Low-value injury admissions in an integrated Canadian trauma system: A multicentre cohort study.

BACKGROUND: Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation. METHODS: We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years). RESULTS: The prevalence of low-value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16-64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC = 37%). CONCLUSION: One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.

Hospital and Intensive Care Unit Length of Stay for Injury Admissions: A Pan-Canadian Cohort Study.

OBJECTIVE: To assess the variation in hospital and intensive care unit (ICU) length of stay (LOS) for injury admissions across Canadian provinces and to evaluate the relative contribution of patient case mix and treatment-related factors (intensity of care, complications, and discharge delays) to explaining observed variations. BACKGROUND: Identifying unjustified interprovider variations in resource use and the determinants of such variations is an important step towards optimizing health care. METHODS: We conducted a multicenter, retrospective cohort study on admissions for major trauma (injury severity score >12) to level I and II trauma centers across Canada (2006-2012). We used data from the Canadian National Trauma Registry linked to hospital discharge data to compare risk-adjusted hospital and ICU LOS across provinces. RESULTS: Risk-adjusted hospital LOS was shortest in Ontario (10.0 days) and longest in Newfoundland and Labrador (16.1 days; P < 0.001). Risk-adjusted ICU LOS was shortest in Québec (4.4 days) and longest in Alberta (6.1 days; P < 0.001). Patient case-mix explained 32% and 8% of interhospital variations in hospital and ICU LOS, respectively, whereas treatment-related factors explained 63% and 22%. CONCLUSIONS: We observed significant variation in risk-adjusted hospital and ICU LOS across trauma systems in Canada. Provider ranks on hospital LOS were not related to those observed for ICU LOS. Treatment-related factors explained more interhospital variation in LOS than patient case-mix. Results suggest that interventions targeting reductions in low-value procedures, prevention of adverse events, and better discharge planning may be most effective for optimizing LOS for injury admissions.

Mortality in Canadian Trauma Systems: A Multicenter Cohort Study.

OBJECTIVE: To measure the variation in trauma center mortality across Canadian trauma systems, assess the contribution of traumatic brain injury and thoracoabdominal injury to observed variations, and evaluate whether the presence of recommended trauma system components is associated with mortality. SUMMARY BACKGROUND DATA: Injuries represent one of the leading causes of mortality, disability, and health care costs worldwide. Trauma systems have improved injury outcomes, but the impact of trauma system configuration on mortality is unknown. METHODS: We conducted a retrospective cohort study of adults admitted for major injury to trauma centers across Canada (2006-2012). Multilevel logistic regression was used to estimate risk-adjusted hospital mortality and assess the impact of 13 recommended trauma system components. RESULTS: Of 78,807 patients, 8382 (10.6%) died in hospital including 6516 (78%) after severe traumatic brain injury and 749 (9%) after severe thoracoabdominal injury. Risk-adjusted mortality varied from 7.0% to 14.2% across provinces (P < 0.0001); 11.1% to 26.0% for severe traumatic brain injury (P < 0.0001), and 4.7% to 5.9% for thoracoabdominal injury (P = 0.2). Mortality decreased with increasing number of recommended trauma system elements; adjusted odds ratio = 0.93 (0.87-0.99). CONCLUSIONS: We observed significant variation in trauma center mortality across Canadian provinces, specifically for severe traumatic brain injury. Provinces with more recommended trauma system components had better patient survival. Results suggest that trauma system configuration may be an important determinant of injury mortality. A better understanding of which system processes drive optimal outcomes is required to reduce the burden of injury worldwide.

Validation of Complications Selected by Consensus to Evaluate the Acute Phase of Adult Trauma Care: A Multicenter Cohort Study.

OBJECTIVE: Evaluate the predictive validity of complications derived using expert consensus methodology to monitor the quality of trauma care. Secondary objectives were to assess the predictive validity of complications not selected by consensus and identify determinants of complications. BACKGROUND: A list of complications to monitor the quality of trauma care has recently been derived using Delphi consensus methodology. However, the predictive validity of consensus complications has not yet been demonstrated. METHODS: We conducted a multicenter cohort study of adults admitted to the 57 adult trauma centers of a Canadian integrated trauma system (2007-2012; n = 84,216). Multiple generalized linear models were used to assess the influence of complications on mortality and acute care length of stay (LOS) and to identify determinants of consensus complications. RESULTS: The presence of at least 1 consensus complication was associated with a 2.7-fold [95% confidence interval (CI): 2.45-2.90] and 2.2-fold (95% CI: 2.11-2.19) increase in the odds of mortality and mean LOS, respectively. Nonselected complications were associated with no increase in mortality (odds ratio = 0.90, 95% CI: 0.80-1.01) and a 60% increase in LOS (geometric mean ratio = 1.60, 95% CI: 1.57-1.62). Patient-related factors and factors related to treatment explained 66% and 34% of the variation in complication rates, respectively. CONCLUSIONS: In addition to the face and content validity ensured by consensus methodology, this study suggests that consensus complications have good predictive validity. Monitoring these complications as part of quality improvement activities would provide an opportunity to improve outcome and resource use for injury admissions.

Evolution of patient outcomes over 14 years in a mature, inclusive Canadian trauma system.

BACKGROUND: The introduction of trauma systems in many countries worldwide has been shown to improve injury survival. However, few data are available on the long-term evolution of outcomes other than mortality. The objective of this study was to describe trends in mortality, unplanned readmission, complications, and length of stay in a mature inclusive trauma system from 1999 to 2012. METHODS: This retrospective cohort study was based on the inclusive trauma system of Quebec, Canada. Data were drawn from the trauma registry linked to the hospital discharge database. Time trends were evaluated using generalized linear mixed models with a correction for hospital clusters and cohort effects. RESULTS: Between 1999 and 2012, risk-adjusted mortality decreased from 5.8 to 4.2% for all patients and from 14.9 to 13.1% for major trauma (p < 0.0001). Mean LOS decreased from 9.5 days to 8.0 days for all patients and from 15.5 days to 11.5 days for major trauma (p < 0.0001). Unplanned readmission and complication rates remained stable over the observation period at around 6.6 and 11.6% for all patients and 7.6 and 25.6% for major trauma, respectively. CONCLUSION: The results of this study suggest that there have been significant decreases in patient mortality and hospital length of stay in the inclusive trauma system of Québec over the last decade. Results also suggest that efforts should be made to reduce in-hospital complications and unplanned readmissions. Future research should attempt to identify determinants of observed decreases in mortality and LOS and assess whether similar improvements have occurred in functional outcomes.

Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study.

BACKGROUND: Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury. This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007-2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression. RESULTS: Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles. CONCLUSIONS: Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.

Derivation and validation of a quality indicator of acute care length of stay to evaluate trauma care.

OBJECTIVE: To derive and internally validate a quality indicator (QI) for acute care length of stay (LOS) after admission for injury. BACKGROUND: Unnecessary hospital days represent an estimated 20% of total LOS implying an important waste of resources as well as increased patient exposure to hospital-acquired infections and functional decline. METHODS: This study is based on a multicenter, retrospective cohort from a Canadian provincial trauma system (2005-2010; 57 trauma centers; n = 57,524). Data were abstracted from the provincial trauma registry and the hospital discharge database. Candidate risk factors were identified by expert consensus and selected for model derivation using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting. RESULTS: The risk adjustment model explains 37% of the variation in LOS. The QI discriminates well across trauma centers (coefficient of variation = 0.02, 95% confidence interval: 0.011-0.028) and is correlated with the QI on processes of care (r = -0.32), complications (r = 0.66), unplanned readmissions (r = 0.38), and mortality (r = 0.35). Performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.80). CONCLUSIONS: We have developed a QI on the basis of risk-adjusted LOS to evaluate trauma care that can be implemented with routinely collected data. The QI is based on a robust risk adjustment model with good internal and temporal validity, and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This QI can be used to target interventions to reduce LOS, which will lead to more efficient resource use and may improve patient outcomes after injury.

Rates, patterns, and determinants of unplanned readmission after traumatic injury: a multicenter cohort study.

OBJECTIVE: This study aimed to (i) describe unplanned readmission rates after injury according to time, reason, and place; (ii) compare observed rates with general population rates, and (iii) identify determinants of 30-day readmission. BACKGROUND: Hospital readmissions represent an important burden in terms of mortality, morbidity, and resource use but information on unplanned rehospitalization after injury admissions is scarce. METHODS: This multicenter retrospective cohort study was based on adults discharged alive from a Canadian provincial trauma system (1998-2010; n = 115,329). Trauma registry data were linked to hospital discharge data to obtain information on readmission up to 12 months postdischarge. Provincial admission rates were matched to study data by age and gender to obtain expected rates. Determinants of readmission were identified using multiple logistic regression. RESULTS: Cumulative readmission rates at 30 days, 3 months, 6 months, and 12 months were 5.9%, 10.9%, 15.5%, and 21.1%, respectively. Observed rates persisted above expected rates up to 11 months postdischarge. Thirty percent of 30-day readmissions were due to potential complications of injury compared with 3% for general provincial admissions. Only 23% of readmissions were to the same hospital. The strongest independent predictors of readmission were the number of prior admissions, discharge destination, the number of comorbidities, and age. CONCLUSIONS: Unplanned readmissions after discharge from acute care for traumatic injury are frequent, persist beyond 30 days, and are often related to potential complications of injury. Several patient-, injury-, and hospital-related factors are associated with the risk of readmission. Injury readmission rates should be monitored as part of trauma quality assurance efforts.

Hospital length of stay after admission for traumatic injury in Canada: a multicenter cohort study.

OBJECTIVE: To describe acute care length of stay (LOS) over all consecutive hospitalizations for the injury and according to level of care [intensive care unit (ICU), intermediate care, general ward], compare observed and expected LOS, and identify predictors of LOS. BACKGROUND: Prolonged LOS has important consequences in terms of costs and outcome, yet detailed information on LOS after trauma is lacking. METHODS: This multicenter retrospective cohort study was based on adults discharged alive from a Canadian trauma system (1999-2010; n = 126,513). Registry data were used to calculate index LOS (LOS in trauma center with highest designation level) and were linked to hospital discharge data to calculate total LOS (all consecutive hospitalizations for the injury). Expected LOS was obtained by matching general provincial discharge statistics to study data by year, age, and sex. Potential predictors of LOS were evaluated using linear regression. RESULTS: Mean index and total LOS were 8.6 and 9.4 days, respectively. ICU, intermediate care unit, and general ward care constituted 8.9%, 2.5%, and 88.6% of total hospital days. Observed mean index and ICU LOS in our trauma patients were 2.9 and 1.3 days longer than expected LOS (P < 0.0001). The strongest determinants of index LOS were discharge destination, age, transfer status, and injury severity. CONCLUSIONS: Results suggest that acute care LOS after injury is underestimated when only information on the index hospitalization is used and that ICU or intermediate care constitute an important part of LOS. This information should be used to inform the development of an informative and actionable quality indicator.

Derivation and validation of actionable quality indicators targeting reductions in complications for injury admissions.

PURPOSE: Approximately, one out of five patients hospitalized following injury will develop at least one hospital complication, more than three times that observed for general admissions. We currently lack actionable Quality Indicators (QI) targeting specific complications in this population. We aimed to derive and validate QI targeting hospital complications for injury admissions and develop algorithms to identify patient charts to review. METHODS: We conducted a retrospective cohort study including patients with major trauma admitted to any level I or II adult trauma center an integrated Canadian trauma system (2014-2019). We used the trauma registry to develop five QI targeting deep vein thrombosis/pulmonary embolism (DVT/PE), decubitus ulcers, delirium, pneumonia and urinary tract infection (UTI). We developed algorithms to identify patient charts to revise on consultation with a group of clinical experts. RESULTS: The study population included 14,592 patients of whom 5.3% developed DVT or PE, 2.7% developed a decubitus ulcer, 8.6% developed delirium, 14.7% developed pneumonia and 7.3% developed UTI. The indicators demonstrated excellent predictive performance (Area Under the Curve 0.81-0.87). We identified 4 hospitals with a higher than average incidence of at least one of the targeted complications. The algorithms identified on average 50 and 20 charts to be reviewed per year for level I and II centers, respectively. CONCLUSION: In line with initiatives to improve the quality of trauma care, we propose QI targeting reductions in hospital complications for injury admissions and algorithms to generate case lists to facilitate the review of patient charts.

Pre- and posttransfer computed tomography imaging in Canadian trauma centers: A multicenter retrospective cohort study.

BACKGROUND: Multiple clinical practice guidelines recommend minimizing radiation in trauma patients but there is a knowledge gap on the importance of this problem for trauma transfers. We aimed to estimate the incidence of pretransfer and repeat posttransfer computed tomography (CT) overall and in patients with an indication for immediate transfer, to assess interhospital practice variation, to identify predictors, and to quantify the influence of pretransfer CT on time to transfer. Methods We conducted a retrospective multicenter cohort study on patients transferred to major trauma centers from 2013 to 2019. Multilevel generalized linear regression was used to generate intraclass correlation coefficients (ICCs) to assess interhospital variation, multilevel logistic regression to generate odds ratios for each predictor, and geometric mean ratios to quantify the influence of CT on time to transfer. Results Of 18,244 patients included, 8501 (47%) had a pretransfer CT and one-quarter (26%) had a repeat posttransfer CT. Interhospital variation was moderate for pretransfer CT (5%-66%, ICC 12.5%) and for repeat posttransfer CT (7%-44%, ICC 14.7%). Pretransfer imaging was more frequent in elders and in males and repeat posttransfer imaging decreased over the study period but was more frequent in patients transferred in from Level III/IV centers than nondesignated hospitals. Time to transfer was doubled in patients who had a pretransfer CT. CONCLUSIONS: Results suggest that pretransfer CT and repeat posttransfer CT are frequent and are subject to significant practice variation. In addition, pretransfer CT is associated with increased times to transfer though additional studies are needed to demonstrate causation. These results highlight potential opportunities to reduce low-value imaging for trauma transfers.

Trends in Injury Outcomes Across Canadian Trauma Systems.

Importance: In response to the burden of injury, the structure of injury care has changed considerably across Canada in the past decade. However, little is known about how patient outcomes have evolved. Objective: To evaluate trends in mortality, hospital length of stay, and unplanned readmission in Canadian trauma systems between 2006 and 2012. Design, Setting, and Participants: A pan-Canadian retrospective cohort study was conducted among adults admitted for major injury to a Canadian level I or II trauma center between April 1, 2006, and March 31, 2012. Data analysis was conducted from April 15 to December 3, 2015. Exposures: Trauma centers and systems. Main Outcomes and Measures: Multilevel generalized linear models were used to evaluate trends in the risk-adjusted incidence of mortality and readmission and risk-adjusted mean length of stay. Trend analyses were conducted globally and by province. Results: Among 78 807 patients (mean [SD] age, 50.7 [22.0] years; 22 540 women and 56 267 men) admitted for major injury during the study period, risk-adjusted mortality decreased from 12.1% (95% CI, 9%-16.1%) to 9.9% (95% CI, 7.4%-13.3%; P < .001) and mean length of hospital stay decreased from 11.6 (95% CI, 9.9-13.6) to 10.6 (95% CI, 9.1-12.5) days (P < .001). Statistically significant reductions in mortality were observed for Ontario (12% [95% CI, 10.7%-13.6%] to 8% [95% CI, 6.9%-9.2%]; P < .001), Alberta (12% [95% CI, 10%-14.3%] to 9.1% [95% CI, 7.7%-10.8%]; P = .02), and Manitoba (13% [95% CI, 9.1%-18.4%] to 11.1% [95% CI, 8.3%-14.7%]; P = .04). Risk-adjusted hospital stay decreased significantly in Québec (11.6 [95% CI, 11.1-12] to 9.1 [95% CI, 8.9-9.5] days; P < .001), British Columbia (12.5 [95% CI, 12-13.1] to 11.4 [10.9-11.9] days; P < .001), and Ontario (10.1 [95% CI, 9.8-10.4] to 9.8 [95% CI, 9.5-10.1] days; P < .001). No change in the incidence of readmission was observed. Conclusions and Relevance: We observed an 18.2% relative decrease in risk-adjusted mortality in Canadian trauma centers during the study period, representing 248 additional lives saved in 2012 vs 2006. Risk-adjusted mean hospital stay decreased by 8.6%, representing nearly 10 000 hospital days saved. A better understanding of the structures and processes behind observed improvements is needed to further reduce the burden of injury in Canada.

Hospital length of stay following admission for traumatic brain injury in a Canadian integrated trauma system: A retrospective multicenter cohort study.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of disability in children and young adults and costs CAD$3 billion annually in Canada. Stakeholders have expressed the urgent need to obtain information on resource use for TBI to improve the quality and efficiency of acute care in this patient population. We aimed to assess the components and determinants of hospital and ICU LOS for TBI admissions. METHODS: We performed a retrospective multicenter cohort study on 11,199 adults admitted for TBI between 2007 and 2012 in an inclusive Canadian trauma system. Our primary outcome measure was index hospital LOS (admission to the hospital with the highest designation level). Index LOS was compared to total LOS (all consecutive admissions related to the injury). Expected LOS was calculated by matching TBI admissions to all-diagnosis hospital admissions by age, gender, and year of admission. LOS determinants were identified using multilevel linear regression. RESULTS: Geometric mean total LOS was 1day longer than geometric mean index LOS (12.6 versus 11.7 days). Observed index and ICU LOS were respectively 4.2days and 2.5days longer than that expected according to all-diagnosis admissions. The six most important determinants of LOS were discharge destination, severity of concomitant injuries, extracranial complications, GCS, TBI severity, and mechanical ventilation, accounting for 80% of explained variation. CONCLUSIONS: Results of this multicenter retrospective cohort study suggest that hospital and ICU LOS for TBI admissions are 56% and 119% longer than expected according to all-diagnosis admissions, respectively. In addition, hospital LOS is underestimated when only the index visit is considered and is largely influenced by discharge destination and extracranial complications, suggesting that improvements could be achieved with better discharge planning and interventions targeting prevention of in-hospital complications. This study highlights the importance of considering TBI patients as a distinct population when allocating resources or planning quality improvement interventions.

Impact of socio-economic status on unplanned readmission following injury: A multicenter cohort study.

BACKGROUND: Unplanned readmissions cost the US economy approximately $17 billion in 2009 with a 30-day incidence of 19.6%. Despite the recognised impact of socio-economic status (SES) on readmission in diagnostic populations such as cardiovascular patients, its impact in trauma patients is unclear. We examined the effect of SES on unplanned readmission following injury in a setting with universal health insurance. We also evaluated whether additional adjustment for SES influenced risk-adjusted readmission rates, used as a quality indicator (QI). STUDY DESIGN: We conducted a multicenter cohort study in an integrated Canadian trauma system involving 56 adult trauma centres using trauma registry and hospital discharge data collected between 2005 and 2010. The main outcome was unplanned 30-day readmission; all cause, due to complications of injury and due to subsequent injury. SES was determined using ecological indices of material and social deprivation. Odds ratios of readmission and 95% confidence intervals adjusted for covariates were generated using multivariable logistic regression with a correction for hospital clusters. We then compared a readmission QI validated previously (original QI) to a QI with additional adjustment for SES (SES-adjusted QI) using the mean absolute difference. RESULTS: The cohort consisted of 52,122 trauma admissions of which 6.5% were rehospitalised within 30 days of discharge. Compared to patients in the lowest quintile of social deprivation, those in the highest quintile had a 20% increase in the odds of all-cause unplanned readmission (95% CI=1.06-1.36) and a 27% increase in the odds of readmission due to complications of injury (95% CI=1.04-1.54). No association was observed for material deprivation or for readmissions due to subsequent injuries. We observed a strong agreement between the original and SES-adjusted readmission (mean absolute difference= 0.04%). CONCLUSIONS: Patients admitted for traumatic injury who suffer from social deprivation have an increased risk of unplanned rehospitalisation due to complications of injury in the 30 days following discharge. Better discharge planning or follow up for such patients may improve patient outcome and resource use for trauma admissions. Despite observed associations, results suggest that the trauma QI based on unplanned readmission does not require additional adjustment for SES.

Derivation and Validation of a Quality Indicator to Benchmark In-Hospital Complications Among Injury Admissions.

IMPORTANCE: The rate of complications among injury admissions has been estimated to be more than 3 times that observed for general admissions, and complications have been targeted as an important quality-of-care metric. Despite the negative effect of complications on resource use and patient mortality and morbidity, there is no standardized method to benchmark trauma centers in terms of in-hospital complications, to our knowledge. OBJECTIVES: To develop a quality indicator (QI) for in-hospital complications that can be used to evaluate the quality of acute injury care and to assess its validity. DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective cohort study. The setting was a well-established inclusive trauma system in Canada. Participants included all 66 048 moderate or major injury admissions to an adult trauma center between April 1, 2006, and March 31, 2012. The dates of the analysis were January to April 2015. MAIN OUTCOMES AND MEASURES: The primary outcome was the occurrence of at least 1 in-hospital complication. We selected risk-adjustment variables by expert consultation and bootstrap resampling. We evaluated internal validity using measures of discrimination, construct validity, and forecasting. RESULTS: The study cohort comprised 66 048 patients. Their mean (SD) age was 59 (22) years, and 48.0% were female. Fifteen percent of patients had at least 1 in-hospital complication. The risk-adjustment model has excellent discrimination (area under the curve, 0.81) and calibration. The QI was correlated with the risk-adjusted incidence of mortality (r = 0.71), unplanned readmission (r = 0.43), and mean length of stay (r = 0.68). Hospital performance on the QI from 2007 to 2009 was predictive of performance from 2010 to 2012 (r = 0.82). CONCLUSIONS AND RELEVANCE: We developed a QI to benchmark trauma centers on in-hospital complications among injury admissions. The QI is based on data that are routinely collected in most trauma systems and demonstrates good internal validity. The integration of this QI in trauma quality improvement programs will facilitate the identification of quality problems, the implementation of solutions, and the evaluation of their effectiveness. Therefore, the QI has the potential to lead to reductions in mortality, morbidity, and resource use after injury.

Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system.

BACKGROUND: According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains. METHODS: Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients. RESULTS: Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS). CONCLUSION: Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.

Influence of access to an integrated trauma system on in-hospital mortality and length of stay.

BACKGROUND: Few data are available on population-based access to specialised trauma care and its influence on patient outcomes in an integrated trauma system. We aimed to evaluate the influence of access to an integrate trauma system on in-hospital mortality and length of stay (LOS). METHODS: All adults admitted to acute care hospitals for major trauma [International Classification of Diseases Injury Severity Score (ICISS<0.85)] in a Canadian province with an integrated trauma system between 2006 and 2011 were included using an administrative hospital discharge database. The influence of access to an integrated trauma system on in-hospital mortality and LOS was assessed globally and for critically injured patients (ICISS<0.75), according to the type of injury [traumatic brain injury (TBI), abdominal/thoracic, spine, orthopaedic] using logistic and linear multivariable regression models. RESULTS: We identified 22,749 injury admissions. In-hospital mortality was 7% and median LOS was 9 days for all injuries. Overall, 92% of patients were treated within the trauma system. Globally, patients who did not have access had similar mortality and LOS compared to patients who had access. However, we observed a 62% reduction in mortality for critical abdominal/thoracic injuries (odds ratio=0.38; 95% CI, 0.16-0.92) and an 8% increase in LOS for TBI patients (geometric mean ratio=1.08; 95% CI, 1.02-1.14) treated within the trauma system. CONCLUSIONS: Results provides evidence that in a health system with an integrated mature trauma system, access to specialised trauma care is high and the small proportion of patients treated outside the system, have similar mortality and LOS compared to patients treated within the system. This study suggests that the Québec trauma system performs well in its mandate to offer appropriate treatment to victims of injury that require specialised care.

Access to a Canadian provincial integrated trauma system: a population-based cohort study.

BACKGROUND: Access to specialised trauma care is an important measure of trauma system efficiency. However, few data are available on access to integrated trauma systems. We aimed to describe access to trauma centres (TCs) in an integrated Canadian trauma system and identify its determinants. METHODS: We conducted a population-based cohort study including all injured adults admitted to acute care hospitals in the province of Québec between 2006 and 2011. Proportions of injured patients transported directly or transferred to TCs were assessed. Determinants of access were identified through a modified Poisson regression model and a relative importance analysis was used to determine the contribution of each independent variable to predicting access. RESULTS: Of the 135,653 injury admissions selected, 75% were treated within the trauma system. Among 25,522 patients with major injuries [International Classification of diseases Injury Severity Score (ICISS<0.85)], 90% had access to TCs. Access was higher for patients aged under 65, men and among patients living in more remote areas (p-value <0.001). The region of residence followed by injury mechanism, number of trauma diagnoses, injury severity and age were the most important determinants of access to trauma care. CONCLUSIONS: In an integrated, mature trauma system, we observed high access to TCs. However, problems in access were observed for the elderly, women and in urban areas where there are many non-designated hospitals. Access to trauma care should be monitored as part of quality of care improvement activities and pre-hospital guidelines for trauma patients should be applied uniformly throughout the province.

Trauma center performance evaluation based on costs: a systematic review of cohort studies.

BACKGROUND: In 2000, more than 50 million Americans were treated in hospitals following injury, with costs estimated at $80 billion, yet no performance indicator based on costs has been developed and validated specifically for acute trauma care. This study aimed to describe how data on costs have been used to evaluate the performance of acute trauma care hospitals. METHODS: A systematic review using MEDLINE, EMBASE, Web of Science, The Cochrane Library, CINAHL, TRIP, and ProQuest was performed in December 2012. Cohort studies evaluating hospital performance for the treatment of injury inpatients in terms of costs were considered eligible. Two authors conducted the screening and the data abstraction independently using a piloted electronic data abstraction form. Methodological quality was evaluated using seven criteria from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and the Downs and Black tool. RESULTS: The search retrieved 6,635 studies, of which 10 were eligible for inclusion. Nine studies were conducted in the United States and one in Europe. Six studies used patient charges as a proxy for patient costs, of which four used cost-to-charge ratios. One study estimated costs using average unit costs, and three studies were based on the real costs obtained from a hospital accounting system. Average costs per patient in 2013 US dollar varied between 2,568 and 74,435. Four studies (40%) were considered to be of good methodological quality. CONCLUSION: Studies evaluating the performance of trauma hospitals in terms of costs are rare. Most are based on charges rather than costs, and they have low methodological quality. Further research is needed to develop and validate a performance indicator based on inpatient costs that will enable us to monitor trauma centers in terms of resource use. LEVEL OF EVIDENCE: Systematic review, evidence, level III.

Derivation and validation of a quality indicator for 30-day unplanned hospital readmission to evaluate trauma care.

BACKGROUND: Unplanned readmissions represent 20% of all admissions and cost $12 billion annually in the United States. Despite the burden of injuries for the health care system, no quality indicator (QI) based on readmissions is available to evaluate trauma care. The objective of this study was to derive and internally validate a QI for a 30-day unplanned hospital readmission to evaluate trauma care. METHODS: We performed a multicenter retrospective cohort study in a Canadian integrated provincial trauma system. We included adults admitted to any of the 57 provincial trauma centers between 2005 and 2010 (n = 57,524). Data were abstracted from the provincial trauma registry and linked to the hospital discharge database. The primary outcome was unplanned readmission to an acute care hospital within 30 days of discharge. Candidate risk factors were identified by expert consensus and selected for derivation of the risk adjustment model using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting. RESULTS: The risk adjustment model includes patient age, sex, the Injury Severity Score (ISS), region of the most severe injury, and 11 comorbid conditions. The QI discriminates well across trauma centers (coefficient of variation, 0.02) and is correlated with QIs that measure hospital performance in terms of clinical processes (r = -0.38), risk-adjusted mortality (r = 0.32), and complication rates (r = 0.38). In addition, performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.59). CONCLUSION: We have developed a QI based on risk-adjusted 30-day rates of unplanned readmission, which can be used to evaluate trauma care with routinely collected data. The QI is based on a comprehensive risk adjustment model with good internal and temporal validity and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This research represents an essential step toward reducing unplanned readmission rates to improve resource use and patient outcomes following injury. LEVEL OF EVIDENCE: Prognostic study, level III.