The Rural Trauma Imperative: Silent Killer in Americas Heartland

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The Rural Trauma ImperativeSilent Killer in
Americas Heartland

• Michael F. Rotondo MD FACS
• Professor and Chairman
• Chief, Trauma and Surgical Critical Care
  Department of Surgery
• The Brody School of Medicine
• East Carolina University

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The Imperative !!!!

• There is no universally acceptable and
  universally applicable definition of
• rural trauma ..

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What is rural trauma?

• when optimal care of the injured is delayed or
  limited by geography, weather, distance,
  resources or lack of experience
• ACS COT Optimal Resource
• Guide for Care of the Injured

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The Imperative !!!!

• nearly 60 of all trauma deaths occur in rural
  areas despite the fact that only 20 of the
  nations population live in these areas
• Report on Injuries in America
• National Safety Council - 2003

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North Carolina Rural Health Research and Policy
Analysis Center US Census 2000
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The Imperative !!!!

• death rate in rural area is inversely related
  to the population density
• Baker et al, NEJM 1987

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DEAD 60,000 / YEAR
North Carolina Rural Health Research and Policy
Analysis Center US Census 2000
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Annual Statistics

• 60,000 Dead
• 150,000 ER Visits
• 12,000,000 Disabled
• 200,000,000,000

Report on Injuries in America National Safety
Council - 2003
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The Imperative !!!!

• adjusting for crash characteristics, age, and
  gender, the relative risk of a rural victim dying
  in a motor vehicle crash was 151 compared with
  an urban crash victim
• Maio et al, Accid Anal Prev 1992

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The Imperative !!!!

• injury related deaths are 40 higher in rural
  communities than in urban areas
• Center for Rural Care Fact Sheet University of
  North Dakota 2003

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Trauma Deaths in a Mature Urban vs. Rural Trauma
System

• Methods Retrospective Review of Autopsy/ME
  Database
• Comparing outcomes urban SDC vs rural VT
• All fatalities were reviewed
• ISS
• Age
• Cause of death
• Mechanism of Injury
• Comorbidities

Rogers et al, Arch Surg 1997
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Results(death at scene)
p lt 0.05
Rogers et al, Arch Surg 1997
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Results(in-hospital deaths 24 hours)
p lt 0.05
Rogers et al, Arch Surg 1997
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Conclusions

• Rural patients are more likely to die at the
  scene, are less severely injured and are older
• Rural patients surviving 24 hours before death
  are older, less severely injured, have more
  co-morbidities and are more likely to die of MOSF
  compared to urban patients

Rogers et al, Arch Surg 1997
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The Imperative !!!!

• 87 of rural pediatric trauma deaths did not
  survive to reach the hospital
• Vane, J Trauma 1995

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The Imperative !!!!

• 18 of rural residents are over age 65 compared
  to 15 of urban residents moreover, the rural
  elders are more often disabled and have more
  severe occupation related illness compared to
  their urban counterparts
• Center for Rural Care Fact Sheet University of
  North Dakota 2003

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Age 45 85 years
2005 NTDB Report
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The Imperative !!!!

• poverty and a rural setting are associated with
  trauma deaths
• Rutledge et al, Ann Surg 1994

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The Imperative !!!!

• rural communities have a disproportionately
  higher percentage of Medicare beneficiaries and
  more patients in need of Medicaid
• Wattenburg Health Care Disparities in Western New
  York 2000

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The Economics of Rural Health Care
Delivery(Hospitals)

• Policy - The 8020 rule applies
• A one size fits all approach
• DRG payment and the area wage index
• The lower the area wages, the lower the payment
• Rural Hospitals 15 lower index
• The case mix effect
• Rural Hospitals 5- 10 lower payments

Heady et al, JAMA 2005
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The Imperative !!!!

• 84 of U.S. residents can reach a Level I or
  Level II trauma center within an hour, but only
  24 of residents in rural areas have access
  within one hour

Branas et al. Health Services Research 2000
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Percent of Residents with One Hour Access to a
Level I or II Trauma Center
Branas et al. Health Services Research 2000
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Summary of the Facts

• No clear definition
• Disproportionate number of deaths relative to
  population
• Increased death rate at equivalent severity
• Increased death rate with decreasing population
  density

• Effects the old
• Effects the young
• Poverty less resources
• Poor Payer Mix
• Maldistribution of Trauma Centers

... the facts create the imperative
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What are the Solutions?
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Trauma System Development

• Overall survival (Nathens 2000)
• improved
• MVC Survival (Nathens 2000)
• improved
• Geriatric Survival (Mann 2001)
• improved
• Remote Rural Survival (Mann 2001)
• Improved
• Process of care (Olson 2001)
• improved

only a sample of the studies
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Analysis of Preventable Trauma Deaths and
Inappropriate Care in a Rural State

• Methods Multidisciplinary Retrospective
  Chart Review
• Analyzing outcomes in a rural environment
• All fatalities were reviewed
• Preventability Determined

Esposito et al, J Trauma 1995
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Results1991
Esposito et al, J Trauma 1995
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Results1998(Institution of a Voluntary Trauma
System)
Esposito et al, J Trauma 2003
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Conclusions

• Education may be the most cost effective method
  of reduction on preventable trauma deaths in a
  rural region.

Esposito et al, J Trauma 1995/2003
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Does Trauma Center Development Help ?
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What Price Commitment? What Benefit? The East
Carolina Experience

• Renewed financial commitment over a 5 year period
• Aggressive Development
• Recruitment of New Leadership
• Recruitment of Fellowship Trained Faculty
• Development of Surgical Critical Care
• Call Pay for Subspecialists
• Strict Performance Criteria
• Aggressive Performance Improvement
• Advanced Level Practitioner Program
• Practice Management Guidelines
• Developing the Culture of Trauma

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Mortality Rates for ISS gt 16 FY 1998 - 2005
Source CISS, PCMH Trauma Registry
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Mortality Rates for Pediatric Patients with
ISS gt 16 FY 1998 - 2005
The Benefit Over 200 lives saved
Source CISS, PCMH Trauma Registry
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Perspective Cost vs. Value

• Value of a Statistical Life - 7 million
• Harvard Law, Economics and Business 2005
• Value / Life Year (Age 45) - 6 million
• 200,000 / Life Year x 30 - NEJM Sept. 2006
• Cost (Crash Safety) - 11 billion
• 544, 482 / Life Saved - NHTSA Dec. 2004

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Conclusions

• Price of Commitment
• 3 million/year
• Cost of a Saved Life
• 70 thousand
• Benefit
• 200 saved lives
• True Benefit
• Only the patients and their families really know

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Strategies

• Trauma System Development
• Trauma Center Development
• Prevention, Education and Outreach
• Legislation and Funding

• Digital Tools
• Diversity and Population Migration
• Economic Development International Studies
• Collaborative Lobbying Efforts

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This is not about pity. Its more about
passion. Pity sees suffering and wants to ease
the pain passion sees injustice and wants to
settle the score. Pity implores the powerful to
pay attention passion warns them about what will
happen if they dont. Nancy Gibbs - Time

• Rural trauma patients need no more condolences,
  further problem identification is
  unwarranted.they need America to get interested
  and then get to work.