Uninsured status may be more predictive of outcomes among the severely injured than minority race

AimWorse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.MethodsWe performed a retrospective analysis of the 2010–2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18–64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.ResultsThere were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29–1.98, p < 0.001) and black race (OR 1.24, 1.04–1.49, p = 0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36–0.51, p < 0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29–2.19, p < 0.001) and decreased post-hospital care (OR 0.45, 0.32–0.63, p < 0.001).ConclusionUninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.     

The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy

Study objectivesSleeve gastrectomy has been one of the most commonly performed bariatric surgery methods. The study aimed to compare the effects of 2 most commonly used inhalation anesthetics, sevoflurane and desflurane, on the peroperative hemodynamic alterations and postoperative respiratory functions in morbidly obese patients undergoing sleeve gastrectomy.DesignNonrandomized cohort.SettingsOperating room, postoperative period.PatientsEighty-four morbidly obese patients with a body mass index greater than 40 kg/m² who had scheduled to undergo sleeve gastrectomy operation were prospectively included in the study.InterventionsPatients were divided into 2 groups. The maintenance of inhalation anesthesia was performed by sevoflurane in 1 group (sevoflurane group) and desflurane (desflurane group) in the other group.MeasurementsDemographic features, peroperative hemodynamic alterations, and the results of preoperative and postoperative 24th hour respiratory function tests were recorded.ResultsThere was not any statistically significant difference between groups regarding age, sex, body mass index, anesthesia time, peroperative mean arterial pressure, arterial oxygen saturation, end-tidal carbon dioxide, and preoperative or postoperative forced expiratory volume 1/forced vital capacity ratios.ConclusionWe determined that both desflurane and sevoflurane provide similar intraoperative hemodynamic and early postoperative respiratory functions in morbidly obese patients in laparoscopic sleeve gastrectomy. Both agents can be regarded as alternatives for inhalation anesthetics in maintenance of anesthesia.     

District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries

IntroductionProspective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly.MethodsConsensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8.ResultsPanellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1 – 0.58; Round 2 – 0.66; Round 3 – 0.76; and Round 4 – 0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage – vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation – a large bore IV was placed within 15 min of patient arrival; referral – if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer.ConclusionThis study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs.