Lesly A. Dossett, MD, MPH; Johanna N. Riesel, MD; Marie R. Griffin, MD, MPH; et al.
free access
Arch Surg. 2011;146(5):565-570. doi:10.1001/archsurg.2010.313
ObjectivesTo describe the prevalence of preinjury warfarin use in a large national sample of trauma patients and to define the relationship between preinjury warfarin use and mortality.DesignRetrospective cohort study.SettingThe National Trauma Databank (7.1).PatientsAll patients admitted to eligible trauma centers during the study period; 1聽230聽422 patients (36聽270 warfarin users) from 402 centers were eligible for analysis.Main Outcome MeasuresPrevalence of warfarin use and all-cause in-hospital mortality. Multivariate logistic regression was used to estimate the odds ratio (OR) for mortality associated with preinjury warfarin use.ResultsWarfarin use increased among all patients from 2.3% in 2002 to 4.0% in 2006 (P聽<聽.001), and in patients older than 65 years, use increased from 7.3% in 2002 to 12.8% in 2006 (P听&濒迟;听.001). Among all patients, 9.3% of warfarin users died compared with only 4.8% of nonusers (OR, 2.02; 95% confidence interval [CI], 1.95-2.10; P听&濒迟;听.001). After adjusting for important covariates, warfarin use was associated with increased mortality among all patients (OR, 1.72; 95% CI, 1.63-1.81; P聽<聽.001) and patients 65 years and older (OR, 1.38; 95% CI, 1.30-1.47; P听&濒迟;听.001).ConclusionsWarfarin use is common among injured patients and its prevalence has increased each year since 2002. Its use is a powerful marker of mortality risk, and even after adjusting for confounding comorbidities, it is associated with a significant increase in death.
Ulf O. Gustafsson, MD, PhD; Jonatan Hausel, MD; Anders Thorell, MD, PhD; et al.
free access
Arch Surg. 2011;146(5):571-577. doi:10.1001/archsurg.2010.309
ObjectivesTo study the impact of different adherence levels to the enhanced recovery after surgery (ERAS) protocol and the effect of various ERAS elements on outcomes following major surgery.DesignSingle-center prospective cohort study before and after reinforcement of an ERAS protocol. Comparisons were made both between and across periods using multivariate logistic regression. All clinical data (114 variables) were prospectively recorded.SettingErsta Hospital, Stockholm, Sweden.PatientsNine hundred fifty-three consecutive patients with colorectal cancer: 464 patients treated in 2002 to 2004 and 489 in 2005 to 2007.Main Outcome MeasuresThe association between improved adherence to the ERAS protocol and the incidence of postoperative symptoms, complications, and length of stay following major colorectal cancer surgery was analyzed.ResultsFollowing an overall increase in preoperative and perioperative adherence to the ERAS protocol from 43.3% in 2002 to 2004 to 70.6% in 2005 to 2007, both postoperative complications (odds ratio, 0.73; 95% confidence interval, 0.55-0.98) and symptoms (odds ratio, 0.53; 95% confidence interval, 0.40-0.70) declined significantly. Restriction of intravenous fluid and use of a preoperative carbohydrate drink were major independent predictors. Across periods, the proportion of adverse postoperative outcomes (30-day morbidity, symptoms, and readmissions) was significantly reduced with increasing adherence to the ERAS protocol (>70%, >80%, and >90%) compared with low ERAS adherence (<50%).ConclusionImproved adherence to the standardized multimodal ERAS protocol is significantly associated with improved clinical outcomes following major colorectal cancer surgery, indicating a dose-response relationship.
Mark L. Francis, MD; Steven L. Scaife, MS; Whitney E. Zahnd, MS
free access
Arch Surg. 2011;146(5):579-583. doi:10.1001/archsurg.2010.306
ObjectiveTo determine whether Medicare beneficiaries in rural areas were less likely to undergo a variety of surgical procedures compared with their urban counterparts.Design, Setting, and PatientsCross-sectional study of Medicare beneficiaries.Main Outcome MeasureAny incidence of the surgical procedures studied.ResultsCompared with urban Medicare beneficiaries, rural Medicare beneficiaries were more likely to undergo a broad array of surgical procedures: 35% more likely for carotid endarterectomy (odds ratio [OR]聽=聽1.35; 95% confidence interval [CI], 1.33-1.38), 32% for lumbar spine fusion (OR聽=聽1.32; 95% CI, 1.29-1.35), 30% for knee replacement surgery (OR聽=聽1.30; 95% CI, 1.28-1.31), 28% for abdominal aortic aneurysm repair (OR聽=聽1.28; 95% CI, 1.24-1.31), 22% for prostatectomy (OR聽=聽1.22; 95% CI, 1.19-1.24), 19% for hip replacement surgery (OR聽=聽1.19; 95% CI, 1.17-1.21), 18% for aortic valve replacement (OR聽=聽1.18; 95% CI, 1.14-1.21), 16% for open reduction and internal fixation of the femur (OR聽=聽1.16; 95% CI, 1.14-1.18), and 15% for appendectomy (OR聽=聽1.15; 95% CI, 1.11-1.19). To determine whether these differences could be explained by known confounding variables, we then used logistic regression to adjust for age, sex, race/ethnicity, median household income, average house value, mean poverty ratio, and state of residence. Rural beneficiaries were still more likely to undergo all of these surgical procedures.ConclusionsMedicare beneficiaries living in rural areas were more likely to undergo a broad array of surgical procedures compared with those living in urban areas. While allaying some concern about rural access to surgical procedures, the uniformity of these results raises concern that people living in rural areas may have an overall poorer quality of health.
Renee Y. Hsia, MD, MSc; Ewen Wang, MD; Olga Saynina, MS; et al.
free access
Arch Surg. 2011;146(5):585-592. doi:10.1001/archsurg.2010.311
ObjectivesTo estimate the likelihood of trauma center admission for injured elderly patients with trauma, determine trends in trauma center admissions, and identify factors associated with trauma center use for elderly patients with trauma.DesignRetrospective analysis.SettingAcute care hospitals in California.PatientsAll patients hospitalized for acute traumatic injuries during the period from January 1, 1999, to December 31, 2008 (n聽=聽430聽081). Patients who had scheduled admissions for nonacute or minor trauma were excluded.Main Outcome MeasureLikelihood of admission to level I or II trauma center was calculated according to age categories after adjusting for patient and system factors.ResultsOf 430聽081 patients admitted to California acute care hospitals for trauma-related diagnoses, 27% were older than 65 years. After adjusting for demographic, clinical, and system factors, compared with trauma patients aged 18-25 years, the odds of admission to a trauma center decreased with increasing age; patients aged 26-45 years had lower odds (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.71-0.80) of being admitted to a trauma center for their injuries than did patients 46-65 years of age (OR, 0.57; 95% CI, 0.54-0.60), patients 66-85 years of age (OR, 0.35; 95% CI, 0.30-0.41), and patients older than 85 years (OR, 0.30; 95% CI, 0.25-0.36). Similar patterns were found when stratifying the analysis by trauma type and severity. Living more than 50 miles away from a trauma center (OR, 0.03; 95% CI, 0.01-0.06) and lack of county trauma center (OR, 0.17; 95% CI, 0.09-0.35) were also predictors of not receiving trauma care.ConclusionAge and likelihood of admission to a trauma center for injured patients were observed to be inversely proportional after controlling for other factors. System-level factors play a major role in determining which injured patients receive trauma care.
Molly M. Cone, MD; Daniel O. Herzig, MD; Brian S. Diggs, PhD; et al.
free access
Arch Surg. 2011;146(5):594-599. doi:10.1001/archsurg.2011.79
Nicholas H. Osborne, MD; Amir A. Ghaferi, MD; Lauren H. Nicholas, PhD; et al.
free access
Arch Surg. 2011;146(5):600-604. doi:10.1001/archsurg.2011.119
Xavier Serra-Aracil, MD; Eloi Espin-Basany, MD; Sebastiano Biondo, MD; et al.
free access
Arch Surg. 2011;146(5):606-612. doi:10.1001/archsurg.2011.90
Stephen W. Behrman, MD; Michael H. Bahr, MD; Paxton V. Dickson, MD; et al.
free access
Arch Surg. 2010;146(5):613-619. doi:10.1001/archsurg.2011.85