Trauma continues to be the leading cause of mortality and morbidity among US citizens aged <44 years. Literature suggests that geographical maldistribution of trauma centers (TCs) is associated with increasing fatality rate. Existing models for TC network design do not address the question often raised by trauma decision makers: how many TCs are required to achieve acceptable levels of mistriages? We propose a model to optimize the network of TCs under mistriage constraints. We propose a notional field triage protocol to estimate mistriages (under and over), based on existing guidelines in the trauma literature. Due to the complexity of the underlying model, we propose a Particle Swarm Optimization based solution approach. We use 2012 data from the State of Ohio, and model both ground and air transportation modes. Our results show that, for 2012 mistriage levels, it is possible to reduce the number of TCs from 21 to 10 by distributing them appropriately across urban and rural areas. Further, redistributing these 21 TCs can help satisfy the recommendation of under-triage ≤0.05 by the American College of Surgeons. In general, our study provides trauma decision makers an ability to determine a network that could improve care and/or reduce cost.
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Performance-Based Assessment of Trauma Systems: Estimates for the State of Ohio
There are no widely accepted metrics to determine the optimal number and geographic distribution of trauma centers (TCs). We propose a Performance-based Assessment of Trauma System (PBATS) model to optimize the number and distribution of TCs in a region using key performance metrics.
The proposed PBATS approach relies on well-established mathematical programming approach to minimize the number of level I (LI) and level II (LII) TCs required in a region, constrained by prespecified system-related under-triage (srUT) and over-triage (srOT) rates and TC volume. To illustrate PBATS, we collected 6002 matched (linked) records from the 2012 Ohio Trauma and EMS registries. The PBATS-suggested network was compared to the 2012 Ohio network and also to the configuration proposed by the Needs-Based Assessment of Trauma System (NBATS) tool.
For this data, PBATS suggested 14 LI/II TCs with a slightly different geographic distribution compared to the 2012 network with 21 LI and LII TC, for the same srUT≈.2 and srOT≈.52. To achieve UT ≤ .05, PBATS suggested 23 LI/II TCs with a significantly different distribution. The NBATS suggested fewer TCs (12 LI/II) than the Ohio 2012 network.
The PBATS approach can generate a geographically optimized network of TCs to achieve prespecified performance characteristics such as srUT rate, srOT rate, and TC volume. Such a solution may provide a useful data-driven standard, which can be used to drive incremental system changes and guide policy decisions.
- NSF-PAR ID:
- 10366390
- Publisher / Repository:
- SAGE Publications
- Date Published:
- Journal Name:
- The American Surgeon
- ISSN:
- 0003-1348
- Page Range / eLocation ID:
- Article No. 000313482110650
- Format(s):
- Medium: X
- Sponsoring Org:
- National Science Foundation
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Trauma continues to be the leading cause of mortality and morbidity among US citizens aged <44 years. Literature suggests that geographical maldistribution of trauma centers (TCs) is associated with increasing fatality rate. Existing models for TC network design do not address the question often raised by trauma decision makers: how many TCs are required to achieve acceptable levels of mistriages? We propose a model to optimize the network of TCs under mistriage constraints. We propose a notional field triage protocol to estimate mistriages (under and over), based on existing guidelines in the trauma literature. Due to the complexity of the underlying model, we propose a Particle Swarm Optimization based solution approach. We use 2012 data from the State of Ohio, and model both ground and air transportation modes. Our results show that, for 2012 mistriage levels, it is possible to reduce the number of TCs from 21 to 10 by distributing them appropriately across urban and rural areas. Further, redistributing these 21 TCs can help satisfy the recommendation of under-triage ≤0.05 by the American College of Surgeons. In general, our study provides trauma decision makers an ability to determine a network that could improve care and/or reduce cost.more » « less
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Abstract Objectives To examine the Animal Trauma Triage (ATT) and modified Glasgow Coma Scale (mGCS) scores as predictors of mortality in injured cats.
Design Observational cohort study conducted September 2013 to March 2015.
Setting Nine Level I and II veterinary trauma centers.
Animals Consecutive sample of 711 cats reported on the Veterinary Committee on Trauma (VetCOT) case registry.
Interventions None.
Measurements and Main Results We compared the predictive power (area under receiver operating characteristic curve; AUROC) and calibration of the ATT and mGCS scores to their components. Overall mortality risk was 16.5% (95% confidence interval [CI], 13.9‐19.4). Head trauma prevalence was 11.8% (n = 84). The ATT score showed a linear relationship with mortality risk. Discriminatory performance of the ATT score was excellent (AUROC = 0.87 [95% CI, 0.84‐0.90]). Each ATT score increase of 1 point was associated with an increase in mortality odds of 1.78 (95% CI, 1.61‐1.97,
P < 0.001). The eye/muscle/integument category of the ATT showed the lowest discrimination (AUROC = 0.60). When this component, skeletal, and cardiac components were omitted from score calculation, there was no loss in discriminatory capacity compared with the full score (AUROC = 0.86 vs 0.87, respectively,P = 0.66). The mGCS showed fair performance overall for prediction of mortality, but the point estimate of performance improved when restricted to head trauma patients (AUROC = 0.75, 95% CI, 0.70‐0.80 vs AUROC = 0.80, 95% CI, 0.70‐0.90). The motor component of the mGCS showed the best predictive performance (AUROC = 0.71); however, the full score performed better than the motor component alone (P = 0.004). When assessment was restricted to patients with head injury (n = 84), there was no difference in performance between the ATT and mGCS scores (AUROC = 0.82 vs 0.80,P = 0.67).Conclusion On a large, multicenter dataset of feline trauma patients, the ATT score showed excellent discrimination and calibration for predicting mortality; however, an abbreviated score calculated from the perfusion, respiratory, and neurologic categories showed equivalent performance.
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Objective Symptomatic head trauma associated with American‐style football (ASF) has been linked to brain pathology, along with physical and mental distress in later life. However, the longer‐term effects of such trauma on objective metrics of cognitive–motor function remain poorly understood. We hypothesized that ASF‐related symptomatic head trauma would predict worse gait performance, particularly during dual task conditions (ie, walking while performing an additional cognitive task), in later life.
Methods Sixty‐six retired professional ASF players aged 29 to 75 years completed a health and wellness questionnaire. They also completed a validated smartphone‐based assessment in their own homes, during which gait was monitored while they walked normally and while they performed a verbalized serial‐subtraction cognitive task.
Results Participants who reported more symptomatic head trauma, defined as the total number of impacts to the head or neck followed by concussion‐related symptoms, exhibited greater dual task cost (ie, percentage increase) to stride time variability (ie, the coefficient of variation of mean stride time). Those who reported ≥1 hit followed by loss of consciousness, compared to those who did not, also exhibited greater dual task costs to this metric. Relationships between reported trauma and dual task costs were independent of age, body mass index, National Football League career duration, and history of musculoskeletal surgery. Symptomatic head trauma was not correlated with average stride times in either walking condition.
Interpretation Remote, smartphone‐based assessments of dual task walking may be utilized to capture meaningful data sensitive to the long‐term impact of symptomatic head trauma in former professional ASF players and other contact sport athletes. ANN NEUROL 2020;87:75–83
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