Insurance Type and Withdrawal of Life-Sustaining Therapy in Critically Injured Trauma Patients.

Importance: Withdrawal of life-sustaining therapy (WLST) decisions for critically injured trauma patients are complicated and multifactorial, with potential for patients' insurance status to affect decision-making. Objectives: To determine if patient insurance type (private insurance, Medicaid, and uninsured) is associated with time to WLST in critically injured adults cared for at US trauma centers. Design, Setting, and Participants: This retrospective registry-based cohort study included reported data from level I and level II trauma centers in the US that participated in the American College of Surgeons Trauma Quality Improvement Program (TQIP) registry. Participants included adult trauma patients who were injured between January 1, 2017, and December 31, 2020, and required an intensive care unit stay. Patients were excluded if they died on arrival or in the emergency department or had a preexisting do not resuscitate directive. Analyses were performed on December 12, 2023. Exposures: Insurance type (private insurance, Medicaid, uninsured). Main Outcomes and Measures: An adjusted time-to-event analysis for association between insurance status and time to WLST was performed, with analyses accounting for clustering by hospital. Results: This study included 307 731 patients, of whom 160 809 (52.3%) had private insurance, 88 233 (28.6%) had Medicaid, and 58 689 (19.1%) were uninsured. The mean (SD) age was 40.2 (14.1) years, 232 994 (75.7%) were male, 59 551 (19.4%) were African American or Black patients, and 201 012 (65.3%) were White patients. In total, 12 962 patients (4.2%) underwent WLST during their admission. Patients who are uninsured were significantly more likely to undergo earlier WLST compared with those with private insurance (HR, 1.54; 95% CI, 1.46-1.62) and Medicaid (HR, 1.47; 95% CI, 1.39-1.55). This finding was robust to sensitivity analysis excluding patients who died within 48 hours of presentation and after accounting for nonwithdrawal death as a competing risk. Conclusions and Relevance: In this cohort study of US adult trauma patients who were critically injured, patients who were uninsured underwent earlier WLST compared with those with private or Medicaid insurance. Based on our findings, patient's ability to pay was may be associated with a shift in decision-making for WLST, suggesting the influence of socioeconomics on patient outcomes.

GAPS phase II: development and pilot results of the global assessment in pediatric surgery, an evidence-based pediatric surgical capacity assessment tool for low-resource settings.

PURPOSE: Pediatric surgical care in low- and middle-income countries is often hindered by systemic gaps in healthcare resources, infrastructure, training, and organization. This study aims to develop and validate the Global Assessment of Pediatric Surgery (GAPS) to appraise pediatric surgical capacity and discriminate between levels of care across diverse healthcare settings. METHODS: The GAPS Version 1 was constructed through a synthesis of existing assessment tools and expert panel consultation. The resultant GAPS Version 2 underwent international pilot testing. Construct validation categorized institutions into providing basic or advanced surgical care. GAPS was further refined to Version 3 to include only questions with a > 75% response rate and those that significantly discriminated between basic or advanced surgical settings. RESULTS: GAPS Version 1 included 139 items, which, after expert panel feedback, was expanded to 168 items in Version 2. Pilot testing, in 65 institutions, yielded a high response rate. Of the 168 questions in GAPS Version 2, 64 significantly discriminated between basic and advanced surgical care. The refined GAPS Version 3 tool comprises 64 questions on: human resources (9), material resources (39), outcomes (3), accessibility (3), and education (10). CONCLUSION: The GAPS Version 3 tool presents a validated instrument for evaluating pediatric surgical capabilities in low-resource settings.

A multidimensional approach to identifying high-performing trauma centers across the United States.

INTRODUCTION: The differentiators of centers performing at the highest level of quality and patient safety are likely both structural and cultural. We aimed to combine five indicators representing established domains of trauma quality and to identify and describe the structural characteristics of consistently performing centers. METHODS: Using American College of Surgeons Trauma Quality Improvement Program data from 2017 to 2020, we evaluated five quality measures across several care domains for adult patients in levels I and II trauma centers: (1) time to operating room for patients with abdominal gunshot wounds and shock, (2) proportion of patients receiving timely venous thromboembolism prophylaxis, (3) failure to rescue (death following a complication), (4) major hospital complications, and (5) mortality. Overall performance was summarized as a composite score incorporating all measures. Centers were ranked from highest to lowest performer. Principal component analysis showed the influence of each indicator on overall performance and supported the composite score approach. RESULTS: We identified 272 levels I and II centers, with 28 and 27 centers in the top and bottom 10%, respectively. Patients treated in high-performing centers had significant lower rates of death major complications and failure to rescue, compared with low-performing centers ( p < 0.001). The median time to operating room for gunshot wound was almost half that in high compared with low-performing centers, and rates of timely venous thromboembolism prophylaxis were over twofold greater ( p < 0.001). Top performing centers were more likely to be level I centers and cared for a higher number of severely injured patients per annum. Each indicator contributed meaningfully to the variation in scores and centers tended to perform consistently across most indicators. CONCLUSION: The combination of multiple indicators across dimensions of quality sets a higher standard for performance evaluation and allows the discrimination of centers based on structural elements, specifically level 1 status, and trauma center volume. LEVEL OF EVIDENCE: Therapeutic /Care Management; Level IV.

Factors associated with acute respiratory distress syndrome in brain-injured patients: A systematic review and meta-analysis.

PURPOSE: Acute respiratory distress syndrome (ARDS) is common in patients with acute brain injury admitted to the ICU. We aimed to identify factors associated with ARDS in this population. METHODS: We searched MEDLINE, Embase, Cochrane Central, Scopus, and Web of Science from inception to January 14, 2022. Three reviewers independently screened articles and selected English-language studies reporting risk factors for ARDS in brain-injured adult patients. Data were extracted on ARDS incidence, adjusted and unadjusted risk factors, and clinical outcomes. Risk of bias was reported using the Quality in Prognostic Studies tool. Certainty of evidence was assessed using GRADE. RESULTS: We selected 23 studies involving 6,961,284 patients with acute brain injury. The pooled cumulative incidence of ARDS after brain injury was 17.0% (95%CI 10.7-25.8). In adjusted analysis, factors associated with ARDS included sepsis (odds ratio (OR) 4.38, 95%CI 2.37-8.10; high certainty), history of hypertension (OR 3.11, 95%CI 2.31-4.19; high certainty), pneumonia (OR 2.69, 95%CI 2.35-3.10; high certainty), acute kidney injury (OR 1.44, 95%CI 1.30-1.59; moderate certainty), admission hypoxemia (OR 1.67, 95%CI 1.29-2.17; moderate certainty), male sex (OR 1.30, 95%CI 1.06-1.58; moderate certainty), and chronic obstructive pulmonary disease (OR 1.27, 95%CI 1.13-1.44; moderate certainty). Development of ARDS was independently associated with increased odds of in-hospital mortality (OR 3.12, 95% CI 1.39-7.00). CONCLUSIONS: Multiple risk factors are associated with ARDS in brain-injured patients. These findings could be used to develop prognostic models for ARDS or as prognostic enrichment strategies for patient enrolment in future clinical trials.

Error reduction in trauma care: Lessons from an anonymized, national, multicenter mortality reporting system.

BACKGROUND: Twenty years ago, the landmark report To Err Is Human illustrated the importance of system-level solutions, in contrast to person-level interventions, to assure patient safety. Nevertheless, rates of preventable deaths, particularly in trauma care, have not materially changed. The American College of Surgeons Trauma Quality Improvement Program developed a voluntary Mortality Reporting System to better understand the underlying causes of preventable trauma deaths and the strategies used by centers to prevent future deaths. The objective of this work is to describe the factors contributing to potentially preventable deaths after injury and to evaluate the effectiveness of strategies identified by trauma centers to mitigate future harm, as reported in the Mortality Reporting System. METHODS: An anonymous structured web-based reporting template based on the Joint Commission on Accreditation of Healthcare Organizations taxonomy was made available to trauma centers participating in the Trauma Quality Improvement Program to allow for reporting of deaths that were potentially preventable. Contributing factors leading to death were evaluated. The effectiveness of mitigating strategies was assessed using a validated framework and mapped to tiers of effectiveness ranging from person-focused to system-oriented interventions. RESULTS: Over a 2-year period, 395 deaths were reviewed. Of the mortalities, 33.7% were unanticipated. Errors pertained to management (50.9%), clinical performance (54.7%), and communication (56.2%). Human failures were cited in 61% of cases. Person-focused strategies like education were common (56.0%), while more effective system-based strategies were seldom used. In 7.3% of cases, centers could not identify a specific strategy to prevent future harm. CONCLUSION: Most strategies to reduce errors in trauma centers focus on changing the performance of providers rather than system-level interventions such as automation, standardization, and fail-safe approaches. Centers require additional support to develop more effective mitigations that will prevent recurrent errors and patient harm. LEVEL OF EVIDENCE: Therapeutic/Care Management, level V.