Evidence-Based Practices Not Used As Recommended For Patients with Rib Fractures

Christopher Tignanelli, MD

New study findings showed significant variations in the delivery of evidence-based practices for rib fractures across US trauma centers.

Christopher Tignanelli, MD, and a team of US-based investigators examined adherence to 6 evidence-based practices for rib fractures across US trauma centers and the association with in-hospital mortality. The team learned that 3 practices were associated with reduced mortality, but evidence-based practice adherence was poor. Trauma center verification level was associated with patients receiving best practices for rib fractures.

Tignanelli, from the surgery department at University of Minnesota, and colleagues conducted a retrospective cohort study of 777 US trauma centers participating in the National Trauma Data Bank from January 2007-December 2014. The investigators evaluated 625,617 patients >16 years old with the presence of >1 rib fracture or flail chest.

The team defined 6 evidence-based practices for patients with rib fractures based on national trauma guidelines: neuraxial blockade; ICU admission; pneumatic stabilization; chest computed tomographic scans for older adults (>65 years old) with >3 rib fractures; surgical rib fixation for flail chest; and tube thoracostomy placement for hemothorax and/or pneumothorax.

Investigators evaluated the association of evidence-based practice adherence with in-hospital mortality by comparing the mortality outcomes between patients who received the practices and those who did not receive the recommended care. The team also computed the propensity score of receiving evidence-based practices using age; sex; race/ethnicity; insurance status; drug use information; and Injury Severity Score, among other covariates.

Among the 625,617 patients included, the median age of was 51 years old, and a majority of the patients (73%) were white and male (69%). The mean Injury Severity Score was 18.1, while patients had a mean of 4.2 rib fractures.

Overall, adherence to evidence-based practices was poor, with only 4% of patients receiving neuraxial blockade; 42% were admitted to the ICU; 1% had pneumatic stabilization; 14% received surgical rib fixation; 42% had tube thoracostomy; and 40% had chest CT scans.

Patients who were treated at verified level I trauma centers were more likely to receive 5-6 of the evidence-based practices (all but pneumatic stabilization).

Three evidence-based practices were associated with decreased mortality neuraxial blockade (OR, .64; 95% CI, .51-.79; P <.001) for patients >65 years old with >3 rib fractures, surgical rib fixation (OR, .13; 95% CI, .01-.18; P< .001), and ICU admission (OR, .93; 95% CI, .86-1; P=.04) for patients >65 years old with >3 rib fractures. Two practices were associated with increased mortality in older patients with >3 rib fractures, pneumatic stabilization (OR, 1.71; 95% CI, 1.25-2.35; P <.001) and chest tub placement (OR, 1.27; 95% CI, 1.21-1.33; P <.001).

Insurance status; race and ethnicity; injury severity; hospital bed size; and trauma center verification level were associated with received evidence-based fractures.

The findings highlighted that significant variations exist in the delivery of such practices across trauma centers for treatment of patients with rib fractures. What’s more, the findings were indicative of the “indisputable paucity of high-quality evidence regarding rib fracture management,” Garth Utter, MD, MSc, and Nikia McFadden, MD, both from the University of California Davis Medical Center, wrote in an accompanied commentary.

The study, “Association Between Adherence to Evidence-Based Practices for Treatment of Patients With Traumatic Rib Fractures and Mortality Rates Among US Trauma Centers,” was published online in JAMA Network Open.