Abstract
This study examines unmanaged chronic medical and psychiatric conditions in hospitalized trauma patients.
Patients with injuries are at risk for long-term adverse medical, psychiatric, and social effects of their trauma.1,2 They are also frequently uninsured3 and have preexisting psychiatric illness.4 Yet, the prevalence of undiagnosed/unmanaged chronic medical and psychiatric conditions in hospitalized patients with injuries is unknown. This study seeks to determine this prevalence and risk factors to serve as a foundation for improving access to primary care for trauma patients.
Methods
This is a retrospective review of all patients admitted for traumatic injuries to a level I trauma center and tertiary referral center from August to December 2018. After institutional review board approval from the University of California, Davis, data were collected from the Trauma One Registry and medical record review. Patient consent was waived owing to the retrospective nature of the study, which was conducted by medical record review and involved no patient communication or intervention. Unmanaged conditions were defined as diseases known to the patient or documented in the medical record prior to admission with no corresponding treatment or monitoring. New diagnoses were made by clinicians, including psychiatrists when appropriate, during the hospitalization. Statistical analyses were performed in Stata, version 14.2 (StataCorp). Two-sided P values were significant at .05. Analysis took place from February to August 2019.
Results
Of 1000 patients, 285 (28.5%) had a new or unmanaged chronic medical or psychiatric condition (116 [11.6%] with new conditions; 191 [19.1%] with unmanaged conditions; 22 [2.2%] with both conditions). Psychiatric conditions were the most common new (25 of 116 [21.6%]) and unmanaged (96 of 191 [50.3%]) conditions. The most common new medical diagnoses were hypertension (9 [7.8%]), diabetes mellitus (7 [6.0%]), and atrial fibrillation (7 [6.0%]). Frequent unmanaged medical conditions included hypertension (61 [31.9%]), diabetes (39 [20.4%]), and chronic obstructive pulmonary disease (20 [10.5%]). Additionally, 135 patients (13.5%) had an incidental finding with specific follow-up recommendations, of which only 71 (52.6%) had a documented primary care physician.
Public health insurance (Medicare or MediCal) covered 574 patients (57.4%), while 281 (28.1%) had private health insurance, 67 (6.7%) had no health insurance, and 78 (7.8%) had unknown coverage. Patients with known chronic conditions were more likely to have a primary care physician than not (298 of 481 [62.0%] vs 183 of 481 [38.0%]), but among patients with a new or unmanaged condition, only 115 (50.7%) had access to a primary care physician.
Patients with new or unmanaged conditions were less likely to be in a motor vehicle collision (40 of 285 [14.0%; 95% CI, 10.0%-18.1%] vs 179 of 715 [25.0%; 95% CI, 21.9%-28.2%]; P < .001) but more likely to have been assaulted (26 of 285 [9.1%; 95% CI, 5.8%-12.5%] vs 37 of 715 [5.2%; 95% CI, 3.6%-6.8%]; P = .02) or hit by a car while walking or on a bicycle (28 of 285 [9.8%; 95% CI, 6.4%-13.3%] vs 40 of 715 [5.6%; 95% CI, 3.9%-7.3%]; P = .02).
On multivariable logistic regression, homelessness (odds ratio [OR], 1.95; 95% CI, 1.03-3.61; P = .03) and public insurance (OR, 1.68; 95% CI, 1.13-2.51; P = .01) were associated with increased odds of having a new/unmanaged chronic condition when adjusting for sex, age, alcohol and drug use, documented primary care physician, and mechanism (Table). Homelessness was associated with increased odds of identifying a medical condition (OR, 3.4; 95% CI, 1.66-6.98; P < .001), while age older than 55 years (age 56-70 years vs 18-35 years: OR, 2.58; 95% CI, 1.42-4.71; P = .002; age >71 years vs 18-35 years: OR, 2.71; 95% CI, 1.39-5.26; P = .003) and public insurance (OR, 2.06; 95% CI, 1.29-3.27; P = .002) were associated with increased odds of identifying a psychiatric condition.
Table. Multivariable Logistic Regressions Examining Risk Factors Associated With New or Unmanaged Chronic Conditions.
| Characteristic | All new or unmanaged chronic conditions | Medical conditions only | Psychiatric conditions only | |||
|---|---|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | OR (95% CI) | P value | |
| Female | 0.84 (0.59-1.19) | .33 | 0.86 (0.52-1.44) | .58 | 0.80 (0.54-1.18) | .26 |
| Age, y | ||||||
| 18-35 | 1 [Reference] | NA | 1 [Reference] | NA | 1 [Reference] | NA |
| 36-55 | 1.30 (0.80-2.13) | .29 | 1.11 (0.59-2.07) | .75 | 1.56 (0.85-2.86) | .16 |
| 56-70 | 1.41 (0.85-2.34) | .19 | 0.57 (0.27-1.20) | .14 | 2.58 (1.42-4.71) | .002 |
| >71 | 1.47 (0.83-2.60) | .18 | 0.61 (0.36-1.42) | .26 | 2.71 (1.39-5.26) | .003 |
| Insurance | ||||||
| Private | 1 [Reference] | NA | 1 [Reference] | NA | 1 [Reference] | NA |
| Medicare/MediCal | 1.68 (1.13-2.51) | .01 | 1.37 (0.75-2.50) | .31 | 2.06 (1.29-3.27) | .002 |
| Uninsured | 1.32 (0.65-2.67) | .44 | 1.49 (0.60-3.67) | .39 | 1.03 (0.42-2.54) | .95 |
| Unknown | 0.77 (0.32-1.82) | .55 | 0.64 (0.17-2.36) | .500 | 0.87 (0.31-2.49) | .80 |
| Homeless | 1.95 (1.05-3.61) | .03 | 3.40 (1.66-6.98) | .001 | 0.99 (0.49-2.03) | .99 |
| Alcohol use | 1.46 (0.84-2.53) | .18 | 1.11 (0.51-2.41) | .79 | 1.78 (0.99-3.21) | .056 |
| Drug use | 1.25 (0.71-2.20) | .43 | 1.20 (0.58-2.46) | .62 | 1.02 (0.52-1.97) | .96 |
| Access to primary care physician | 0.77 (0.54-1.09) | .14 | 0.73 (0.43-1.20) | .21 | 0.73 (0.49-1.09) | .12 |
| Mechanism | ||||||
| Ground-level fall | 1 [Reference] | NA | 1 [Reference] | NA | 1 [Reference] | NA |
| Motor vehicle/motorcycle collision | 0.70 (0.42-1.15) | .16 | 0.51 (0.23-1.13) | .10 | 0.76 (0.43-1.33) | .34 |
| Other blunt trauma (assault, fall from height, hit by car) | 1.16 (0.70-1.92) | .57 | 0.71 (0.33-1.55) | .39 | 1.44 (0.84-2.50) | .19 |
| Penetrating trauma | 1.13 (0.53-2.41) | .76 | 1.54 (0.59-4.00) | .38 | 1.18 (0.49-2.84) | .71 |
| Other | 0.95 (0.53-1.72) | .87 | 1.00 (0.44-2.28) | >.99 | 0.76 (0.38-1.56) | .48 |
Abbreviations: NA, not applicable; OR, odds ratio.
Discussion
More than one-quarter of trauma patients had a new or unmanaged chronic medical and/or psychiatric comorbidity, and many were underinsured or uninsured. Most at risk were elderly individuals, individuals experiencing homelessness, and those with public health insurance. This highlights the vulnerability of the trauma population but also demonstrates an opportunity for injury to provide an entry point into the health care system. Examples of offering preventive care in emergency settings already exist, including screening for communicable diseases and providing vaccinations,5,6 but identifying unmanaged chronic conditions is needed to improve the care of patients with injuries.
This study is limited by retrospection and lack of outcomes data. It potentially underestimates the prevalence of new or unmanaged conditions and primary care physician access.
Although beyond this study’s scope, undiagnosed/unmanaged chronic comorbidities may worsen both immediate and long-term outcomes. These medical and psychiatric conditions, exacerbated or incited by traumatic injuries,1,2 and adverse social conditions may perpetuate one another, thereby creating an unrecognized chronic lethal triad of trauma (Figure). Efforts should focus on a multidisciplinary approach to identifying unmanaged chronic conditions in patients with injuries and improving access to primary care to improve long-term outcomes.
Figure. Schematic of the Proposed Chronic Lethal Triad of Trauma With Proposed Solutions to Halt the Triad.
References
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