Cutting Edge Newsletter
01 Aug 2024
by Research and Education Fund SubCommittee, Palliative Trauma Committee, Geriatric Trauma/ACS Committee, Diversity, Equity, and Inclusion Committee, Healthcare Economics Committee, JTACS Editorial Board, Communications Committee

Editor’s Note

Written by: Shannon Marie Foster, MD, FACS 

Friends and Colleagues:

Summer Olympics Paris 2024.  I suspect all are indulging in one way or another to watch the Biles, Lyles, and Ledecky records, or the surfing, breaking, and sport climbing that are redefining sport.  Whatever you may feel about the politics and controversies of the event, the Olympics are a time of unrivaled competition and amazing displays of athleticism.  Years of training.  Blood, sweat, tears.  Failures and successes.  All whittled to a single moment.  Sounds like a profession we all know and love.  While you may wear no jersey or medal, each of you represents the same:  tireless effort, rigorous training, unyielding commitment to success, required every day to manifest unerring performance in the decisions and technical prowess to care for our patients. 

Interestingly, the Games have evolved in many ways paralleling our own surgical professional growth:  increased attention to mental health as a priority, demanding a culture of safety where abuse and misbehavior will not be tolerated, expanding pipeline efforts to optimize exposure and representation, and preventative measures to protect the body from harm and dysfunction due to repetitive and stressful positions.   As you welcome new trainees or partners into the fold, and further refine and grow your own practice, please ensure an environment where those issues are not something aspirational, but rather the foundation of the workplace.  Our membership and active participation in AAST creates a network and community where we can achieve elevated foundational structures together. 

I laud and applaud each one of you for pushing our profession forward. 

Enjoy the Games.

Respectfully,

SMF

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President's Message

Written by: Patrick Reilly, MD

The countdown clock to the 2024 AAST Annual Meeting in Las Vegas has started.  This year, the meeting is held in conjunction with the World Trauma Congress.  Attendess from around the world can benefit from double the educational content.  Abstracts for both programs look exceptional and the additional content of lectures and lunch sessions as well as pre- and post-sessions should have something for everyone.  Amy Goldberg will be delivering the Expert Surgeon Lecture, and Mike Rotondo will be serving as the 2024 Fitts Lecturer.  And I heard there might be some fun to be had in Vegas as well!  If you haven’t already, please register for the meeting.  Plenty of affordable hotel rooms in the city so last minute plans shouldn;’t be a problem.   More details about the meeting can be found in this issue of Cutting Edge.

Time is also running out to get your committee volunteer forms into the AAST office.  Our committees have done amazing work this year, much of which will be on display throughout the Annual Meeting.  But there is more to do…and we welcome your involevement. Dr. Stewart will be making appointments in the next month or so; we always need hard working dedicated AAST members to help round out the committees and fill the slots of those who are timing out.  The form only takes a few minutes to complete and can be found at:  https://www.aast.org/committee-volunteer-form

 As this may be one of my last contributions to Cutting Edge, I wanted to thank the Executive Committee, the Board of Managers, and all of the many Committee Chairs for their tireless service to the organization.  They really are the engine that is responsible for all that the AAST accomplishes.  It is truly an honor to work with them all.  And finally, thanks to Sharon Gautschy and the entire AAST staff whom work tirelessly behind the scenes to keep everything moving forward.  All those involved in committee work know we couldn’t do it without them!  Please make an effort to thank them in person this September.

Safe travels to the meeting.  I look forward to seeing you in Las Vegas next month. 

Program Chair’s Message 

Written by: Karen J. Brasel, MD, MPH

As I sit here writing this, there is less than two months before we gather in Las Vegas for the 83rd AAST Annual Meeting and the 7th WTC.  We have an incredible event lined up for you: fantastic science, great networking, interesting and provocative panels, excellent invited speakers, outstanding professional development, and more.  I encourage you to look at the online program to view this year’s educational offerings that include but are not limited to: lunch/add-on/pre-sessions, the 2nd Annual Military Symposium, and the Emergency Surgery Course. Be sure to block out time in your schedule for networking breakfasts and evening receptions. DEI, international attendees, WTC members, new members, associate members, WITS, residents, military personnel, fellows and medical students—there is something for all.

As in the past, we have tried to incorporate as many members and associate members as possible in the meeting.  Many thanks to those who have filled out the volunteer form and have identified your areas of expertise—your contributions make the society and the meeting so much better, stronger, fun, and enables AAST to continuously improve our meeting year to year.  If you filled out the form and were not able to contribute, please let me know, and we will continue to work to get all involved.

Dr. Reilly, the incredible AAST staff, and I look forward to seeing you all in Las Vegas!!

Research and Education Fund Update

Written by: Andrew C. Bernard, MD

I look forward to seeing many of you in a few short weeks when we meet in Las Vegas for the 83rd Annual Meeting of the AAST. Whether you’ll be considering some gambling in Vegas or not, here’s one safe bet: AAST REF.

Your bet on AAST’s Research and Education Fund will always be a winner. In 2023, more than 230 AAST members and friends became winners by supporting research scholarships and meeting travel for residents, students and military members. If you have given to AAST REF this year, THANK YOU! You should be proud that the research you supported made this year’s program. When the students, residents and military members who received meeting travel scholarships are announced at the opening, you should smile widely. You made that happen. Again this year, we will offer lots of ways to WIN WITH AAST REF.

 

You could just walk up and donate at the registration desk or from your phone using the QR code that will be flashing on the screen during breaks all week. For a souvenir, AAST calendars and swag will be on sale. And if you’re a REF donor, join us on Thursday at the Barista café in the foyer where we’ll thank you with a latte.  Silent auction items will be up for bids throughout the meeting. And Friday night’s live auction always brings lively bidding for travel and experiences. And the auction items don’t just support the REF and its missions, most of them involve a personal connection with an AAST family member. And that is indeed a win. AAST REF continues to serve AAST members and friends. You can bet on it! See you in Vegas!

 

Palliative Care Committee

Palliative Care Education Opportunities for Surgeons

Written by: Alison Haruta, MD;  Zara Cooper, MD, MSc 

Introduction

Palliative care encompasses principles that address and support care of the whole patient. The goal is to improve quality of life, deliver patient and family centered care, and treat symptoms across physical, emotional, spiritual, and psychosocial domains for seriously ill patients and their families. Palliative care is ideally delivered alongside life sustaining care and comfort focused care, depending on the patient’s goals. Both the ACS Statement of Principles of Palliative Care (2005)1 and the ACS TQIP Best Practice Guidelines for Palliative Care (2017)2 highlight the importance of surgeons in delivering palliative care, yet these skills are rarely taught during surgical training. Here we provide an overview of several resources surgeons can use to hone their skills in serious illness communication and palliative care. 

Just in Time Resources
For surgeons looking to brush up on specific skills, there are several concise, high yield resources available. VitalTalk is a training organization which focuses on teaching serious illness communication. They offer a range of resources including quick guides with frameworks, or conversation maps, to use in a variety of situations such as breaking bad news, discussing prognosis, or addressing goals of care. These guides include tips to help navigate common difficult scenarios3. The Serious Illness Conversation Guide is another one page reference that includes patient tested language to set up and explore key topics in a goals of care conversation4. Additionally, the Palliative Network of Wisconsin has a “Fast Facts” database which contains succinct, evidenced based, peer reviewed overviews of a broad range of primary palliative care topics5. Recently, the AAST Palliative Care Committee has developed “One Pagers”  which offer a concise reference to manage common situations in acute care surgery such as running a family meeting, dealing with malignant bowel obstructions, or withdrawing life sustaining care6.

Self Paced Learning
There are also more in-depth reviews of primary palliative care topics for those looking to deepen these skills. VitalTalk offers online modules that address serious illness conversations and delivering serious news3. If interested in a broader range of topics, the Center to Advance Palliative Care (CAPC) is a national organization that has interactive, case based, online modules covering communication, advance care planning, and symptom management issues, though some may dive into specialty level detail. These courses are free to members and membership is often free through one’s institution. For those that prefer texts,  Navigating Communication with Seriously Ill Patients by Arnold, et al, provides an overview of communication tactics7. Surgical Palliative Care: Integrating Palliative Care by Mosenthal and Dunn Eds., is a comprehensive review of applying palliative care across surgical specialties8. Table 1 from Ellison et al provides a number of text resources9. Some surgical podcasts discuss integration of palliative care into surgical practice including the East Traumacast10 and Behind the Knife11-16.

Courses
For a more intensive training experience, VitalTalk offers a virtual course for mastering tough conversations where instructors observe learners through simulated patient interactions and provide real time feedback to grow communication skills in a low stakes environment3. Many institutions also offer graduate certificate programs for palliative care, for example the Palliative Care Training Center at the University of Washington17 or the Center for Palliative Care at Harvard Medical School18. These are intensive, longitudinal programs with multidisciplinary students for those looking for more structured teaching of palliative care principles.

 Fellowship training

Specialty training in Hospice and Palliative Medicine is available through a 12-month, ACGME approved fellowship. Surgeons can enter fellowship after completing at least three years of clinical training, applying through ERAS, and can achieve board certification once certification in their primary specialty is obtained.

Conclusion

Primary palliative care skills should be part of every surgeon’s toolkit. An array of resources are available to help surgeons learn and practice these skills, and build confidence delivering palliative care.

Table 1(Reprinted with Permission )9

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References

  1. American College of Surgeons. Statement of Principles of Palliative Care. Accessed August 7, 2023. https://www.facs.org/about-acs/statements/principles-of-palliative-care/
  2. American College of Surgeons. ACS TQIP Palliative Care Best Practice Guidelines. Accessed June 1, 2023. https://www.facs.org/media/g3rfegcn/palliative_guidelines.pdf
  3. VitalTalk. Accessed July 2, 2024. https://www.vitaltalk.org/
  4. Ariadne Labs: A Joint Center for Health Systems Innovation at Brigham and Women's and Harvard School of Public Health. Serious Illness Conversation Guide. 2023.
  5. Palliative Care Network of Wisconsin. Fast Facts. Accessed July 2, 2024. https://www.mypcnow.org/fast-facts/
  6. The American Association for the Surgery of Trauma: Palliative Care Committee. Accessed July 3, 2024. https://www.aast.org/committees/palliative-trauma-ad-hoc-committee
  7. Arnold R, Back A, Carey E, Tulsky J, Wood G, Yang H. Navigating Communication with Seriously Ill Patients. 2 ed. 2024.
  8. Mosenthal A, Dunn G. Surgical Palliative Care: Integrating Palliative Care. 1st ed. 2019.
  9. Ellison HBM, FACS, Lau LAM, FACS, Cook ACM, Hoffman RM, ND, FACS, Berlin AM, MPH, FACS. Surgical Palliative Care: Considerations for Career Development in Surgery and Hospice and Palliative Medicine. Accessed august 1, 2023. https://www.facs.org/for-medical-professionals/news-publications/journals/rise/articles/surgical-palliative-care/
  10. Hoffman R, Blondeau B. EAST Traumacast. Palliative Care in your ACS Practice.
  11. Hoffman R, Johnston F, Stastny A. Behind the Knife. Clinical Challenges in Surgical Palliative Care: The Family Meeting, Code Status, and Goals of Care.
  12. Hoffman RC, Zara, Stastny A. Behind the Knife. Clinical Challenges in Surgical Palliative Care: Non-Beneficial Surgery (and How to Avoid it) and Care of the Imminently Dying Patient.
  13. Hoffman RC, Zara, Stastny A. Behind the Knife. Journal Review in Surgical Palliative Care: Advance Care Planning, Serious Illness Conversations, and Perioperative Decision Making.
  14. Haruta A, Dickerson L, Wang V, O'Connell K. Behind the Knife. Clinical Challenges in Surgical Palliative Care. When the Horse is Out of the Barn: Skills to Avoid Offering Surgical Overtreatment at the End of Life.
  15. Wang V, Haruta A, Dickerson L, O'Connell K. Behind the Knife. RCTs in Surgical Palliative Care.
  16. Haruta A, Wang V, Dickerson L, O'Connell K. Behind the Knife. Communication Skills for Difficult Conversations.
  17. Palliative Care Training Center. Accessed July 5, 2024. https://pctc.uw.edu/
  18. Center for Palliative Care: Palliative Care Education and Practice (PCEP). Accessed 2024, July 5. https://pallcare.hms.harvard.edu/courses/pcep

 

Geriatric Committee 

Anticoagulant Guidelines and Palliative Care in the Geriatric Trauma Patient         

Written by: Vanessa Ho, MD, MPH, PhD; Melissa Hornor, MD, MSc; Elizabeth Gorman, MD; Tanya Egoodage, MD
Anticoagulant Guidelines

Anticoagulant use in the geriatric trauma patient population is common and has been shown to contribute to poor outcomes after traumatic injury.1,2 With the rising popularity of novel anticoagulants including Factor Xa inhibitors and direct thrombin inhibitors, it is important for trauma surgeons to have an understanding of appropriate specific reversal agents, and these should be given as soon as possible to patients with life-threatening bleeding. Fresh frozen plasma (FFP) may be harmful in the geriatric patient population as it typically requires large fluid volumes, which can cause volume overload in frail patients with kidney or liver dysfunction. Prothrombin complex concentrate (PCC) contains four clotting factors (II, VII, IX, and X) and may be advantageous in this population, as it is effective for reversal of vitamin K inhibitors and Xa inhibitors but can be given in lower volumes. Some anticoagulants have specific antidotes newly approved by the FDA; for example, direct thrombin inhibitors such as Pradaxa can be reversed with Praxbind (Idarucizamab), and Factor Xa inhibitors such as Xarelto may be reversed with AndexXa (Andexanet Alfa) (Table I). However, these antidotes can be prohibitively expensive and may not be covered by hospital formularies, so it is important for physicians to familiarize themselves with what is available at their own institutions. For patients on antiplatelets, there is no substantial evidence that giving platelets improves mortality; therefore, platelet transfusion is not currently recommended for routine use.3

 

Table I

Screenshot 2025-08-20 at 3.04.25 PM.png

 

Best Practice Guidelines: Geriatric Trauma Management. November 2023. ACS Trauma Programs
 

Palliative Care

Palliative care is another important facet of the care of the geriatric trauma patient. Palliative medicine uses a multidisciplinary approach to address patient symptoms such as pain and anxiety, while also providing emotional support to patients and their families. ACS Trauma guidelines recommend early consideration of goals of care in geriatric trauma patients.3 It also provides recommendations for physicians conducting family meetings; these include techniques on delivering prognostic information, expecting and responding to emotion, exploring patient values and preferences, and developing a treatment recommendation.  One technique for guiding family meetings is called “REMAP,” an acronym for “Reframing the situation,” “Expect emotions,” “MAP what is important,” “Align with the patient and family,” and “Propose a value-based plan.”4 This technique can serve as a blueprint for trauma surgeons as they engage patients and their families in shared decision-making. “NURSE” statements (Naming, Understanding, Respecting, Support, Explore) can help clinicians respond to patient and family member emotions during difficult conversations (Table II). 

 

Table IV­­: NURSE Statements

Screenshot 2025-08-20 at 3.04.35 PM.png

Best Practice Guidelines: Geriatric Trauma Management. November 2023. ACS Trauma Programs

Frailty and the Geriatric Trauma Patient

Frailty is a distinct clinical syndrome that represents the progressive decline of physiologic reserves, and results in increased vulnerability to adverse outcomes.1 The prevalence of frailty in the geriatric trauma patient population is high, and the identification and treatment of frailty is important for several reasons. In addition to frailty being one of the strongest predictors for bad outcomes, aspects of the frailty syndrome can be mitigated and treated. Strong supportive evidence exists for interdisciplinary inpatient care models that emphasize geriatric-centered care through nurse-driven protocols that help minimize “microharms” to the vulnerable frail geriatric patient that result as a side effect of the hospital environment. Specifically within the trauma patient population, studies have shown frailty care pathways to significantly decrease risk for delirium, 30-day readmissions, and loss of independence, and reduce hospital length of stay.2,3

How to Screen for Frailty

Multiple frailty screening tests exist, some of which are validated in the literature for the trauma patient population. The FRAIL scale (Fatigue, Resistance, Aerobic capacity, Illnesses, and Loss of weight) is an efficient screening tool that has been shown to reliably diagnose frailty in trauma patients.3 It involves five questions which are scored based on yes or no answers. The score is then added together to screen the patient as frail (≥3), prefrail (1-2), or not frail (0).

Screenshot 2025-08-20 at 3.04.52 PM.png

 

https://www.singhealth.com.sg/rhs/about -us/Documents/HSRE/2.%20Dr%20Richard%20Hui_OK.pdf

The Trauma Specific Frailty Index (TSFI) is another screening tool that was prospectively validated in a multi-institutional trial among geriatric trauma patients. The authors found that TSFI was an independent predictor of worse outcomes, including major complication, discharge to an institution, and mortality.4

Screenshot 2025-08-20 at 3.05.56 PM.png

Interdisciplinary Frailty Pathway Care

The goal of a frailty pathway is to bring together multiple disciplines to work collaboratively to improve outcomes for geriatric patients. They can be adapted based on the resources available at your institution, but typically they involve input from nursing, physical therapy, occupational therapy, nutrition, pharmacy, social work, and geriatric medical specialists. Each disciplines contributes by focusing on a best practice for geriatric surgical care within the scope of their practice. The utilization of frailty pathways have been shown to improve outcomes for trauma and emergency general surgery patients.2,3

Screenshot 2025-08-20 at 3.06.10 PM.png

 

Trauma Team Activation and Geriatric Triage

As the percentage of older adults in the United States increases, mechanisms to identify and appropriately manage these patients is imperative. New Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in November 2023 highlight this. Falls remain the most common etiology of injury amongst older adults. Despite the low velocity mechanism, significant injury may ensue. Triage mechanisms in both the pre-hospital and hospital settings often incur significant bias against geriatric patients, and should be amended to identify this population of patients, who may suffer severe injuries such as traumatic brain injury rather than hemorrhagic shock, for which general triage systems were created. A National Trauma Data Bank (NTDB) review of over 1 million patients demonstrated that a systolic blood pressure of 110 mmHg in older patients conferred a higher sensitivity for severe injury, with a similar mortality compared to younger patients triaged at 90 mmHg as a cutoff for hypotension. This review further identified that a heart rate above 90 beats per minute should be utilized as criterion for trauma triage in older patients.9 Another NTDB review identified that a shock index ≥ 1 was the strongest predictor of mortality in geriatric patients, with an odds ratio of 3.1. Those patients were also more likely to require blood transfusions, undergo a laparotomy, and sustain complications.10 Finally, a prospective trial evaluating several Emergency Medical Service agencies found that pre-injury anticoagulation resulted in increased risk of intracranial hemorrhage even for patients sustaining ground level falls.11 Given these trials, the following amended triage criteria were recommended in the recent TQIP guidelines.
 

Table V: Criteria for Trauma Team Activation 

Screenshot 2025-08-20 at 3.06.23 PM.png

 

References

  1. Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol Ser A. 2001;56(3):M146-M157. doi:10.1093/gerona/56.3.M146
  2. Engelhardt KE, Reuter Q, Liu J, et al. Frailty screening and a frailty pathway decrease length of stay, loss of independence, and 30-day readmission rates in frail geriatric trauma and emergency general surgery patients. J Trauma Acute Care Surg. 2018;85(1):167-173. doi:10.1097/TA.0000000000001931
  3. Bryant EA, Tulebaev S, Castillo-Angeles M, et al. Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients. J Am Coll Surg. 2019;228(6):852-859.e1. doi:10.1016/j.jamcollsurg.2019.02.052
  4. Joseph B, Saljuqi AT, Amos JD, et al. Prospective validation and application of the Trauma-Specific Frailty Index: Results of an American Association for the Surgery of Trauma multi-institutional observational trial. J Trauma Acute Care Surg. 2023;94(1):36-44. doi:10.1097/TA.0000000000003817
  5. Patel N, Kania T, Demissie S, et al. Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients- a retrospective cohort study. Ann Med Surg. 2023 Sep, 85 (9): 4223-4227
  6. Coleman J, Baldawi M, Heidt D. The effect of anticoagulation status on geriatric fall trauma patients. American Journal of Surgery. 2016 Dec; 212 (6): 1237-1242
  7. Best Practice Guidelines: Geriatric Trauma Management. November 2023. ACS Trauma Programs
  8. VitalTalk.org

 

 
Diversity, Equity, and Inclusion, Communication, and Education Committees

Diversity, Equity, and Inclusion Committee Update

Written by: Melissa Grigsby, MD
 

It was just a few years ago that we, as trauma surgeons, refused to “stay in our lane” regarding gun violence. We know the faces of gun violence, we hear the stories, share the tears, and feel loss of it; and together, we made our voices heard. Now, diversity, equity and inclusion (DEI) programs have been politicized and are under threat all over the country, including those in our medical schools and hospitals. Programs that educate the next generation of doctors to be more culturally sensitive, that target the recruitment and retention of faculty from underrepresented groups, and that aim to tackle deep-seated inequities in our medical system, are most certainly “in our lane” and deserve our collective voice.

We know that patients who are treated by physicians of the same race and ethnicity have better outcomes, likely due to more effective communication, perception of better care, and improved adherence to medical advice given an increased level of patient-provider trust.  If this research was expanded to similarly examine the LGBTQ+ doctor-patient relationship and associated outcomes, it would not be surprising to find similar themes. The response to this growing body of research, which emphasizes improving patient care, should be a focus on effective cultural sensitivity training and diversification of the physician workforce. Instead, the recent response has increasingly been to cut funding and support for DEI initiatives and programming.

Several of the leading medical organizations, including the American Medical Association and the Accreditation Council for Graduate Medical Education voiced their support for DEI programs in a joint statement, “Excellence in patient care cannot exist until we have a physician workforce capable of caring for our patients and their needs holistically, and until the profession of medicine is accessible to all qualified individuals.” Below are some suggestions to support the nationwide effort for diversity, equity and inclusion in surgery:

  • Join your institution’s curriculum or DEI committee to ensure that these important subjects continue to be taught in a meaningful way.
  • Urge your division and department to adopt and adhere to transparent hiring and promotion policies that are equitable, realistic and created through an intersectional lens
  • Support or join DEI activities at your institution—the burden of DEI should not be on those who are underrepresented in medicine.
  • Ensure that your institution has equitable mentoring, networking and professional development opportunities, ultimately leading to diversity in advancement and leadership roles
  • Engage in clinical research that prioritizes the capture and measurement of health equity metrics and their relationship to patient outcomes.
  • Call your local representative to voice your support of DEI programs and initiatives in surgery and surgical education.
  • Serve as a member of the AAST-DEI committee!

 

Healthcare Economics Committee

Health Economics and the Acute Care Surgeon

Written by: Stefan Leichtle, MD, MBA, FACS

You Do Not Get What You Pay For

In 2022, the United States (U.S.) spending on healthcare exceeded $4.5 trillion or 17.5% of the country’s gross domestic product (1). The high price tag of healthcare in the U.S., which is about twice as much as that in most European countries, Canada, Australia, and Japan, is unfortunately not reflective of its measurable quality and patient outcomes. Life expectancy at birth in the U.S. is the lowest of all peer countries: 74.8 years compared to an average of 80 years for men, and 80.2 years compared to an average of 84.4 years for women. Access to care, health equity, and system efficiency (2,3) compare similarly unfavorable. Annual per capita expenditures average about $13,500, though the 5% of patients with the highest medical needs average more than $71,000 in annual health expenditures. Insurance premiums for family coverage increased by 55% from 2007 to 2017 (4), and medical debt is a pervasive problem affecting particularly those with chronic health problems, low income, a minority background, and individuals experiencing sudden, unexpected health problems, such as our trauma and emergency surgery patients (5).

 

Implications: Physician Reimbursement. Financial Toxicity. Workload and Burnout

This less-than-ideal state of the U.S. healthcare system has persisted for years, with some positive impact from insurance coverage expansion following the Affordable Care Act of 2010, and negative effects of the opioid epidemic and COVID pandemic in recent years (4). What has changed is the increasing impact of these problems on patients and on clinicians’ daily practice, particularly in our specialty of Acute Care Surgery (ACS).

 

ACS has a large “economic footprint”. Using 2014 data of 29.2 million adult patients admitted to U.S. hospitals, Knowlton and coauthors from the American Association for the Surgery of Trauma (AAST) Health Economics Committee determined that approximately 5.9 million or 20% of all hospital admissions were patients with an “ACS diagnosis”, i.e., a trauma or emergency general surgery (EGS) condition (6). These patients accounted for $85.8 billion or 25% of total inpatient costs. With the increasing age, degree of frailty, and prevalence of comorbidities seen in our trauma and EGS population, the clinical and economic footprint of ACS has been getting even larger. Additionally, these numbers did not include the impact of ACS patients requiring surgical critical care (SCC) services, which have an even higher, outsize contribution to total hospital costs (7). For Acute Care Surgeons, SCC services make up about 25% of their total billing, which makes this substantial contribution to hospital revenue particularly vulnerable to changes in critical care reimbursement (8), such as the narrowly avoided bundling of critical care services into the global surgical period, which was proposed in the 2022 Centers for Medicare and Medicaid (CMS) Physicians’ Fee Schedule (9). Similarly, due to the substantial contribution of ACS patients to inpatient costs and the high proportion of un- and underinsured patients, reimbursement for patient care in our specialty is highly sensitive to case and payer mix (4). With hospital, clinic, and physician services adding up to about half of the $4.5 trillion annual healthcare costs, reimbursement for clinical services is a frequent object of policy efforts and legislation aiming to curb expenditures in the U.S. healthcare system.

 

The transition from a volume-driven, fee-for-service system to a payment system based on value has been heralded as the solution to the challenges of the U.S. healthcare system. Value in healthcare is most commonly defined as health outcomes achieved per dollar spent (10). High-value care can thus be achieved by ensuring superior outcomes while stabilizing or lowering cost. As intuitive and reasonable as this concept is, the practical implementation of value-based payment systems has been challenging and slow. A fundamental problem lies in the difficulty to objectively determine the key components of “value”, i.e., quality and cost. Both variables can differ substantially based on stakeholder perspective or can be challenging to calculate, especially for complex and unpredictable care pathways as those in ACS. A more in-depth discussion on this topic can be found in the AAST Health Economic Committee’s series on “Value in Acute Care Surgery”, which describes how to measure cost (11), determine meaningful outcomes (12), and consider the impact of stakeholder perspective (13).

 

Despite such challenges, the number of value-based care arrangements continues to grow and will increasingly impact our bedside and operating room care. Clinicians have long been involved with the “outcomes side” of value considerations, through systematic quality improvement efforts such as the Trauma Quality Improvement Project (TQIP) and National Surgical Quality Improvement Program (NSQIP), or by “simply” focusing on providing high-quality patient care. Financial and cost considerations have traditionally not been the focus of many clinicians. Yet the ongoing shift to value-based care, the lack of sustainability of the current system, and the increasing impact of these changes on our daily practice will require more clinician involvement in both aspects of quality and cost.

 

For our patients, cost considerations have long been a crucial part of their health care experience. Scott and coauthors explain the concept of “financial toxicity” as both the objective adverse financial impact of patients’ health care expenses and the subjective concerns patients experience regarding the financial consequences of illness or injury (14). Especially the consequences of unexpected and sudden traumatic injury or emergency surgical care can be devastating, with the costs of acute hospitalization, prolonged absence from work, possible loss of job and health insurance, and expenses for physical therapy and rehabilitation all potentially adding up to an insurmountable amount of medical debt. More than 70% of uninsured patients with trauma or EGS diagnosis are at risk of “catastrophic healthcare expenditures” and even those with insurance face an average of $5,000 out-of-pocket spending (15). A long-term follow-up study at three major Boston trauma centers found that more than two years following traumatic injury, 40% of previously employed trauma patients had not been able to return to work (16). High out-of-pocket costs, medical debt, and financial worries in turn compromise patients’ physical and mental health. As such, cost is not just a denominator in the “value equation”, but an integral part of outcomes and quality, making the financial implications of illness and injury an important aspect of trauma care (14,17).

 

Traumatic injuries and emergency surgical care can not only be detrimental to patients’ physical, mental, and financial well-being, but also take a heavy toll on those who care for them. A 2016 systematic review on “surgeon burnout” revealed widespread symptoms of burnout and low career satisfaction across many surgical specialties (18) – well before the COVID pandemic, which substantially exacerbated and highlighted these problems. Weekly work hours and call frequency were found to be main contributors, making these concerns particularly relevant for Acute Care Surgeons. We all know how it feels to be post-call (or “post-post-call”), and we now also have the data on physiologic effects and lasting health consequences of working overnight (19,20). ACS call is busy. In addition to trauma, EGS, and SCC services, many Acute Care Surgeons have busy elective general surgical practices and ensure 24-hour in-house availability for surgical rescue (21) – in addition to academic obligations such as teaching, research, and administrative work. A much discussed 2022 paper by Murphy et al. described the current state of ACS staffing models, which vary widely across the U.S. (22). The increasing demands of our specialty require the definition of what constitutes an appropriate clinical and academic or administrative workload for a full-time Acute Care Surgeon.

 

There’s a Committee (and Literature) for That

The wide range of issues from quality and cost of healthcare in the U.S., the potentially devastating financial toll of illness and injury on patients, to crucial reimbursement considerations for Acute Care Surgeons and ideal staffing models for ACS groups are all a part of what the AAST Health Economics Committee tackles. The field of Health Economics applies the theories and principles of economics to the healthcare system. This goes far beyond financials and cost considerations, but includes deliberations on health care access and equity, high-value care, how clinicians and patients make decisions, and the development of models for rational and strategic decision making (23). In addition to publications authored by members of the AAST Health Economics Committee on the state of the U.S. healthcare system and the role of ACS (4,6,8), considerations on quality, cost, and value in ACS (11–13), and financial toxicity (14,17), interested readers can find an increasing amount of literature on economic considerations relevant for Acute Care Surgeons such as Trauma Center cost and funding (24–27), and cost analyses for common operations and scenarios (28,29), among others.

 

A basic understanding of the economic principles and considerations underlying the U.S. healthcare system is vital for all Acute Care Surgeons – to be more effective advocates for their patients, for their specialty, and for themselves.

Bibliography

 

  1. Peterson Center on Healthcare and Kaiser Family Foundation. How has U.S. spending on healthcare changed over time? [Internet]. [cited 2024 Jun 19]. Available from: https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/
  2. Peterson Center on Healthcare and Kaiser Family Foundation. How does U.S. life expectancy compare to other countries? [Internet]. [cited 2024 Jun 19]. Available from: https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/#Life%20expectancy%20at%20birth%20by%20sex,%20in%20years,%202022
  3. Schneider EC, Shah A, Doty MM, Fields, Katharine, Williams II RD. MIRROR, MIRROR 2021 Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries [Internet]. The Commonwealth Fund; 2021 Aug [cited 2024 Jun 28]. Available from: http://resource.nlm.nih.gov/9918300978506676
  4. Staudenmayer K, Bernard A, Davis KA, Doucet J, Haider A, Tres Scherer LR, et al. The current and future economic state of acute care surgery. J Trauma Acute Care Surg. 2019 Aug;87(2):413–9.
  5. Peterson Center on Healthcare and Kaiser Family Foundation. The burden of medical debt in the United States [Internet]. [cited 2024 Jun 21]. Available from: https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/#Share%20of%20adults%20with%20medical%20debt,%20by%20health%20status%20and%20income,%202021
  6. Knowlton LM, Minei J, Tennakoon L, Davis KA, Doucet J, Bernard A, et al. The economic footprint of acute care surgery in the United States: Implications for systems development. J Trauma Acute Care Surg. 2019 Apr;86(4):609–16.
  7. Fakhry SM, Martin B, Al Harakeh H, Norcross ED, Ferguson PL. Proportional costs in trauma and acute care surgery patients: dominant role of intensive care unit costs. J Am Coll Surg. 2013 Apr;216(4):607–14; discussion 614-616.
  8. Bernard A, Staudenmayer K, Minei JP, Doucet J, Haider A, Scherer T, et al. Macroeconomic trends and practice models impacting acute care surgery. Trauma Surg Acute Care Open. 2019;4(1):e000295.
  9. Centers for Medicare & Medicaid Services. Medicare Program; CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; Provider and Supplier Prepayment and Post-Payment Medical Review Requirements [Internet]. 2021 [cited 2024 Jun 25]. Available from: https://www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part
  10. Porter ME. What Is Value in Health Care? N Engl J Med. 2010 Dec 23;363(26):2477–81.
  11. Martin RS, Lester ELW, Ross SW, Davis KA, Tres Scherer LR, Minei JP, et al. Value in acute care surgery, Part 1: Methods of quantifying cost. J Trauma Acute Care Surg. 2022 Jan 1;92(1):e1–9.
  12. Ross SW, Wandling MW, Bruns BR, Martin RS, Scott JW, Doucet JJ, et al. Value in acute care surgery, part 2: Defining and measuring quality outcomes. J Trauma Acute Care Surg. 2022 Jul 1;93(1):e30–9.
  13. Ayoung-Chee PR, Gore AV, Bruns B, Knowlton LM, Nahmias J, Davis KA, et al. Value in Acute Care Surgery, Part 3: Defining Value in Acute Surgical Care - It Depends on the Perspective. J Trauma Acute Care Surg. 2024 May 6;
  14. Scott JW, Knowlton LM, Murphy P, Neiman PU, Martin RS, Staudenmayer K, et al. Financial toxicity after trauma and acute care surgery: From understanding to action. J Trauma Acute Care Surg. 2023 Nov;95(5):800–5.
  15. Fu SJ, Arnow K, Trickey A, Spain DA, Morris A, Knowlton L. Financial Burden of Traumatic Injury Amongst the Privately Insured. Ann Surg. 2022 Mar 1;275(3):424–32.
  16. Haider AH, Herrera-Escobar JP, Al Rafai SS, Harlow AF, Apoj M, Nehra D, et al. Factors Associated With Long-term Outcomes After Injury: Results of the Functional Outcomes and Recovery After Trauma Emergencies (FORTE) Multicenter Cohort Study. Ann Surg. 2020 Jun;271(6):1165–73.
  17. Knowlton LM, Scott JW, Dowzicky P, Murphy P, Davis KA, Staudenmayer K, et al. Financial toxicity part II: A practical guide to measuring and tracking long-term financial outcomes among acute care surgery patients. J Trauma Acute Care Surg. 2024 Jun;96(6):986–91.
  18. Dimou FM, Eckelbarger D, Riall TS. Surgeon Burnout: A Systematic Review. J Am Coll Surg. 2016 Jun;222(6):1230–9.
  19. Coleman JJ, Robinson CK, von Hippel W, Holmes KE, Kim J, Pearson S, et al. What Happens on Call Doesn’t Stay on Call. The Effects of In-house Call on Acute Care Surgeons’ Sleep and Burnout: Results of the Surgeon Performance (SuPer) Trial. Ann Surg. 2023 Oct 1;278(4):497–505.
  20. Coleman JJ, Robinson CK, von Hippel W, Lawless RA, McMasters KM, Cohen MJ. Home Is Not Always Where the Sleep Is: Effect of Home Call on Sleep, Burnout, and Surgeon Well-Being. J Am Coll Surg. 2024 Apr 1;238(4):417–22.
  21. Kutcher ME, Sperry JL, Rosengart MR, Mohan D, Hoffman MK, Neal MD, et al. Surgical rescue: The next pillar of acute care surgery. J Trauma Acute Care Surg. 2017 Feb;82(2):280–6.
  22. Murphy PB, Coleman J, Karam B, Morris RS, Figueroa J, de Moya M. A national study defining 1.0 full-time employment in trauma and acute care surgery. J Trauma Acute Care Surg. 2022 Apr 1;92(4):648–55.
  23. Lee RH. Economics for Healthcare Managers, Fourth Edition. 2019. 342 p.
  24. Ashley DW, Mullins RF, Dente CJ, Johns TJ, Garlow LE, Medeiros RS, et al. How much green does it take to be orange? Determining the cost associated with trauma center readiness. J Trauma Acute Care Surg. 2019 May;86(5):765–73.
  25. Grossman Verner HM, Figueroa BA, Salgado Crespo M, Lorenzo M, Amos JD. Trauma center funding: time for an update. Trauma Surg Acute Care Open. 2021;6(1):e000596.
  26. Acus KE, Indrakanti DL, Miller JL, Parikh PP, Cheslik TG, McCarthy MC. The Affordable Care Act: Long-Term Financial Impact on a Level I Trauma Center. J Surg Res. 2019 Nov;243:488–95.
  27. Byskosh A, Shi M, Helenowski I, Holl JL, Hsia RY, Liepert AE, et al. Is state trauma funding associated with mortality among injured hospitalized patients? Am J Surg. 2024 Mar;229:133–9.
  28. Glasgow RE, Mulvihill SJ, Pettit JC, Young J, Smith BK, Vargo DJ, et al. Value Analysis of Methods of Inguinal Hernia Repair. Ann Surg. 2021 Oct 1;274(4):572–80.
  29. Schneeberger S, Phillips S, Huang LC, Pierce RA, Etemad SA, Poulose BK. Cost-Utility Analysis of Biologic and Biosynthetic Mesh in Ventral Hernia Repair: When Are They Worth It? J Am Coll Surg. 2019 Jan;228(1):66–71.

 

 
The Journal of Trauma and Acute Care Surgery

The Journal of Trauma and Acute Care Surgery Update

Written by: Raul Coimbra, MD, PhD, Editor-in-Chief

 

Journal of Trauma 2024 Edition: WTA Algorithms! Available in August!

The 2024 edition of the Journal of Trauma (JOT) features algorithms developed by the Western Trauma Association (WTA). Dr. David Livingston serves as the editor for this edition, which covers spleen injury, vascular injury, abdominal vascular injury, pelvic fracture, penetrating neck injury, penetrating chest and neck injuries, abdominal stab wounds, and resuscitative thoracotomy. Dr. Livingston’s Introduction delivers an overview of the utility of the WTA algorithms and what sets the WTA algorithms apart from other guidelines. In addition, Dr. Livingston’s brief commentaries after each article provide context and insight into the WTA algorithms and their enduring guidance in critical decision-making. The PDF edition will be available for free online download from the journal site < https://journals.lww.com/jtrauma/pages/default.aspx> in August.

If you missed it, read the 2023 Journal of Trauma edition, Trauma Scoring Systems < https://journals.lww.com/jtrauma/Documents/Journal%20of%20Trauma%202023.pdf>, edited by Dr. Raul Coimbra.

 

Join us for “Case Studies in Publishing and Reviewing for the Journal of Trauma and Acute Care Surgery” Journal Session at AAST 2024!

Join us for the Journal of Trauma and Acute Care Surgery (JTACS) journal lunch session at AAST 2024: Case Studies in Publishing and Reviewing for JTACS. You will have the opportunity to learn how to enhance your peer reviews, improve your JTACS submissions, and refine your biostatistical skills in identifying common flaws in performing and reporting multivariate analysis and propensity scoring. Members of the JTACS editorial board will present:

Real-life examples of flaws caught by reviewers
David Morris, MD

Real-life examples of what not to do when writing and submitting a manuscript
Kenji Inaba, MD

Types of Multivariate Analyses. When to use them and How should it be reported in the manuscript regarding the model used?
Bishoy Zakhary, PhD

Types of Propensity Scoring. When to use them and How should it be reported in the manuscript?
Bishoy Zakhary, PhD

Moderator
Walt Biffl, MD

The session will be held on Friday, September 13, 12:00 pm–1:15 pm. Check the meeting program on-site for location information.

 

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