Biomedical subjects

E J MacKenzie

Publications and source records attributed to E J MacKenzie.

At least 55 records · Page 3Linked to original sources

PubMed1991

Evaluating quality, cost-effective health care. Vascular database predicated on hospital discharge abstracts.

This population-based study examines all carotid endarterectomies (CE) performed by all surgeons in a single state over a 10-year period. The methodology is designed to determine morbidity rate, mortality rate, cost, and length of stay, as well as to understand the effect of pre-existing chronic disease, physician, and hospital volume on these outcome variables. The data source consisted of hospital discharge abstract data uniformly collected on all admissions (N = 5.9 million) to acute care hospitals in the state. In the decade 1979 to 1988, 11,199 patients underwent CE. Mortality rate from CE was 2.1%, and the postoperative stroke rate was 3.7% over this period. High physician volume decreased the mortality rate (p less than 0.05) and stroke rate (p less than 0.01) by 50% and significantly (p less than 0.001) reduced hospital cost and length of stay independent of patient complexity. Examination of cost data, adjusted for inflation, showed a decrease in mean cost for CE over the decade. Thus physicians are providing better care for less hospital dollars. Both patient and payor outcome is improved by concentrating CE patients in the hands of high-volume surgeons. Although the data suggests this trend is already evolving, the pace of this evolution can be expected to increase as payors recognize that regionalization of this procedure lowers costs.

Arteriosclerosis↗

PubMed1991

Effect of associated injuries and blood volume replacement on death, rehabilitation needs, and disability in blunt traumatic brain injury.

OBJECTIVE: To examine the effects of associated injuries on death, disability, rehabilitation needs, and cost in patients with blunt traumatic brain injury. DESIGN: A retrospective case series analysis of 1,709 patients with blunt traumatic brain injury, or 37.2% of 4,590 consecutive blunt trauma patients, was combined with a prospective study of a subset of 202 of the 1,709 brain-injured patients obtained during the same time period with regard to need for rehabilitation services, residual disability, and costs at 1 yr after discharge from the acute trauma center. SETTING: A level I regional trauma center that is also the statewide neurotrauma and multiple trauma unit serving a population of more than 3 million persons. RESULTS: Contingency table analysis showed the Glasgow Coma Scale to be highly predictive (p less than .0001) of likelihood of mortality, need for postacute inpatient rehabilitation, or discharge home. Of the blunt traumatic brain injury patients, 40.4% (691) had an isolated brain injury and 59.6% (1,018) had brain plus at least one other systemic injury. The mortality rate of the isolated brain injury group was 11.1% compared with 21.8% in all brain plus systemic injury groups (p less than .0001). Spine, lung, visceral, pelvis, or extremity injuries in blunt traumatic brain injury all increased mortality rate to greater than 25% (all simultaneously significant, p less than .0001). Analysis of the interaction of brain injury (quantified by Glasgow Coma Scale) with blood replacement in the initial 24 hrs showed that at any Glasgow Coma Scale range, percent mortality increased as the volume of blood increased. Hypovolemic shock increased the mortality rate from 12.8% to 62.1% (p less than .0001). The need for postacute inpatient rehabilitation in survivors also increased as blood replacement increased, and shock increased the percent of patients requiring post-acute inpatient rehabilitation from 39.7% to 60.3%. In 202 consecutive surviving brain trauma patients followed for 1 yr, isolated brain-injured patients with moderate brain injuries had a 4% need for posttrauma, postacute inpatient rehabilitation with a total cost per case of $12,489 compared with the brain plus extremity injury group, who had a 23% postacute inpatient rehabilitation rate and a total cost per case of $36,177 at 1 yr. With severe brain injury, isolated brain injury increased postacute inpatient rehabilitation to 29% and 1-yr cost to $59,274, but with the brain plus extremity injury group, postacute inpatient rehabilitation increased to 49% and cost to $84,950. CONCLUSIONS: In blunt traumatic brain injury, the addition of major visceral or extremity injuries, with need for blood replacement or shock, increases the risk of death, the need for rehabilitation, and the costs of disability.

Baltimore↗

PubMed1991

Trauma patients return to productivity.

Economic issues threaten the development of a national trauma system. Much work has focused on the cost of trauma care; little has been done to define society's long-term economic return. We asked three questions about high cost trauma patients: (1) Do they survive?, (2) Do they continue to require expensive care?, and (3) Do they return to productivity? Of 6,129 consecutive trauma admissions, 114 had hospital charges over $100,000 (mean = $143,000), 102 (89.5%) were discharged alive, and 10 (8.8%) were lost to followup. Ninety-two patients or families were interviewed at least 1 year (mean = 2.6 year) after discharge. There were 88 survivors and 4 deaths (3.5%). Of the 88 survivors 73% had no limitation of ADLs, 67% received rehabilitation, 58% were still improving, and 37% were involved in litigation. Five survivors (5.7%) were confined to a nursing home, 48 (54.5%) had returned to productivity (RTP), 35 (39.8%) were unemployed, and five of these still require medical therapy. We conclude: (1) The majority of high cost patients survive (89.5%) and return to productivity (54.5%); (2) the severity of injury predicts survival but not return to productivity; and (3) the RTP rate may be increased by addressing nonmedical need.

Activities of Daily Living↗

PubMed1991

Trauma care reimbursement: comparison of DRGs to an injury severity-based payment system.

Concern exists that per case payment using Diagnosis Related Groups (DRGs) inadequately pays trauma centers. In this study, 45 Trauma Resource Groups (TRGs), an alternative patient classification system based on the Injury Severity Score and patient age, is developed and compared to 172 Diagnosis Related Groups (DRGs) that include trauma diagnoses. TRGs were developed using 1983 Maryland trauma patient hospital discharge abstracts (n= 34,702), the same source used to assign a DRG. We compared estimated TRG and DRG payments to actual charges for 17,398 trauma cases treated during 1986 at five trauma centers and 18 community hospitals in the Central Maryland Metropolitan Statistical Area. The unexpected findings of this study are that an anatomic severity-based classification of hospital trauma discharges (TRGs) does not perform as well as DRGs in: 1) explaining variations in length of stay for trauma cases, or 2) assuring an appropriate distribution of revenues to regional trauma centers and community hospitals. Solutions discussed include segregating community hospital and trauma center costs in computation of average per case rate setting, and inclusion of physiologic and mechanism of injury parameters in prospective payment classification systems to increase explained variance of resource use.

Diagnosis-Related Groups↗

PubMed1991

Trauma case mix and hospital payment: the potential for refining DRGs.

Uniform hospital discharge abstract data from Maryland were used to examine the homogeneity of trauma-related DRGs with respect to a well-established measure of injury severity, the Injury Severity Score (ISS). Thirty DRGs were identified as including trauma cases with a wide range of severity; for each of these DRGs, ISS explains a significant amount of variation in length of stay. By applying statistical techniques similar to those used to create the original DRG groupings, these 30 DRGs were subdivided by severity and age categories to create a new set of severity-modified DRGs. The potential effects of using DRGs and modified DRGs to pay for inpatient care within the Maryland state regionalized system of trauma care were examined. Payments based on regional averages per DRG and per modified DRG were compared to actual hospital charges regulated by the state's Health Services Cost Review Commission. Using average charges per DRG as a basis of payment, approximately !1.4 million (11 percent of total hospital charges) would be shifted from trauma centers to nontrauma centers. This shift represents an 18 percent loss in revenues to trauma centers and a 30 percent gain in revenues to nontrauma centers. Using a payment system based on severity-modified DRGs, trauma centers would still experience a net loss in revenues and the nontrauma centers a net gain, but the total amount of the shift would be reduced from $11.4 million to $9.8 million. The results argue for the need to explore alternative payment systems not strictly based on current DRGs. Because of DRGs do not adequately reflect severity differences, using them to pay hospitals will create financial incentives that discourage regionalization of trauma care.

Analysis of Variance↗

PubMed1990

The effect of preexisting conditions on mortality in trauma patients.

A case-control design was used to investigate the effects of preexisting chronic conditions on in-hospital mortality in adult trauma patients. Cases consisted of all trauma deaths (n = 3074) that occurred in 1983 in any of the 331 acute care hospitals in California. Three to four control patients (injured survivors) were matched to each case patient on the basis of injury severity, age, and individual hospital (n = 9869). The data source consisted of hospital discharge abstract data uniformly collected on all admissions to acute care hospitals in the state. Conditional logistic regression techniques were used to estimate the relative odds of dying for patients with and without one or more of 11 preexisting chronic conditions identified as potentially detrimental to outcome. The presence of cirrhosis (relative odds = 4.5), congenital coagulopathy (relative odds = 3.2), ischemic heart disease (relative odds = 1.8), chronic obstructive pulmonary disease (relative odds = 1.8), and diabetes (relative odds = 1.2) all significantly increased the risk of dying. These data provide statistical evidence to support the recommendation of the American College of Surgeons that the presence of underlying disease be considered in decisions to triage and transfer patients to trauma centers. They also underscore the importance of underlying disease in the case-mix adjustment of case-fatality rates and the identification of unexpected deaths for quality assurance review.

Adolescent↗

PubMed1990

Acute hospital costs of pediatric trauma in the United States: how much and who pays?

National estimates of the numbers and expenditures associated with hospitalization due to injury among children (aged 0 to 14) were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS) and the 1980 National Medical Care Utilization and Expenditures Study (NMCUES). In this report, age- and sex-specific estimates of the numbers of hospital admissions and expenditures are reported for subgroup of patients defined by external cause of the injury and by nature and severity of the injury. In 1985, over 266,000 children sustained a traumatic injury resulting in hospitalization (rate of 51 per 10,000 children). Expenditures totaled nearly $1 billion. Over 80% of the hospitalizations and two thirds of total expenditures were for minor (Maximum AIS = 1.2) trauma. Moderate (Maximum AIS = 3) and severe (Maximum AIS = 4,5) trauma accounted for 18% and 2% of admissions and 31% and 8% of expenditures, respectively. Falls ranked first in expenditures and admissions (36% of the total). Motor vehicle-related injuries accounted for 19% of trauma admissions and 24% of expenditures. Other less common causes included bicycle injuries, penetrating injuries and injuries caused by the child being hit by an object or person. An estimated 28% of the total hospital charges were paid for by public sources (15% from federal government programs, 13% from state and local programs). An additional 63% of total expenditures were paid for by private sources, with the remaining 9% considered uninsured care.(ABSTRACT TRUNCATED AT 250 WORDS)

Accidental Falls↗

PubMed1990

Evaluating performance of statewide regionalized systems of trauma care.

A new methodology is presented for evaluating the extent to which patients within regionalized systems of trauma care are treated at the appropriate hospitals. Criteria are proposed for retrospectively classifying trauma patients as to whether they should have been treated at a trauma center. The criteria were developed by a panel of nationally recognized trauma experts and are based on the age of the patient and the type and AIS severity of injuries sustained. The criteria were then applied to uniformly collected data available for all trauma discharges in 1988 from acute care hospitals in a state with a well developed system of regionalized trauma care. According to the criteria, 19% of all trauma discharges in 1988 should have been treated at a trauma centers. Of those who should have been treated at a trauma center according to criteria, 66% actually received treatment at a center. Of those who were classified not to have required care at a trauma center, 62% actually were treated at non-trauma center hospitals. The congruence between where patients should have been treated and the actual level of hospital care received varied by the type and severity of the traumatic injuries sustained. The results of the analysis provide insights into the characteristics of trauma patients at higher risk of not getting the appropriate level of trauma care and should assist in improving guidelines for triage and transfer within a regionalized system of care.

Adolescent↗

PubMed1990

Three or more rib fractures as an indicator for transfer to a Level I trauma center: a population-based study.

UNLABELLED: The presence of major chest wall injury is an indication for transfer to a Level I trauma center. We hypothesized that the presence of three or more rib fractures on initial chest X-ray would identify a small subgroup of patients with a high probability of requiring trauma center care. All trauma discharges in Maryland between 1984 and 1986 (N = 105,683) were reviewed. Patients were divided by the presence of rib fractures (no rib fractures, 1-2 fractures, 3+ fractures) and age in years (0-13, 14-64, 65+). RESULTS: The presence of three or more rib fractures in the pediatric age group was rare and precluded further evaluation. When comparing patients with 1-2 rib fractures versus 3 or more rib fractures, significant differences were found in mortality, mean Injury Severity Score, mean hospital stay and mean number of ICU days (p less than 0.001). The significant differences occurred in all age groups 14 years old and older. The presence of three or more rib fractures increased the relative risk of splenic injury (6.2) and liver injury (3.6) but did not predict the presence of aortic injury. CONCLUSION: The presence of 3 or more rib fractures identifies a small subgroup of patients (2.4%) likely to require tertiary care. This triage tool is useful in all patients over the age of 14 years.

Adolescent↗

PubMed1990

Acute hospital costs of trauma in the United States: implications for regionalized systems of care.

As part of a larger effort to determine total direct and indirect costs of injury in the United States, national estimates of the numbers and expenditures associated with acute hospitalization due to traumatic injury were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS). Estimates of the numbers of hospital episodes and total expenditures are reported in this paper for subgroups of patients defined by age, sex, and body region and AIS severity of the injuries sustained. In 1985 2.1 million individuals sustained a traumatic injury which resulted in hospitalization. Hospital expenditures totaled $11.4 billion inclusive of professional fees. Adolescents and young adults aged 15-44 years accounted for nearly one half of all discharges and total hospital costs. The elderly, who represent only 12% of the population, accounted for an additional one quarter of total discharges and hospital costs. Nearly three quarters of the hospitalizations and one half of total expenditures were for minor (ICD/AIS = 1, 2) injuries. Moderate (ICD/AIS = 3) and severe (ICD/AIS = 4, 5), injuries respectively accounted for 23% and 3% of total episodes and 37% and 11% of total expenditures. Only 12% of patients and 25% of trauma care dollars involved injuries sufficiently severe to require treatment at a trauma center.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1990

Coding external causes of injury (E-codes) in Maryland hospital discharges 1979-88: a statewide study to explore the uncoded population.

We examined the trends in hospital discharge E-coding in Maryland over a 10-year period. The overall proportion of E-coded discharges has increased from 40 percent in 1979 to 55 percent in 1988. E-coding was lower in the severely injured, the elderly, and patients with long hospital stays. Our findings demonstrate that E-code reporting varies because of the limited number of data fields available for coding of discharge diagnoses. Universal, systematic reporting of E-codes in hospital discharge data is essential if these data are to provide critically needed information about nonfatal injuries. Hospital discharge data formats should contain separate fields for E-codes and the use of these codes, we believe, should be mandated.

Age Factors↗

PubMed1990

Trends in hospitalized discharge rates for head injury in Maryland, 1979-86.

Hospital discharge data from all acute care hospitals in Maryland were used to examine trends in hospitalized head injury incidence and outcome by severity. From 1979 to 1986, discharge rates increased by 3.4/100,000 per year; the largest percent increase was for more severe injuries. Discharge rates increased the most for adults ages 15-24 and ages 75+ but declined for children ages 0-4. Coinciding with the increase in head injury discharges was a decrease in the hospital case-fatality rate across all severity groups.

Adolescent↗

PubMed1990

The lifetime cost of injury.

This paper discusses the development of estimates of the lifetime costs of injuries for 1985. Total costs are estimated to be $158 billion for the 57 million persons injured in 1985. Updating these costs to 1988, the results are even more impressive-$182 billion. We describe the methodology for estimating costs and discuss theoretical issues and past research. We develop an injury cost model to estimate direct costs, morbidity costs, and mortality costs. Cost estimates are presented by type of cost, age, sex, cause of injury, and class of injury. Finally, we explore the implications of our results for public health policy.

Adolescent↗

PubMed1990

Mortality in trauma patients: the interaction between host factors and severity.

Data on host factors influencing mortality in trauma patients is sparse and contradictory. To develop a model for health policy decisions, we examined all trauma admissions to acute care hospitals in the state of California in the year 1986. We looked at the influence of the following host factors: age, gender, and preinjury medical conditions, on mortality stratified by injury severity. The study group (N = 199,737) had an overall mortality rate of 1.9%. Mortality increased starting at age 40 years and was independently influenced by gender, the presence of pre-existing disease, and the body region injured. In patients with minor injury, mortality rates became higher in the elderly at age 65+. However, in patients with injuries of moderate severity, mortality increased in both middle age (40-64) and elderly groups (65+). Male gender was also a risk factor, present in both the elderly and middle age groups. While the presence of both pre-existing medical disease or injury to head or abdomen was related to increased mortality in middle-aged patients at all severity levels, neither accounted for the effect of gender. Conclusion. Age and gender influence mortality in trauma patients. These effects are not explained by documented pre-existing disease or region of injury. Age and gender serve only as observable markers for subgroups of patients with impaired response to injury. Middle-aged males comprise a previously unrecognized high-risk subgroup for this impaired response.

Adolescent↗

PubMed1989

Effect of pre-existing disease on length of hospital stay in trauma patients.

Hospital discharge data for all adult trauma admissions (n = 27,029) to acute care hospitals in a five-county area were used to examine the effect of pre-existing chronic conditions (PECs) on length of hospital stay (LOS). The per cent increase in mean LOS and the relative odds of an extended LOS (i.e., greater than or equal to 3 weeks) were estimated for surviving trauma patients with and without one or more of 11 pre-existing medical conditions, taking into account both the ISS severity of injuries and patient age. Nineteen per cent (n = 5,224) of the trauma cases had one or more of the 11 PECs; 5% (n = 1,384) had two or more PECs. Those with one or more PECs stayed significantly longer (p less than 0.001) than those who had none. Mean LOS was shown to be 69% higher for those with versus those without PECs. Furthermore, patients with PECs were more than twice as likely as those without PECs to have stayed in the hospital 3 weeks or longer. The size of the effect, however, varied by patient age and injury severity; the effect of PECs on length of stay was larger among younger patients and patients with less severe injuries. With regionalization, trauma centers treat the majority of these patients and potentially suffer disproportionate financial losses when reimbursement is based on DRGs.

Adolescent↗

PubMed1989

Classifying trauma severity based on hospital discharge diagnoses. Validation of an ICD-9CM to AIS-85 conversion table.

This report describes the development and validation of a computerized system for converting ICD-9CM rubrics to Abbreviated Injury Scale (AIS) scores. In collaboration with the Committee on Injury Scaling of the Association for the Advancement of Automotive Medicine, AIS-85 scores were assigned to 2,062 injury-related ICD-9CM rubrics. To validate the conversion table, AIS and Injury Severity Scores (ISS), derived using the conversion, were compared with those obtained by reviewing the complete medical record for 1,120 trauma cases. Percent agreement in maximum AIS scores (MAXAIS) ranged from 48% for head/neck injuries to 74% for extremity injuries. In 68% of the cases, grouped ISS scores (one to 12; 13 to 19; 20+) were in agreement. Previous studies of the interrater reliability of AIS coding directly from the medical charts have shown that agreement in MAXAIS scores ranges, on average, between 62% for head/neck injuries to 76% for extremity injuries. Grouped ISS scores agree, on average, 75% of the time. The results show that while the computerized conversion is not perfect, it provides reasonably good information on severity that might otherwise be unavailable for large population-based research and evaluation. This paper discusses the potential applications of the conversion table with specific attention to its use in evaluating the extent of trauma care regionalization.

Delphi Technique↗

PubMed1989

Hospitalized head-injured patients in Maryland: incidence and severity of injuries.

Hospital discharge data collected from all acute care hospitals in Maryland were used to examine severity-specific rates of hospitalized head injuries in 1986. Findings indicate that males are at twice the risk of females for hospitalization for head injury; whites and nonwhites are at similar risk. Evidence that the rate of hospitalization for head injury may be increasing underscores the importance of head injury as a major public health problem in Maryland.

Adolescent↗

PubMed1988

The economic impact of traumatic injuries. One-year treatment-related expenditures.

Considerable attention has focused in recent years on developing estimates of the economic costs associated with illness and injury. Consistent throughout all of this work has been the finding that traumatic injuries rank among the most costly of conditions. This article provides detailed information on one-year charges related to the receipt of health care and rehabilitation services for a panel of 487 trauma patients aged 16 to 45 years who were injured severely enough to be initially hospitalized at one of two trauma centers. Per case one-year treatment charges ranged from an average of $8100 for those sustaining minor (Abbreviated Injury Scale severity score of 1 or 2) injuries to $105,350 for those with severe (Abbreviated Injury Scale severity score of 5) head or spinal cord injuries. When results were generalized to the population of all individuals aged 16 to 45 years who were hospitalized in Maryland hospitals in 1983 for treatment of an injury, total charges were estimated at $109 million, with 43% of the total incurred by individuals with a principal injury to one or more of the extremities.

Adolescent↗