M. Kwak1, P. J. Chung1, M. C. Smith1, V. Roudnitsky2, A. Alfonso1, G. Sugiyama1 1SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Department Of Acute Care Surgery/Trauma,Brooklyn, NY, USA
Introduction:
Falls are the most common mechanism of injury for which patients are admitted to trauma centers in the United States. Patients at highest risk for ground level falls (GLF) include the elderly, who are also more likely to have comorbidities such as end-stage renal disease (ESRD). Patients with ESRD are at higher risk for fractures and bleeding. We performed an observational study of a national database to assess whether ESRD affects outcomes of patients who suffer GLF with rib fractures.
Methods:
Using the Nationwide Inpatient Sample (NIS) from 2005-2012, we identified adult patients 18 years and older, experiencing a fall from standing or similar height (E-codes E880, E884, E885, E886, E888) with confirmed diagnosis of rib fracture(s) (ICD-9 807). Cases missing demographic or inpatient death information were excluded. The Trauma Mortality Prediction Model (TMPM) score and the Elixhauser-Van Walraven score were used to assess trauma and comorbidity status respectively. Multivariable logistic regression analysis, using inpatient mortality as the outcome, was performed adjusting for demographics, TMPM score, Elixhauser-Van Walraven score, ESRD status, and presence of hemothorax.
Results:
There were 58,095 patients meeting the inclusion/exclusion criteria. Median age was 80 years. The majority were White (86.81%) and female (55.52%), 1,096 (1.89%) had ESRD, and 4,633 (7.97%) had hemothoracies. Inpatient mortality occurred in 1,992 patients (3.43%). On a multivariable logistic regression analysis, statistically significant independent variables associated with mortality were age (OR 2.43 [2.21-2.68, 95% CI], p<0.0001), male gender (OR 1.49 [1.36-1.64, 95% CI], p<0.0001), having private insurance vs Medicare (OR 1.33 [1.12-1.57, 95% CI], p=0.0079), no insurance vs Medicare (OR 1.50 [1.05-2.15, 95% CI], p=0.0079), TMPM score (OR 1.09 [1.08-1.10, 95% CI], p<0.0001), having hemothorax (OR 1.25 [1.09-1.45, 95% CI], p<0.0001), Elixhauser-Van Walraven Score (OR 2.22 [2.09-2.35, 95% CI], p<0.0001), and having ESRD (OR 1.74 [1.35-2.25, 95% CI], p<0.0001). Protective variables included Black vs. White race (OR 0.72 [0.54-0.97, 95% CI], p=0.0481), and Hispanic vs. White ethnicity (OR 0.74 [0.58-0.95, 95% CI], p=0.0481).
Conclusion:
In this large observational study of a national database, we found that ESRD is highly associated with inpatient mortality for patients that sustain GLF resulting in rib fractures, even after adjusting for mechanism and sequelae of injury such as the development of hemothorax. In the setting of trauma, patients with ESRD are an especially vulnerable population for poor outcomes. Prospective studies are warranted to identify optimal treatment strategies to reduce the risk of mortality in patients with ESRD.