J R Hedges

Oregon Health and Science University, Portland, OR, United States

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Publications (230)745.14 Total impact

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    ABSTRACT: This study proposes a definition of futile care and quantifies its cost in injured elders. This was a retrospective study of Medicare patients with an International Classification of Diseases-9 injury diagnosis admitted to 171 Oregon and Washington facilities from January 1, 2001, through December 31, 2002, who died within 6 months of admission. Futile care was defined as death within 7 days of discharge from a hospitalization of at least 14 days. We compared health care costs in the last 6 months of life with those who did and did not meet our definition of futility. To simulate predicting and preventing futility early in the hospital course, we examined the effect of reducing spending on the futile care cohort to the level of those who survived 7 to 10 days after injury. There were 6,832 elders who died within 6 months of injury, of whom 230 (3.4%) met our definition of futility. The median cost of care in the last 6 months of life was $33,373 for those not meeting our definition of futility and $87,391 for the futile care group (p < 0.001). The 3.4% receiving futile care incurred 8.9% of total costs. Reducing expenditures in the futile care group to the level of those who died from 7 to 10 days after injury (median, $25,633) would result in an overall cost savings of 6.5%. End-of-life health care costs were significantly higher for those who received futile care. However, even aggressive reductions in futile care would result in small savings overall. Economic analysis, level III.
    The journal of trauma and acute care surgery. 07/2012; 73(1):146-51.
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    ABSTRACT: The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort. This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16. There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings. The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
    Journal of the American College of Surgeons 12/2011; 213(6):709-21. · 4.50 Impact Factor
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    Tina M Shelton, Jerris R Hedges
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    ABSTRACT: JABSOM takes its responsibility to improve health among Hawai'i's people to heart. The school's vision is, ALOHA: to Attain Lasting Optimal Health for All, a theme adopted through a strategic planning process which engaged JABSOM's partners in the health and life sciences including its private sector collaborators and its sister colleges throughout the University of Hawai'i's ten-campus system. JABSOM's ability to collaborate and contribute in these areas has been irrevocably enhanced by tobacco-related funding that the State of Hawai'i has committed to develop the Kaka'ako campus. The taxpayers' generosity has improved the education and reach of clinicians and researchers who, in turn, dedicate their lives to preventing, treating and eliminating the deadly grip tobacco holds on too many of the people of Hawai'i.
    Hawaii medical journal 11/2011; 70(11):245-7.
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    ABSTRACT: The decision-making processes used for out-of-hospital trauma triage and hospital selection in regionalized trauma systems remain poorly understood. The objective of this study was to assess the process of field triage decision making in an established trauma system. We used a mixed methods approach, including emergency medical services (EMS) records to quantify triage decisions and reasons for hospital selection in a population-based, injury cohort (2006-2008), plus a focused ethnography to understand EMS cognitive reasoning in making triage decisions. The study included 10 EMS agencies providing service to a four-county regional trauma system with three trauma centers and 13 nontrauma hospitals. For qualitative analyses, we conducted field observation and interviews with 35 EMS field providers and a round table discussion with 40 EMS management personnel to generate an empirical model of out-of-hospital decision making in trauma triage. A total of 64,190 injured patients were evaluated by EMS, of whom 56,444 (88.0%) were transported to acute care hospitals and 9,637 (17.1% of transports) were field trauma activations. For nontrauma activations, patient/family preference and proximity accounted for 78% of destination decisions. EMS provider judgment was cited in 36% of field trauma activations and was the sole criterion in 23% of trauma patients. The empirical model demonstrated that trauma triage is driven primarily by EMS provider "gut feeling" (judgment) and relies heavily on provider experience, mechanism of injury, and early visual cues at the scene. Provider cognitive reasoning for field trauma triage is more heuristic than algorithmic and driven primarily by provider judgment, rather than specific triage criteria.
    The Journal of trauma 06/2011; 70(6):1345-53. · 2.35 Impact Factor
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    Jerris R Hedges, Bruce Shiramizu, Todd Seto
    Hawaii medical journal 01/2011; 70(1):18-9.
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    ABSTRACT: To compare mortality rates of hospitalized injured aged 67 and older across commonly used follow-up periods (e.g., in-hospital, 30-day, 1-year) and to determine the postinjury time after which mortality rates stabilize. Retrospective analysis of Medicare claims. Oregon and Washington Medicare patients. Patients admitted to 171 Oregon and Washington facilities during 2001/02 with injuries identified according to International Classification of Diseases, Ninth Revision, code and followed for 1 year. The primary outcome was in-hospital mortality and mortality at 30, 60, 90, 180, and 365 days. Kaplan-Meier survival curves and daily postadmission mortality rates were also evaluated. The rate of change (slope) of the survival curves and daily mortality rates were analyzed to select the point after which mortality rates were no longer decreasing. There were 32,135 injured older adults hospitalized over the 2-year period, with a median age of 82 (interquartile range 77-88). Cumulative in-hospital mortality and at 30, 60, 90, 180, and 365 days was 4.1%, 9.7%, 13.6%, 16.1%, 21.3%, and 28.4%, respectively. Mortality rates stabilized by 6 months after injury, with 89% of the change occurring within 60 days. Although serious injuries, medical comorbidities, and preinjury nursing facility residence were all associated with higher mortality, they did not affect the pattern of mortality after injury. In-hospital mortality is much lower than postdischarge mortality in injured older adults, with a substantial portion of persons dying shortly after discharge from the hospital. Mortality appears to stabilize by 6 months after injury, although 60-day postadmission follow-up captures most of the excess daily mortality rate.
    Journal of the American Geriatrics Society 10/2010; 58(10):1843-9. · 4.22 Impact Factor
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    ABSTRACT: To determine whether routine surgeon consultation with medicine specialists and multidisciplinary care conferences-potentially modifiable hospital characteristics-are associated with lower 1-year mortality in older adults with hip and lower extremity injuries. Retrospective cohort study. Oregon hospitals. Two thousand five hundred thirty-eight Medicare recipients aged 67 and older hospitalized in Oregon hospitals in 2002 with hip or lower extremity injuries. Demographic, injury, comorbidity, and survival information were gathered from Medicare records for 2000 to 2003. All Oregon hospitals with a qualifying case were surveyed using a structured telephone interview to collect information about routine surgeon consultations and multidisciplinary care conferences for older adult orthopedic patients. Multivariable generalized estimating equation models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between hospital characteristics and mortality. After adjusting for age, injury severity, comorbid conditions, trauma center status, and hospital annual volume of patients with hip fracture, the relative odds of dying in the year after injury for inpatients treated in settings with routine surgeon consultation with medical staff was 0.69 (95% CI 0.57-0.83) compared with patients not treated in such settings. Inpatient treatment in settings with routine multidisciplinary care conferences did not significantly affect the relative odds of dying in the year after injury (OR=1.06, 95% CI=0.89-1.26). Routine consultation by attending orthopedic surgeons with medicine or primary care specialists for Medicare inpatients is associated with better survival 1 year after injury.
    Journal of the American Geriatrics Society 10/2010; 58(10):1835-42. · 4.22 Impact Factor
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    ABSTRACT: We aimed to present herein the case of a potentially preventable death involving traumatic aortic rupture and to develop a critical pathway for the management of isthmic aortic ruptures consistent with the available resources. A retrospective record review by a multidisciplinary panel of experts was done, and the probability of survival was estimated based on the Revised Trauma Score and Injury Severity Scale score. Literature review and expert consensus were used in a quality and safety analysis to develop a critical care pathway for future cases. A 32-year-old man, injured in a motorcycle accident, was referred to a trauma center in a state of shock. Thoracic aortic rupture was highly suspected. For educational purposes, the classic signs of a widened mediastinum, right tracheal deviation, and left-sided hemothorax (in a context of significant deceleration injury) are incorporated into an acute care triad for traumatic aortic rupture. In such cases, in the absence of poor access to aortography, we suggest (serial - if needed) contrast-enhanced chest computed tomography scanning for diagnosis confirmation and operative planning. Assumption of hemodynamic stability can be catastrophic, and transferring the patient to a second facility may endanger survival, when operative capacity exists at the initial trauma facility.
    Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery: TJTES 05/2010; 16(3):271-4. · 0.34 Impact Factor
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    ABSTRACT: Emergency medicine (EM) has grown rapidly over the past 50 years, evolving from a specialty defined by its locational identity--a hospital receiving room--to the specialty picked fourth-most-frequently by graduating U.S. medical students and to being the focal point of clinical care and of research on time-sensitive medical conditions. The authors review the forces that led to the growth of EM and those that will shape its future--in particular, cost, quality, and technology. A balancing of cost and quality considerations will likely drive EM education and research endeavors. The future of the field will be determined in part by resolution of the tension between the current inefficient conditions of emergency departments (EDs), which are crowded because of the temporary boarding of admitted patients for whom a bed is not yet ready, and the desired provision of quality care under emergent conditions. That is, patients with stroke, myocardial infarction, sepsis, or severe injuries from trauma require a working diagnosis and interventions that are initiated shortly after presentation, but ED personnel distracted by the demands of caring for boarded patients are unable to deliver optimal ED care. The reduction or elimination of boarding will enhance education and research within EDs and will contribute to an efficient system of high-quality EM services.
    Academic medicine: journal of the Association of American Medical Colleges 03/2010; 85(3):490-5. · 2.34 Impact Factor
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    ABSTRACT: While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD-9), injury diagnosis (years 2005-2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998-2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001-2002). In-hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] >or= 16 or ICD-9 ISS <or= 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0-14, 15-64, and >or=65 years), hospital type, and hospital annual admission volume. The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied.
    Academic Emergency Medicine 02/2010; 17(2):142-50. · 2.20 Impact Factor
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    ABSTRACT: It remains unclear whether the American College of Surgeons Committee on Trauma (ACSCOT) "step 1" field physiologic criteria could be further restricted without substantially sacrificing sensitivity. We assessed whether more restrictive physiologic criteria would improve the specificity of this triage step without missing high-risk patients. We analyzed an out-of-hospital, consecutive patient, prospective cohort of injured adults >or=15 years collected from December 1, 2005, to February 28, 2007, by 237 emergency medical service agencies transporting to 207 acute care hospitals in 11 sites across the United States and Canada. Patients were included based on ACSCOT field decision scheme physiologic criteria systolic blood pressure <or=90, respiratory rate <10 or >29 breaths/min, Glasgow Coma Scale score <or=12, or field intubation. Seven field physiologic variables and four additional demographic and mechanism variables were included in the analysis. The composite outcome was mortality (field or in-hospital) or hospital length of stay >2 days. Of 7,127 injured persons, 6,259 had complete outcome information and were included in the analysis. There were 3,631 (58.0%) persons with death or LOS >2 days. Using only physiologic measures, the derived rule included advanced airway intervention, shock index >1.4, Glasgow Coma Scale <11, and pulse oximetry <93%. Rule validation demonstrated sensitivity 72% (95% confidence interval: 70%-74%) and specificity 69% (95% confidence interval: 67%-72%). Inclusion of demographic and mechanism variables did not significantly improve performance measures. We were unable to omit or further restrict any ACSCOT step 1 physiologic measures in a decision rule practical for field use without missing high-risk trauma patients.
    The Journal of trauma 02/2010; 68(2):452-62. · 2.35 Impact Factor
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    ABSTRACT: The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs. To assess injury hospitalization as a potential marker for subsequent EMS utilization and costs by Medicare patients. This observational study analyzed a retrospective cohort of all Medicare patients (> or = 67 years old) with an International Classification of Diseases, Ninth Revision (ICD-9) injury diagnosis admitted to 125 Oregon and Washington hospitals during 2001 and 2002 who survived to hospital discharge. The numbers of EMS transports and the total EMS costs were compared one year before and one year following the index hospitalization. There were 30,655 injured elders in our cohort. Their median ICD-9-based injury severity score was 0.97, with 4.1% meeting a definition of serious injury and 37% having hip fractures. The mean (range) numbers of EMS transports before and after the injury were 0.5 (0-45) and 0.9 (0-56), for an unadjusted incidence rate ratio (IRR) of 1.7 (95% confidence interval [CI] 1.7-1.8). The increase in EMS utilization following an injury hospitalization was even greater after adjusting for risk period and other model predictors (IRR 2.4, 95% CI 2.3-2.5). Annual mean EMS costs rose 74% following the injury hospitalization, from $211 to $367 per person. The greatest increase was in nonemergent EMS use, accounting for 67% of the increase in the number of uses. Institutionalization in a skilled nursing or rehabilitation facility either before or after injury was strongly associated with the need for EMS care. An injury hospitalization in the elderly serves as a sentinel marker for an abrupt increase in EMS utilization and costs, even after accounting for confounders.
    Prehospital Emergency Care 01/2010; 14(4):425-32. · 1.86 Impact Factor
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    ABSTRACT: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged > or =15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.
    Annals of emergency medicine 09/2009; 55(3):235-246.e4. · 4.33 Impact Factor
  • Jerris R Hedges, Daniel A Handel
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    ABSTRACT: We have previously reviewed the challenges facing Hawai'i and the nation in terms of healthcare. Successfully addressing these challenges will require major changes in the delivery of healthcare and societal/legal perspectives. In this issue, we outline the key factors needed collectively and simultaneously to address these challenges. These factors are: (1) a capitated care model focused on health and chronic disease management; (2) universal access to a basic healthcare delivery system, and acceptance of the service limitations associated with such a model of care delivery; (3) a universal electronic shared health information system as a mechanism by which care in such a system can be coordinated; (4) an approach to developing state sanctioned, legal approaches to avoiding or minimizing futile care; (5) enhancement of systems of care (e.g., statewide trauma systems); (6) alignment of practitioner and hospital reimbursement with societal health goals, with legal protections; (7) a system of no-fault patient compensation when injuries occur in the course of medical care; and (8) support of expanded training programs for physicians, nurses and other practitioners.
    Hawaii medical journal 08/2009; 68(6):124-7.
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    ABSTRACT: The Emergency Medical Treatment and Active Labor Act (EMTALA) was conceived as a means to ensure that patients with emergent conditions would receive stabilizing care and to avert the potentially dangerous, economically driven, interhospital transfer of patients. This legislation and its subsequent application arrived near the time that regional and statewide trauma systems were established. Trauma systems were developed to guide optimal resource use for the injured patient regardless of the patient's ability to pay. Unfortunately, when coupled with current economic and litigation threats to community emergency and surgical practitioners, EMTALA represents a threat to the continuation of the trauma system concept. Trauma systems are dependent on a tiered hospital network where severely injured patients are taken to a hospital with resources aligned to manage the worst of injuries. When primary triage from the field cannot accomplish this task, secondary triage from a nondesignated or lower-level hospital to the higher-level trauma center is needed. EMTALA has served as a driver to change the priority for secondary triage from addressing the needs of the severely injured patient to filling community hospital surgical specialist emergency department on-call coverage gaps for less severely injured patients. Further, legal action associated with claims of EMTALA violations has needlessly extended medical examination and "stabilization" efforts at community emergency departments prior to needed secondary triage. Higher-level trauma centers will benefit from codifying system-wide emergency medical services practices related to primary and secondary triage, establishing trauma center capacity and divert practices, and initiating "transfer center" operations that control transfer of patients to these centers.
    Prehospital Emergency Care 07/2009; 10(3):332-9. · 1.86 Impact Factor
  • Jerris R Hedges, Daniel A Handel
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    ABSTRACT: Although there is consensus regarding the existence of a healthcare crisis, that point is where the consensus stops, even within defined professional and demographic groups. Clearly there is evidence that we must address a growing societal expenditure for healthcare, an aging and more complex patient population, a shortage of physicians and other health care providers, and health outcomes disparities amongst population groups. This article emphasizes how these factors impact healthcare nationally and in Hawai'i. The second part of this series outlines approaches that can enhance health in the United States without creating economic collapse.
    Hawaii medical journal 07/2009; 68(5):101-3.
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    ABSTRACT: Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse. To determine if there is improved survival among injured patients hospitalized in states that categorize rural hospitals as trauma centers. We analyzed a retrospective cohort of injured patients included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 1997 to 1999. We used generalized estimating equations to compare survival among injured patients hospitalized in states that categorize rural hospitals as Level III and IV trauma centers versus those that do not. Multivariable models adjusted for important confounders, including patient demographics, co-morbid conditions, injury severity, and hospital-level factors. There were 257,044 admitted patients from 7 states with a primary injury diagnosis, of whom 64,190 (25%) had a "serious" index injury, 32,763 (13%) were seriously injured (by ICD-9 codes), and 12,435 (5%) were very seriously injured (by ICD-9 codes). There was no survival benefit associated with rural hospital categorization among all patients with a primary injury diagnosis or for those with specific index injuries. However, seriously injured patients (by ICD-9 codes) had improved survival when hospitalized in a categorizing state (OR for mortality 0.72, 95% confidence interval [CI] 0.53-0.97; OR for very seriously injured 0.68, 95% CI 0.52-0.90). There was no survival benefit to categorizing rural hospitals among a broad, heterogeneous group of hospitalized patients with a primary injury diagnosis; however the most seriously injured patients did have increased survival in such states.
    The Journal of Rural Health 01/2009; 25(2):182-8. · 1.44 Impact Factor
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    ABSTRACT: For trials involving exception from informed consent, some IRBs require that community members be allowed to "opt out" prior to enrollment. We tested for geospatial clustering of opt-out requests and the associated census tract characteristics in one study region. This was a retrospective study at a single site of a multicenter exception from informed consent resuscitation trial. We collected and geocoded mailing addresses for persons requesting opt-out bracelets over 16 months, then tested for geospatial clustering using geographic information systems (GIS) analysis. Characteristics for tracts with and without bracelet clustering were compared using univariate tests, multivariable regression, and classification and regression tree (CART) analysis. We received 395 phone calls requesting 718 bracelets, of which 673 were analyzable. Of 397 census tracts in the region, 208 (52%) had at least one request and 38 (10%) demonstrated clustering. In multivariable models, an increasing proportion of family households (OR .90, 95%CI .85-.93), veterans (OR .91, 95%CI .81-1.02), and renters (OR .96, 95%CI .92-.99) were associated with lower odds of requesting an opt-out bracelet, while census tracts with higher income had higher odds of opting-out (OR 1.07, 95%CI 1.02-1.11). Using CART, the proportion of family households and graduate education identified the majority of opt-out requests by census tracts (cross-validation sensitivity 92%, specificity 56%). Opt-out requests for an exception from informed consent trial at one study site were geographically clustered and associated with certain population demographics. These findings may help identify key target groups for community consultation in future trials.
    Resuscitation 12/2008; 80(1):89-95. · 4.10 Impact Factor
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    ABSTRACT: Studies of trauma systems have identified traumatic brain injury as a frequent cause of death or disability. Due to the heterogeneity of patient presentations, practice variations, and potential for secondary brain injury, the importance of early neurosurgical procedures upon survival remains controversial. Traditional observational outcome studies have been biased because injury severity and clinical prognosis are associated with use of such interventions. We used propensity analysis to investigate the clinical efficacy of early neurosurgical procedures in patients with traumatic brain injury. We analyzed a retrospectively identified cohort of 518 consecutive patients (ages 18-65 years) with blunt, traumatic brain injury (head Abbreviated Injury Scale score of >or= 3) presenting to the emergency department of a Level-1 trauma center. The propensity for a neurosurgical procedure (i.e., craniotomy or ventriculostomy) in the first 24 h was determined (based upon demographic, clinical presentation, head computed tomography scan findings, intracranial pressure monitor use, and injury severity). Multivariate logistic regression models for survival were developed using both the propensity for a neurosurgical procedure and actual performance of the procedure. The odds of in-hospital death were substantially less in those patients who received an early neurosurgical procedure (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.05-0.41). The mortality benefit of early neurosurgical intervention persisted after exclusion of patients who died within the first 24 h (OR 0.13; 95% CI 0.04-0.48). Analysis of observational data after adjustment using the propensity score for a neurosurgical procedure in the first 24 h supports the association of early neurosurgical intervention and patient survival in the setting of significant blunt, traumatic brain injury. Transfer of at-risk head-injured patients to facilities with high-level neurosurgical capabilities seems warranted.
    Journal of Emergency Medicine 12/2008; 37(2):115-23. · 1.33 Impact Factor
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    ABSTRACT: A paucity of board-certified Emergency Physicians practice in rural Emergency Departments (EDs). One proposed solution has been to train residents in rural EDs to increase the likelihood that they would continue to practice in rural EDs. Some within academic Emergency Medicine question whether rural hospital EDs can provide adequate patient volume for training an Emergency Medicine (EM) resident. To compare per-physician patient-volumes in rural vs. urban hospital EDs in Oklahoma (OK) and the proportion of board-certified EM physicians in these two ED settings. A 21-question survey was distributed to all OK hospital ED directors. Analysis was limited to non-military hospitals with EDs having an annual census > 15,000 patient visits. Comparisons were made between rural and urban EDs. There were 37 hospitals included in the analysis. Urban EDs had a higher proportion of board-certified EM physicians than rural EDs (80% vs. 28%). There were 4359 vs. 4470 patients seen per physician FTE (full-time equivalent) in the rural vs. urban ED settings, respectively (p = 0.84). Patient volumes per physician FTE do not differ in rural vs. urban OK hospital EDs, suggesting that an adequate volume of patients exists in rural EDs to support EM resident education. Proportionately fewer board-certified Emergency Physicians staff rural EDs. Opportunities to increase rural ED-based EM resident training should be explored.
    Journal of Emergency Medicine 11/2008; 37(2):172-6. · 1.33 Impact Factor

Publication Stats

5k Citations
745.14 Total Impact Points

Institutions

  • 1990–2012
    • Oregon Health and Science University
      • • Department of Emergency Medicine
      • • Department of Surgery
      • • Department of Medicine
      Portland, OR, United States
  • 2011
    • University of Hawai'i System
      Honolulu, Hawaii, United States
  • 2009–2011
    • University of Hawaiʻi at Mānoa
      • John A. Burns School of Medicine
      Honolulu, HI, United States
    • University of Ottawa
      • Department of Emergency Medicine
      Ottawa, Ontario, Canada
  • 2010
    • University of New Mexico
      • Department of Emergency Medicine
      Albuquerque, NM, United States
    • University of Washington Seattle
      • Department of Epidemiology
      Seattle, WA, United States
  • 2008–2010
    • Tehran University of Medical Sciences
      • Eye Research Center
      Tehrān, Ostan-e Tehran, Iran
  • 2008–2009
    • Portland State University
      • Department of Sociology
      Portland, OR, United States
  • 2005
    • The Clinical Trial Center, LLC
      Jenkintown, Pennsylvania, United States
  • 2004
    • University of Texas Health Science Center at Houston
      Houston, Texas, United States
  • 2003
    • The Portland Hospital
      Londinium, England, United Kingdom
    • Yale University
      • Department of Surgery
      New Haven, CT, United States
  • 2000–2002
    • University of Utah
      • School of Medicine
      Salt Lake City, UT, United States
    • Wake Forest School of Medicine
      Winston-Salem, North Carolina, United States
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
  • 2001
    • Salt Lake City Community College
      Salt Lake City, Utah, United States
  • 1991
    • Northeast Ohio Medical University
      Ravenna, Ohio, United States
  • 1989
    • University of Oregon
      Eugene, Oregon, United States
  • 1987–1989
    • The Ohio State University
      • Department of Emergency Medicine
      Columbus, OH, United States
    • Cincinnati Children's Hospital Medical Center
      • Division of Emergency Medicine
      Cincinnati, OH, United States
    • Christ Hospital
      Jersey City, New Jersey, United States
  • 1984–1988
    • University of Cincinnati
      • Department of Emergency Medicine
      Cincinnati, OH, United States
    • The University of Arizona
      Tucson, Arizona, United States
  • 1986
    • CSU Mentor
      Long Beach, California, United States