressure, operations, length of stay, hospital charges, and outcome. Thirty-nine patients underwent immediate splenectomy. Nonoperative treatment was successful in 31 of 37 patients (83.7%). Mean OIS grade (American Association for the Surgery of Trauma) was significantly different between patients treated nonoperatively (1.6 +/- 0.9) and patients treated with immediate splenectomy (3.9 +/- 1.1), (P = <0.001). American Association for the Surgery of Trauma OIS grade correlated well between CT classification and classification at operation (r = 0.7, P = 0.0001) but did not predict success in nonoperative management. Hemodynamic stability, injury severity, and abdominal CT scan findings determine choice of therapy. Splenorrhaphy is frequently discussed but infrequently performed. Splenectomy remains the most commonly performed operation for splenic injury in adults with blunt splenic trauma. Nonoperative management is the most common method of splenic salvage at the Level II community hospital trauma center.

Fine-needle aspiration cytology and thyroid surgery in the community hospital.

BACKGROUND: To assess the use and usefulness of fine-needle aspiration cytologic biopsy (FNAB) of the thyroid in our hospital. METHODS: All cytology slides and charts of patients who had FNAB of the thyroid done in our hospital in 1993 were reviewed. Charts of all patients having thyroid surgery in our hospital in 1993 were reviewed to determine the pathological diagnosis and whether FNAB had been performed preoperatively. Finally, we reviewed all consecutive thyroid surgery cases for an 8-year period, and we calculated the yearly percentage of malignancy. RESULTS: Fifty-five FNAB were done in 53 patients. In 21 patients the FNAB gave indication for thyroid surgery, yet surgery was done in only 12 (57.1%). Forty-two patients had surgery for a thyroid nodule, but only 20 patients (47.6%) had a preoperative FNAB. There were 3 malignancies among the 20; 2 were correctly predicted by FNAB. The FNAB was correct in 18 of 20. In all, 378 thyroid operations were done from 1987 to 1994. The yearly proportion of thyroid malignancy ranged from 11% to 29%, but showed no change corresponding with increasing diagnostic sophistication. CONCLUSIONS: Fine-needle aspiration cytologic biopsy in the workup of patients with thyroid masses is strikingly underutilized in our institution. While accurate in 90% of cases where used, FNAB appears to play a minor role in the surgeon's decision regarding surgery. As a result of these findings, we developed a grading system for better communication of the FNAB report and a clinical guideline to improve the evaluation of patients with thyroid masses.

Patient, hospital, and surgeon factors associated with breast conservation surgery. A statewide analysis in North Carolina.

OBJECTIVE: The objective of this study was to determine the trend of breast conservation surgery (BCS) in North Carolina over a 6-year period and to identify patient, hospital, and surgeon factors associated with the use of BCS. SUMMARY BACKGROUND DATA: Despite evidence that BCS is an appropriate method of treatment for early stage breast cancer, surgeons in the United States have been slow to adopt this treatment method. METHODS: Cases of primary breast cancer surgery in all 157 hospitals in the state from 1988 to 1993, inclusive (N = 20,760), were obtained from the State Medical Database Commission, Area Resource File, American Hospital Association and State Board of Medical Examiner's Databases. Multiple logistic regression was used to generate odds ratios (ORs) and 95% confidence intervals (CIs) to determine factors associated with BCS. RESULTS: The rate of BCS doubled from 7.3% in 1988 to 14.3% in 1993, with an overall rate of 10.2% (2117/ 20.760). Multiple logistic regression identified the following factors associated with BCS: patient age younger than 50 years of age (OR = 1.7, 95% CI = 1.4, 2.1), patient age 50 to 69 years of age (OR = 1.2, 95% CI = 1.1, 1.4), private insurance (OR = 1.2, 95% CI = 1.0, 1.4), hospital bed size 401+(OR = 2.0, 95% CI = 1.6, 2.5), bed size 101 to 400 (OR = 1.7, 95% CI = 1.3, 2.1), and surgeon graduation from medical school since 1981 (OR = 1.6, 95% CI = 1.2, 2.0). CONCLUSIONS: Rates of BCS in North Carolina are low. Least likely to have BCS were women older than 70 years of age, without private insurance, treated at small hospitals by older surgeons. To increase the use of BCS, widespread education of surgeons, other health care providers, policy makers, and the general public is warranted.

Poor hospital documentation of violence against women.

OBJECTIVE: This study sought to determine if violence against women is accurately documented in the trauma registry, and if poor documentation in the medical record is associated with incorrect coding in the registry. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We identified women aged 15 to 49 in the trauma registry of a regional medical center who had unintentional and intentional injuries over three years, and retrospectively reviewed their medical records to verify registry coding. MEASUREMENTS AND MAIN RESULTS: Of the 41 assault victims in the registry, 32 were verified by the medical record. Of the 87 unintentional injuries, only 28 were verified; 21 were assault victims according to the medical record, and for the remaining 38, the medical record was too vague to determine intentionality. Thus, the sensitivity of the trauma registry in documenting violence against women was only 57%. Injuries correctly coded in the registry had the details well documented in the medical record, whereas injuries incorrectly coded had poor documentation in the medical record. CONCLUSIONS: Violence against women often goes undocumented in hospital data systems.

Factors affecting number of prenatal care visits during second pregnancy among adolescents having rapid repeat births.

PURPOSE: To examine factors associated with the number of prenatal care visits during second pregnancy for adolescents having a short interval between pregnancies. METHODS: The sample includes all adolescents aged 13 to 17 years whose first pregnancy resulted in a birth at a regional medical center in southeastern North Carolina from January 1983 to December 1989 and who had a repeat pregnancy within 24 months which resulted in a birth. We abstracted data from medical records and birth certificates. We fit a negative binomial regression model to determine the effects of various factors on the number of prenatal care visits during second pregnancy. RESULTS: The number of prenatal care visits during the first pregnancy, poor first birth outcome, interval between first and second pregnancy, and care provided by health department staff during first pregnancy were all positively associated with number of prenatal care visits during second pregnancy when controlling for gestation age of second birth. Other independent variables in the model included maternal age, education, black race, and being unmarried at the time of second birth. CONCLUSIONS: Because prenatal care is important for healthy mothers and babies, adolescents should be encouraged to seek prenatal care early in the first pregnancy. This could be an important time to implement interventions aimed at increasing prenatal care utilization in this and subsequent pregnancies.

PIP: Researchers analyzed data on 287 adolescents who delivered their first child between January 1983 and December 1989 at a regional medical center in southeastern North Carolina and had a repeat pregnancy within 24 months of the first birth to identify factors linked to the number of prenatal care visits during the second pregnancy for these adolescents. They were 13-17 years old during the first pregnancy and 15-19 years old during the second pregnancy. The interval between pregnancies was no more than 12 months for about 50% of the teens and no more than 18 months for more than 80%. The mean interval between pregnancies was 11.1 months. The teens were more likely to have received no prenatal care during their second pregnancy than their first pregnancy (7.9% vs. 2.9%; p 0.001). They also had fewer prenatal visits (7.5 vs. 9.2; p 0.0001). After controlling for gestation age of second birth, factors positively associated with the number of prenatal care visits during the second pregnancy were poor first birth outcome, number of prenatal care visits during first pregnancy, pregnancy interval, and care provided by the county health department. A poor first birth outcome had the greatest impact on the number of prenatal care visits during second pregnancy. These findings indicate the need to encourage teens to seek prenatal care early in their first pregnancy so clinicians can implement interventions which increase prenatal care use during this and subsequent pregnancies.

The financial impact of intentional violence on community hospitals.

The purpose of this study was to examine the financial impact of assault-related penetrating trauma. We specifically reviewed hospital charges and reimbursement data. Two hundred eleven patients were identified from our Trauma Registry in a 4-year period: 108 with firearm injuries and 103 with injuries related to cutting or piercing instruments. Assault-related penetrating injuries generated more than $2,000,000 in hospital charges. Sixty-seven percent of this amount was incurred by patients who had no source of third-party payment. Reimbursement covered only 30% of charges. There were no differences in demographics, procedures, or in insurance status, mean charges, and unpaid balances between patients directly admitted and those transferred from other hospitals. Financial losses incurred by community hospitals from the care of penetrating injuries are substantial, and must be borne by cost shifting or other strategies. No evidence of "dumping" was found among this group of patients. The specter of injury caused by intentional violence extends beyond urban trauma centers, and has a serious negative financial impact on community trauma centers.

Oral contrast is not necessary in the evaluation of blunt abdominal trauma by computed tomography.

The administration of oral contrast (OC) is widely recommended for computed tomography (CT) of the abdomen in patients with blunt trauma. The purpose of this study was to determine whether routine abdominal CT scans performed without OC were associated with diagnostic error in patients with blunt trauma. Four hundred ninety-two patients were identified from our Trauma Registry who had CT scans for the evaluation of blunt abdominal trauma between January 1988 and December 1991. Seventy-six percent (372) of the CT scans were interpreted as negative, and 24% (120) were considered positive. OC was used in 8 (1.6%) of 492 patients. Only 1 of 372 patients whose initial non-OC--enhanced scan was negative subsequently required surgery. There were 5 bowel injuries among the 42 patients who underwent an abdominal operation; in none would the use of OC have ensured the preoperative diagnosis. We found that the omission of OC did not represent a disadvantage to patients with blunt trauma undergoing a routine abdominal CT scan. Potential time delays and the hazards associated with the use of OC were minimized.

Results of staged bilateral carotid endarterectomy.

To determine differences in outcome between unilateral and staged bilateral carotid endarterectomies, we reviewed 850 carotid endarterectomies done by 14 surgeons in a community hospital. Results of 528 unilateral procedures were compared with those of 161 bilateral procedures. Data were abstracted from records for an 11-year period. Twelve of the patients in the unilateral group had nonfatal strokes, and 14 died within 30 days of surgery (stroke + death rate, 4.9%). There were no nonfatal strokes among patients in the bilateral group, and nine died (stroke + death rate, 5.6%). Seven of 14 deaths in the unilateral group and six of nine deaths in the bilateral group were due to neurologic events. In the bilateral group, death was associated with postoperative hypertension and a short intersurgical interval. The stroke + death rate was not significantly different between unilateral and bilateral procedures and compared favorably with North American Symptomatic Carotid Endarterectomy Trial guidelines and other published reports. Staged bilateral carotid endarterectomy can be safely performed in a community hospital.

The effects of a prematurity prevention program on births to adolescents.

This study evaluates the effectiveness of the North Carolina Prematurity Prevention Program in reducing low-birthweight births among adolescents seeking prenatal care at the New Hanover Memorial Hospital obstetric clinic. Modeled on programs developed by Papiernik and Creasy, the program includes three components: staff education, patient identification, and patient education. Thirteen percent of the clinic population is 13-17 years old. The same prematurity prevention protocol is used for both adults and adolescents. Overall, 12% of the 847 women who delivered prior to the program had a low-birthweight infant. Among the 748 women who delivered during the program, the number of low-birthweight infants declined to 9.5%. For mothers 13-17 years old, 14% of the preprogram group had a low-birthweight infant, as did 14% of those in the program. A logistic regression model, controlling for certain risk factors, suggests that the program was not effective in reducing low-birthweight births among these adolescents (OR = 0.9; 95% CI = 0.2, 1.8).

Effects of the North Carolina Prematurity Prevention Program among public patients delivering at New Hanover Memorial Hospital.

Twelve per cent of the 847 women who delivered in one hospital prior to implementation of the North Carolina Prematurity Prevention Program had low-birthweight births compared with 9.5 per cent of the 748 women who delivered during the program. Controlling for known risk factors, both low- and very-low birthweight births among Whites (Odds Ratio 2.0 and 3.7 respectively) and very-low-birthweight births among Blacks (OR 2.9) were reduced.