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Article 1
Prevention of all-terrain vehicle injuries: A systematic review from The Eastern Association for the Surgery of Trauma. Rattan R, D’Andrea KJ, Dente C, Klein EN, Kimbrough MK, Nguyen J, Simmons JD, O’Keeffe T, Crandall M. J Trauma Acute Care Surg. 2018 Jun 84(6): 1017-1026.
All terrain vehicle (ATVs) crashes are responsible for approximately 500 deaths and 100,000 emergency room visits annually. While advancements have been made in the speed and power of ATVs, little has been done to improve its safety. The medical community has produced a number of position statements and recommendations to promote ATV safety, however none have been evidence-based. This study attempts to make recommendations on ATV safety measures and legislation based on the quality of existing evidence in the current literature.
The study uses the GRADE methodology in an attempt to answer four PICO questions related to ATVs.
- Should helmets be used to reduce the incidence of traumatic brain injury?
- Should legislation requiring the use of helmets be enacted to increase helmet utilization?
- Should non-helmet protective gear be utilized to lessen injury severity?
- Should legislation regarding ATVs be enacted to lessen injury severity?
They identified 28 studies that were reviewed to make their recommendations. The majority of the studies focused on the first PICO question, where the authors concluded that there is moderate quality evidence that helmet use decreases the incidence of TBI among ATV riders. The study therefore recommends using helmets to reduce the incidence of TBI in ATV riders. There were few studies available for review to answer the remaining PICO questions. Overall, for PICO #2, the guidelines committee conditionally recommends using legislation as a method to increase helmet use among ATV riders. However, this recommendation is based on low-quality evidence with selection bias. The committee was not able to make a recommendation for PICO #3 due to a lack of data. Finally, they conditionally recommend the use of ATV safety legislation to reduce ATV injuries, but again this is based on low quality evidence.
Overall, this systematic review is an excellent attempt to identify preventative measures to decrease ATV injuries. However, due to the dearth of literature, the authors highlight the limitations of the ATV literature and the need for more work to be done in this field.
Article 2
Trauma transitional care coordination: A mature system at work. Hall EC, Tyrrell RL, Doyle KE, Scalea TM, Stein DM. J Trauma Acute Care Surg. 2018 May 84(5): 711-717.
A large number of trauma patients are at risk for recidivism. Similarly, patients with certain socioeconomic and medical risk factors are at higher risk for unplanned 30-day readmission. The Hospital Readmission Reduction Program was instituted in 2012 to decrease Medicare payments to hospitals with higher than average readmission rates after certain medical hospitalizations. This program has encouraged hospitals across the country to develop programs to lower their unplanned 30-day readmission rates. Although the program does not yet include trauma patients, it is reasonable to develop a program to decrease this outcome in high-risk trauma patients. This study analyzes readmission rates of trauma patients after implementation of such a program.
In a prior single institution study, Hall et al. describes the development and implementation of a Trauma Transitional Care Coordination (TTCC) program. The goal of the program is to identify high-risk trauma patients (previously defined by the group) and pair them with a TTCC to assist in their medical care after discharge. The TTCC program assists in scheduling appointments, medical reconciliation and wound care. The program was started in January 2014. The authors examined trauma admission and readmission data between January 2013- September 2016 recorded by the Maryland Health Services Cost Review Commission (HSCRC). Using the database, the authors broke down readmission rates in TTCCs participants and non-TTCC participants by diagnosis related groups (APR-DRGs). They organized the APR-DRGs into categories including infection, obstruction, lower extremity procedures, and musculoskeletal complications.
Overall, 475 patients were enrolled in the TTCC program from January 2014-September 2016. The TTCC patients were younger and more likely to be male than non-TTCC patients. They were more likely to be uninsured and have a longer initial length of stay. When analyzing unplanned 30-day readmission rates, TTCC participants had lower rates among patients with initial admission for knee and lower leg procedures, those requiring prolonged mechanical ventilation, tracheostomy, major bowel procedures and amputation of lower extremities. However, TTCC participants had higher 30-day readmission rates among patients undergoing abdominal/thoracic procedures, MKS procedures and vascular procedures.
The study has several limitations that are acknowledged in the paper. The most obvious is using an administrative database when comparing readmission rates in TTCC and non-TTCC patients. Second, the populations being compared (TTCC and non-TTCC) are significantly different and it is hard to compare readmission rates between the two groups when the TTCC group is clearly a higher risk group. While the methodology is flawed, the authors acknowledge the problem of not knowing the true readmission rates of these higher risk trauma patients and understand the limitations of their results.
Article 3
Motor Vehicle Crash Fatalities and Undercompensated Care Associated with Legalization of Marijuana. Susan Steinemann, Daniel Galanis, Tiffany Nguyen and Walter Biffl. J Trauma Acute Care Surg. 2018 Sep;85(3):566-571.
This is a cohort analysis of motor vehicle crash fatalities and trauma patients in Hawaii before and after the state’s legalization of marijuana (a.k.a. cannabis). The authors provide a concise summary of previously-reported data, describing conflicting associations between trauma and the commercialization of marijuana. The authors hypothesize that cannabis legalization in Hawaii is associated with an increase in the proportion of motor vehicle crash fatalities involving cannabis-positive (a.k.a. THC-positive) drivers and that cannabis use among trauma patients is associated with high-risk behavior and poor insurance status. Fatality Analysis Reporting System (FARS) data were analyzed for before (1993-2000) and after (2001-2015) legalization cohorts. The presence of cannabinoids and other drugs were compared. A subset of FARS data for 2011-2015 was used to examine the association between cannabis-positivity, methamphetamine and alcohol use and crash demographics. Statewide trauma registry data for 2011-2015 were used to examine THC-positivity among trauma patients compared to risky behavior and payer mix.
1,578 motor vehicle drivers were killed in traffic (automobile and motorcycle) crashes in Hawaii over the 23-year study period. THC-positivity among fatally-injured drivers increased nearly three-fold from 5.5% (1993-2000) to 16.3% (2011-2015) while methamphetamine- and alcohol-positivity were similar. FARS data also showed that in recent years, THC-positive drivers were significantly younger than THC-negative drivers and that alcohol use was 63% higher among THC-positive drivers. THC-positive drivers were also more likely to have died in a nighttime crash and to have been speeding. Also, the use of seatbelts and helmets was significantly lower among THC-positive drivers. Similarly, among trauma patients, THC-positivity increased from 11% before to 20% after legalization, and from 2011-2015, THC-positive trauma patients were significantly less likely to have been wearing a seatbelt or helmet (33% vs. 56%) and were twice as likely to have Medicaid insurance (28% vs. 14%).
As more states legalize marijuana, the use of marijuana is likely to increase, and the effects of such increased use on injuries are unclear. This study’s data provide evidence that injured patients in Hawaii have increasing incidence of THC-positivity as well as increased incidence of risky behavior. In addition, these data demonstrate THC-positivity is associated with public funding for costs of trauma care. The authors are careful to state that their data are insufficient to demonstrate causality between cannabis use and injury or death. Further research is necessary, but based on their and others’ data, the authors reasonably recommend policy development to address cannabis-related trauma.
Article 4
State Firearm Laws and Interstate Firearm Deaths from Homicide and Suicide in the United States: A Cross-sectional Analysis of Data by County. Elinore J. Kaufman, Christopher N. Morrison, Charles C. Branas and Douglas J. Wiebe. JAMA Intern Med. 2018 May 1;178(5):692-700.
This is a cross-sectional epidemiologic analysis of firearm death rates among United States counties from January 2010 to December 2015. The authors hypothesized that counties located in states with more restrictive firearm laws would have lower rates of firearm suicide and homicide, and that firearm death rates would be higher in counties near adjoining states with more lenient laws. Using data from the Centers for Disease Control and Prevention, the authors analyzed decedents for 3,108 counties in the 48 contiguous United States. Each county was given a score based on the number of the county’s home state firearm control policies and a second score based on adjacent states’ policies (a.k.a. interstate). Scores were grouped into low, medium and high similarly-sized cohorts to facilitate analysis. These scores, demographic data and FBI crime statistics were compared to suicide and homicide rates among counties, using a multilevel spatial Poisson model.
The authors determined that counties with low home state firearm control policies had the highest rates of firearm suicide (incidence rate ratio [IRR] 1.35-1.43), medium had lower rates (IRR 1.22-1.35) and high had lowest rates (IRR 0.91-1.19)—interstate policy scores did not seem to affect firearm suicide rates. Though attenuated, these relationships carried over to total suicide rates. For homicides, the authors found the highest rates of firearm homicide and overall homicide in counties with both low home state and low interstate policy scores (IRR 1.38). The authors also found that counties with low home state policy scores had lower firearm homicides rates when interstate policy scores were high (IRR 1.18) and that counties in states with high policy scores had lower rates of firearm homicide even when the interstate policy score was low (IRR 1.13). Some demographic data were variably associated with suicide and homicide rates. The authors note their data correlate with and build upon previous knowledge of suicide and homicide epidemiology and acknowledge several limitations related to the nature of the available data, the broadness of the generated scores and the inability to distinguish influence from multiple adjacent and non-adjacent states.
This complex study draws on a wide range of related datasets to describe firearm deaths as they relate to firearm control policies in the United States. Each state varies in its firearm control laws, and as this study concludes, the effect of local laws as well as neighboring states’ laws may influence the rates of firearm deaths. Causality cannot be determined by this study design; however, this seems to be one of the most accurate and detailed designs that may be used to address the multifaceted population-level relationship between firearm policies and firearm deaths. The authors support strengthening firearm policies to reduce the incidence of firearm suicide and firearm homicide locally and across state lines.
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