Follow-up disparities after trauma: a real problem for outcomes research

doi:10.1016/j.amjsurg.2009.09.021

The American Journal of Surgery

Volume 199, Issue 3, March 2010, Pages 348-353

Presented at the 52nd annual meeting of the Midwest Surgical Association, Lake Geneva, WI August 2–5, 2009.

https://doi.org/10.1016/j.amjsurg.2009.09.021 Get rights and content

Abstract

Introduction

The objectives of this study were to (1) determine risk factors associated with failure to follow-up (FTF) after traumatic injury and (2) in those patients who do follow up, to determine if information within the electronic medical record (EMR) is an adequate data-collection tool for outcomes research.

Methods

A 6-year retrospective analysis was conducted on all admitted trauma patients using data from the trauma registry, National Death Index, 2000 Census Data, and the EMR. Bivariate and logistic regression analyses identified risk factors for FTF. A subgroup analysis evaluated the utility of using the EMR to determine basic functional outcomes (Glasgow outcome scale, diet, ambulation, and employment status).

Results

A total of 14,784 patients were discharged, and 61% had follow-up appointments. Lower income, higher poverty rates, and lower education were significantly (P < .05) associated with FTF. Logistic regression analysis (excluding census data) identified that older age, lower Injury Severity Score, less severe head injury, nonwhite race, blunt injury, death after discharge, zip code within 25 miles, and patients discharged to home independently predicted FTF after traumatic injury. A subgroup analysis of the EMR showed the inability to reliably determine functional outcomes.

Conclusions

There are several disparities related to follow-up after trauma. Furthermore, charting deficiencies, even with an EMR, highlight the weaknesses of data available for trauma outcomes research. Trauma process improvement programs could target patients at risk for not following up and use a structured electronic outpatient note.

Section snippets

Methods

A 6-year retrospective analysis was conducted on all trauma patients admitted to a regional level I trauma center from 2000 through 2005. Data were collected from the hospital-wide electronic medical record system (Epic Systems Corporation, Madison, WI), the trauma registry, the National Death Index, and census data. Follow-up appointments were analyzed by using the outpatient EMR and were defined as an outpatient visit to our hospital system within 3 months of injury to the service related to

Patient characteristics

Our center admitted 15,285 trauma patients during the 6-year study period. The hospital mortality was 3.3%. There were 14,786 trauma patients who were discharged. Using our records and the NDI; the postdischarge mortality was 4.8% with follow-up ranging from 0 to 6 years. All further analysis is based on 14,786 discharged trauma patients. The mean age was 36.3 years old (range 0–103) with 71.3% males. Patients were discharged to 6 general locations: 83.7% to home, 8.4% to rehabilitation, 6.3%

Comments

The fact that hospital discharge has been shown to be a limited marker for trauma outcomes analysis8, 14 stresses the importance of follow-up. However, there are no standards or benchmarks for an “acceptable” rate of trauma follow-up. Our institution had a 61% follow-up rate within 3 months of injury. The Trauma Recovery Project had a 79% follow-up rate at 6 months; however, the project was a prospective study and only enrolled patients with a Glasgow Coma Score of 12 or greater on admission.

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Loss to follow-up after traumatic injury occurs at rates of up to 47%. However, the most recent data are over a decade old, and recent changes in traumatic injury patterns necessitate an updated assessment of risk factors for loss to follow-up after trauma.
We conducted a retrospective chart review of trauma admissions from January 1, 2018 to December 31, 2021. Categorical variables were compared using χ² analyses, and continuous variables were analyzed using Mann–Whitney Wilcoxon tests. Multivariable logistic regression was used to adjust for relevant factors identified on unadjusted analysis.
Among 3,034 patients, overall loss to follow-up was 36.9%. Non-White patients, patients who underwent operations or non-surgical procedures, and patients discharged to rehabilitation facilities were more likely to have follow-up appointments within 30 days. Patients with substance use disorder and, among White patients, those with public insurance had higher loss to follow-up rates. Having a follow-up appointment scheduled with a primary care provider was the single most significant factor associated with attending a follow-up appointment.
Social determinants of health, such as insurance status and substance use disorder, are associated with loss of follow-up after trauma. Primary care appointments are associated with the highest attendance rates, supporting that all patients should be offered primary care appointments after traumatic injury.
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Citation Excerpt :
Only two-thirds of patients came at 1-month consultation follow-up and 22% of patients were lost of follow-up at hospital level. This failure to follow-up (FTF) had ever been reported in the current literature.22,23 Indeed, Alarcon et al.22 found a 32% rate of compliance with trauma clinic follow-up on a population study of 6800 patients.
The data concerning long-term follow-up and outcomes of penetrating trauma are poorly detailed in the literature. The main objective of our study was to analyze the hospital and extra-hospital follow-up of penetrating trauma victims and to evaluate the late complications and long-term consequences of these traumas.
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A total number of 165 patients were included. Median (Q1, Q3) of hospital follow-up was 28 (4, 66) days. One hundred one patients (61.2%) went to their one-month consultation at hospital. GP follow-up was achieved for 76 patients (55.2%). Median (Q1, Q3) of GP follow-up was 47 (21, 75) months. Twenty-four patients (14.5%) have been totally lost to follow up. The overall follow-up identified 54 patients (32.7%) with long-term consequences, 20 being psychiatric disorders and 30 organic injuries. Organic consequences were mainly peripheral nerve damages (n = 20; 12.1%). Most of the psychiatric consequences were diagnosed during GP follow-up (n = 14; 70%). Seventeen cases (10.3%) of recurrence were found and late mortality occurred in 4 patients (2.4%). High injury severity score, older age and gunshot wound were significantly linked to long-term consequences. Data collection and analysis were carried out in accordance with MR004 reference methodology.
This study showed a high rate of long-term consequences among patients managed for penetrating injury. If all organic lesions are diagnosed during hospital follow-up and jointly managed by hospital and extra-hospital physicians, most socio-psychiatric consequences were detected and followed by extra-hospital workers. However, for half of the patients, the extra-hospital follow-up could not be assessed. Thus, these consequences are very probably underestimated. It appears imperative to strengthen the compliance and adherence of these patients to the care network. Awareness and involvement of medical, paramedical teams and GP role seems essential to screen and manage these consequences.
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Evidence regarding recommendations for treatment of ballistic fractures remains limited. This paucity of literature has largely been attributed to gunshot wound victims being a difficult population to study secondary to loss to follow-up. The purpose of this study was to examine the epidemiology of operatively treated ballistic femur fractures at our institution, the frequency of outpatient follow-up and risk factors for loss to follow-up.
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Additionally, there was variability in length of follow up. This is likely a function of our institution’s role as a tertiary referral center with a large catchment area, as well as a function of expected follow up rates previously described in trauma patients.22,23 Given our institution’s designation as a level I trauma center, the number of operative geriatric hip fractures recorded per year in our study is likely an underestimate of the actual number treated.
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A retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables.
The DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p = 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p = 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p = 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p = 0.892).
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: Supported in part by grant number 1KL2RR024990 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Road map for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.

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The Midwest Surgical AssociationFollow-up disparities after trauma: a real problem for outcomes research

Abstract

Introduction

Methods

Results

Conclusions

Section snippets

Methods

Patient characteristics

Comments

J Am Coll Surg

J Am Coll Surg

J Am Coll Surg

Injury

The Major Trauma Outcome StudyEstablishing national norms for trauma care

J Trauma

A national evaluation of the effect of trauma-center care on mortality

N Engl J Med

Significant variations in mortality occur at similarly designated trauma centers

Arch Surg

Are statewide trauma registries comparable?Reaching for a national trauma dataset

Acad Emerg Med

The Midwest Surgical Association
Follow-up disparities after trauma: a real problem for outcomes research