Determination of neurologic prognosis and clinical decision making in adult patients with severe traumatic brain injury: a survey of Canadian intensivists, neurosurgeons, and neurologists.

OBJECTIVES: Accurate prognostic information in patients with severe traumatic brain injury remains limited, but mortality following the withdrawal of life-sustaining therapies is high and variable across centers. We designed a survey to understand attitudes of physicians caring for patients with severe traumatic brain injury toward the determination of prognosis and clinical decision making on the level of care. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional study of intensivists, neurosurgeons, and neurologists that participate in the care of patients with severe traumatic brain injury at all Canadian level 1 and level 2 trauma centers. INTERVENTION: None. MEASUREMENTS: The main outcome measure was physicians' perceptions of prognosis and recommendations on the level of care. MAIN RESULTS: Our response rate was 64% (455/712). Most respondents (65%) reported that an accurate prediction of prognosis would be most helpful during the first 7 days. Most respondents (>80%) identified bedside monitoring, clinical exam, and imaging to be useful for evaluating prognosis, whereas fewer considered electrophysiology tests (<60%) and biomarkers (<15%). In a case-based scenario, approximately one-third of respondents agreed, one-third were neutral, and one-third disagreed that the patient prognosis would be unfavorable at one year. About 10% were comfortable recommending withdrawal of life-sustaining therapies. CONCLUSIONS: A significant variation in perceptions of neurologic prognosis and in clinical decision making on the level of care was found among Canadian intensivists, neurosurgeons, and neurologists. Improved understanding of the factors that can accurately predict prognosis for patients with traumatic brain injury is urgently needed.

Evaluating trauma center structural performance: The experience of a Canadian provincial trauma system.

BACKGROUND: Indicators of structure, process, and outcome are required to evaluate the performance of trauma centers to improve the quality and efficiency of care. While periodic external accreditation visits are part of most trauma systems, a quantitative indicator of structural performance has yet to be proposed. The objective of this study was to develop and validate a trauma center structural performance indicator using accreditation report data. MATERIALS AND METHODS: Analyses were based on accreditation reports completed during on-site visits in the Quebec trauma system (1994-2005). Qualitative report data was retrospectively transposed onto an evaluation grid and the weighted average of grid items was used to quantify performance. The indicator of structural performance was evaluated in terms of test-retest reliability (kappa statistic), discrimination between centers (coefficient of variation), content validity (correlation with accreditation decision, designation level, and patient volume) and forecasting (correlation between visits performed in 1994-1999 and 1998-2005). RESULTS: Kappa statistics were >0.8 for 66 of the 73 (90%) grid items. Mean structural performance score over 59 trauma centers was 47.4 (95% CI: 43.6-51.1). Two centers were flagged as outliers and the coefficient of variation was 31.2% (95% CI: 25.5% to 37.6%), showing good discrimination. Correlation coefficients of associations with accreditation decision, designation level, and volume were all statistically significant (r = 0.61, -0.40, and 0.24, respectively). No correlation was observed over time (r = 0.03). CONCLUSION: This study demonstrates the feasibility of quantifying trauma center structural performance using accreditation reports. The proposed performance indicator shows good test-retest reliability, between-center discrimination, and construct validity. The observed variability in structural performance across centers and over-time underlines the importance of evaluating structural performance in trauma systems at regular intervals to drive quality improvement efforts.

Influence of socioeconomic status on trauma center performance evaluations in a Canadian trauma system.

BACKGROUND: Trauma center performance evaluations generally include adjustment for injury severity, age, and comorbidity. However, disparities across trauma centers may be due to other differences in source populations that are not accounted for, such as socioeconomic status (SES). We aimed to evaluate whether SES influences trauma center performance evaluations in an inclusive trauma system with universal access to health care. STUDY DESIGN: The study was based on data collected between 1999 and 2006 in a Canadian trauma system. Patient SES was quantified using an ecologic index of social and material deprivation. Performance evaluations were based on mortality adjusted using the Trauma Risk Adjustment Model. Agreement between performance results with and without additional adjustment for SES was evaluated with correlation coefficients. RESULTS: The study sample comprised a total of 71,784 patients from 48 trauma centers, including 3,828 deaths within 30 days (4.5%) and 5,549 deaths within 6 months (7.7%). The proportion of patients in the highest quintile of social and material deprivation varied from 3% to 43% and from 11% to 90% across hospitals, respectively. The correlation between performance results with or without adjustment for SES was almost perfect (r = 0.997; 95% CI 0.995-0.998) and the same hospital outliers were identified. CONCLUSIONS: We observed an important variation in SES across trauma centers but no change in risk-adjusted mortality estimates when SES was added to adjustment models. Results suggest that after adjustment for injury severity, age, comorbidity, and transfer status, disparities in SES across trauma center source populations do not influence trauma center performance evaluations in a system offering universal health coverage.