Poor Adherence to Evidence-Based Treatments for Traumatic Rib Fractures

By Reuters Staff

April 07, 2020

NEW YORK (Reuters Health) - Several evidence-based practices for treating patients with traumatic rib fractures are associated with decreased mortality, but adherence to these measures is poor, according to new U.S. research.

Nearly 15% of patients who experience trauma sustain rib fractures, which are associated with significant morbidity and mortality. Management guidelines and treatment algorithms have been published for this type of fracture, but little is known about adherence to these practices.

To investigate, Dr. Christopher J. Tignanelli of the University of Minnesota Medical School, in Minneapolis, and colleagues analyzed data from the American College of Surgeons (ACS) National Trauma Data Bank (NTDB) spanning 2007 to 2014.

The evidence-based practices included neuraxial blockade, admission to the intensive-care unit, surgical rib fixation, pneumatic stabilization, tube thoracostomy and chest CT scans.

Adherence to these practices was poor overall: 4% of patients received neuraxial blockade, 42% were admitted to the ICU, 14% received surgical rib fixation, 1% received pneumatic stabilization, 42% received tube thoracostomy, and 40% received chest CT scans.

Institutional adherence rates across centers ranged from 2.79% to 50.6%, and patients treated at verified level-I trauma centers were more likely to receive five of the six practices (all but pneumatic stabilization), the researchers report in JAMA Network Open.

Adherence to these practices also varied with patient age, sex, Injury Severity Score and other factors.

Adherence to three evidence-based practices was associated with significantly reduced mortality. Epidural placement in patients aged 65 years or older with three or more rib fractures was associated with 36% lower odds of mortality; rib fixation for flail chest was associated with 87% lower odds of mortality; and ICU admission for patients aged 65 years or older with three or more rib fractures was associated with 7% lower odds of mortality.

Paradoxically, noninvasive ventilation and chest tube placement were associated with significantly increased mortality in some patients.

For two of the three practices associated with reduced mortality, there were racial disparities in use. Hispanic and Asian individuals were less likely than white patients to receive neuraxial blockade, and black and Hispanic patients were less likely than white patients to receive rib fixation. And for all three practices, underinsured patients and patients treated at non-ACS-verified level I trauma centers were less likely to receive them.

"Optimal care for patients with rib fractures is complex and requires engaged, multidisciplinary care," the authors note. "It is possible that centers may develop treatment protocols adhering to evidence-based practice measures but poorly integrate and deliver ancillary practices that likely also improve care (e.g., multimodal pain therapy, aggressive pulmonary hygiene, and daily ambulation). The delivery of such care pathways for patients with rib fracture has been shown to significantly reduce complication rates and reduce mortality by nearly 3-fold."

"Future directions should seek to leverage highly granular electronic health record data repositories to characterize which practices within care pathways are most associated with improved clinical outcomes," they conclude.

"Perhaps unintentionally, what the report by Tignanelli et al. highlights most is the indisputable paucity of high-quality evidence regarding rib fracture management," write Dr. Garth H. Utter and Dr. Nikia R. McFadden of the University of California Davis Medical Center, in Sacramento, in a linked commentary.

"Numerous barriers impede the conduct of randomized clinical trials in acute injury care, and calling for more such studies has been criticized as hackneyed, but those truths do not make such studies any less relevant or necessary," they note.

"Perhaps consideration should be given to encouraging and guiding junior investigators - whose greatest asset might be so-called sweat equity - to conduct smaller, simpler, and lower-cost single-center trials that could be aggregated in meta-analyses," they suggest. "Perhaps investigators should receive more academic recognition for enrolling and collecting data from a few patients who contribute to a multicenter randomized clinical trial than they do for authoring an observational study with obvious design flaws and risk of bias."

"Even if the effort requires unconventional approaches, our patients would stand to benefit if we were to dedicate more resources to, and truly align academic incentives with, producing the highest-quality evidence," the commentary concludes.

Dr. Tignanelli did not respond to a request for comments.

SOURCE: https://bit.ly/2UtOoc6 and https://bit.ly/2yocYCG JAMA Network Open, online March 26, 2020.

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