Comparison of trauma care structures, processes and outcomes between the English National Health Service and Quebec, Canada.

BACKGROUND: Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada. METHODS: We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury. RESULTS: The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. "scoop and run" in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09-1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52-0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries. CONCLUSION: We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement.

Validation of Quality Indicators Targeting Low-Value Trauma Care.

Importance: Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences. Objective: To assess the validity of quality indicators on low-value trauma care using trauma registry data. Design, Setting, and Participants: Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts. Main Outcomes and Measures: Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time). Results: The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs. Conclusions and Relevance: This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.

Interhospital Variations in Resource Use Intensity for In-hospital Injury Deaths: A Retrospective Multicenter Cohort Study.

OBJECTIVE: Evaluate interhospital variation in resource use for in-hospital injury deaths. BACKGROUND: Significant variation in resource use for end-of-life care has been observed in the US for chronic diseases. However, there is an important knowledge gap on end-of-life resource use for trauma patients. METHODS: We conducted a multicenter, retrospective cohort study of injury deaths following hospitalization in any of the 57 trauma centers in a Canadian trauma system (2013-2016). Resource use intensity was measured using activity-based costing (2016 $CAN) according to time of death (72 h, 3-14 d, ≥14 d). We used multilevel log-linear regression to model resource use and estimated interhospital variation using intraclass correlation coefficients (ICC). RESULTS: Our study population comprised 2044 injury deaths. Variation in resource use between hospitals was observed for all 3 time frames (ICC = 6.5%, 6.6%, and 5.9% for < 72 h, 3-14 d, and ≥14 d, respectively). Interhospital variation was stronger for allied health services (ICC = 18 to 26%), medical imaging (ICC = 4 to 10%), and the ICU (ICC = 5 to 6%) than other activity centers. We observed stronger interhospital variation for patients < 65 years of age (ICC = 11 to 34%) than those ≥65 (ICC = 5 to 6%) and for traumatic brain injury (ICC = 5 to 13%) than other injuries (ICC = 1 to 8%). CONCLUSIONS: We observed variation in resource use intensity for injury deaths across trauma centers. Strongest variation was observed for younger patients and those with traumatic brain injury. Results may reflect variation in level of care decisions and the incidence of withdrawal of life-sustaining therapies.

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.

Inter-hospital variation in surgical intensity for trauma admissions: A multicentre cohort study.

BACKGROUND: Guidelines for injury care are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. We aimed to assess inter-hospital variation in surgical intensity for injury admissions and evaluate the correlation between hospital surgical intensity and mortality/complications. METHODS: We included adults admitted for major trauma between 2006 and 2016 in a Canadian provincial trauma system. Analyses were stratified for orthopaedic (n = 16 887), neurological (n = 12 888) and torso injuries (n = 9816). Surgical intensity was quantified with the number of surgical procedures <72 hours. Inter-hospital variation was assessed with the intra-class correlation coefficient (ICC). We assessed the correlation between the risk-adjusted mean number of surgical procedures and risk-adjusted incidence of mortality and complications using Pearson correlation coefficients (r). RESULTS: Moderate inter-hospital variation was observed for orthopaedic surgery (ICC = 14.0%) whereas variation was low for torso surgery (ICC = 2.7%) and neurosurgery (ICC = 0.8%). Surgical intensity was negatively correlated with hospital mortality for torso injury (r = -.32, P = .02) and neurotrauma (r = -.65, P = .08). A strong positive correlation was observed with hospital complications for orthopaedic injuries (r = .36, P = .006) whereas the opposite was observed for neurotrauma (r = -.71, P = .05). CONCLUSIONS: Results should be interpreted with caution as they may be a result of residual confounding. However, they may suggest that there are opportunities for quality improvement in surgical care for injury admissions, particularly for orthopaedic injuries. Moving forward, we should aim to prospectively evaluate adherence to guidelines on non-operative management and their impact on mortality and morbidity.

A comparison of methods to obtain a composite performance indicator for evaluating clinical processes in trauma care.

BACKGROUND: Process performance indicators that evaluate trauma centers in clinical case management provide information essential to the improvement of trauma care. However, multiple indicators are needed to adequately evaluate process performance, which renders comparisons cumbersome. Several methods are available for generating composite indicators that measure global performance. The goal of this study was to compare three composite methods that are widely used in other health care domains to identify the most appropriate for trauma care process performance evaluation. METHODS: In this retrospective, multicenter cohort study, 15 process performance indicators were implemented using data from a Canadian provincial trauma registry (19,853 patients; 59 centers) on patients with an Injury Severity Score (ISS) greater than 15. Composite scores were derived using three methods as follows: the indicator average, the opportunity model, and a latent variable model. Composite scores were evaluated in terms of discrimination, construct validity (association with an indicator of trauma center structural performance), criterion predictive validity (association with clinical outcomes), and forecasting (correlation over time). RESULTS: All composite scores discriminated well between trauma centers. Only the average indicator score was correlated with improved structure (r = 0.29; 95% confidence interval [CI], 0.07-0.53), lower risk-adjusted mortality (r = -0.22; 95% CI, -0.46 to 0.04), and lower risk-adjusted complication rate (r = -0.48; 95% CI, -0.65 to -0.25). Composite scores calculated with 1999 to 2002 data all correlated with those calculated with 2003 to 2006 data (r = 0.49, 0.87, and 0.84 for the indicator average, the opportunity model, and the latent variable model, respectively). CONCLUSION: Results suggest that of the three composite scores evaluated, only the indicator average demonstrates content and predictive criterion validity, discriminates between centers, and has good forecasting properties. In addition, this score is simple and intuitive and not subject to variation in weights over trauma systems and time. The observed association between higher indicator average scores and lower risk-adjusted mortality and complication rates suggests that improving process performance may improve patient outcome.

Surgical management of blunt thoracic and abdominal injuries in Quebec: a limited volume.

BACKGROUND: Trauma care of thoracic and abdominal injuries is currently in turmoil because of both a decrease in the number of these injuries and a concomitant increase in their nonsurgical management. The goal of this study was to evaluate the incidence of thoracic and abdominal injuries in the province of Quebec and the number of associated surgical procedures. METHODS: Patients with blunt thoracic or abdominal injuries taken to a tertiary trauma center in the province of Quebec from April 1, 1998 to March 31, 2002 were identified. Patients who were dead on arrival were excluded. Only patients with an Abbreviated Injury Scale score > or =2 for the thoracic or abdominal regions were included. RESULTS: During the study period, a total of 16,430 blunt trauma patients were admitted to one of the four trauma centers. A total of 2,660 (16.2%) patients sustained thoracic and/or abdominal injuries with an Abbreviated Injury Scale score >1. Among these, the median Injury Severity Score was 24 (range: 4-75) and the in-hospital mortality rate was 11.0%. There were 2,196 patients (82.5%) with thoracic injuries, 977 patients (36.7%) with abdominal injuries, and 520 patients (19.5%) with injuries to both regions. A surgical intervention was undertaken in 76 patients with thoracic injuries (3.5%) and in 414 patients with abdominal injuries (42.3%). On average, 4.7 thoracic and 28.8 abdominal trauma procedures were performed per center, yearly. Each trauma surgeon performed, on average, less than one thoracic and less than five abdominal trauma procedures yearly. CONCLUSIONS: The incidence of blunt thoracic and abdominal injuries needing surgical intervention is low in Quebec tertiary trauma centers. The competence of general surgeons in trauma-related procedures might be compromised by such low patient volume unless they frequently perform non-trauma surgical procedures. We think that in Quebec, trauma care must be provided by surgeons who practice both acute emergency and elective surgical care in addition to trauma care. These findings should have an important impact on the development of on-going education and resident training programs.

Penetrating thoracoabdominal injuries in Quebec: implications for surgical training and maintenance of competence.

BACKGROUND: The frequency of penetrating trauma is low in Canada. Current recommendations for the care of patients with penetrating injuries originate from inner city trauma centres with a high volume of such injuries and may not apply to Canada. The purpose of this study was to review the incidence and treatment of penetrating thoracoabdominal injuries in the 4 tertiary trauma centres in Quebec. METHODS: We identified all patients with penetrating thoracic or abdominal injuries who were taken to any of the 4 tertiary trauma centres in the province of Quebec between Apr. 1, 1998, and Mar. 31, 2001. Patients who were dead on arrival were excluded. Only patients with an Abbreviated Injury Scale of 2 or greater for the thoracic or abdominal regions were included. RESULTS: In total, 245 patients meeting our inclusion criteria were identified. Of these 223 (91%) were male. The mean (and standard deviation) age was 33.8 (13.2) years; range 15-90 years. The median Injury Severity Score was 10 (range 4-75). Overall in-hospital mortality was 6.9%. There were 203 patients (82.8%) with thoracic injuries and 192 patients (78.4%) with abdominal injuries. Fifty (20.4%) of these patients had injuries to both regions. A thoracotomy was carried out in 48 (31.4%) of 153 patients who had injuries to the thorax, and the abdomen was explored in 133 (93.7%) of the 142 patients with abdominal injuries. The incidence of these injuries in the study period varied from 3 to 49 cases per centre. CONCLUSIONS: The annual incidence of penetrating thoracoabdominal injuries is extremely low in all 4 of Quebec's tertiary trauma centres, and the number of thoracoabdominal procedures is even lower. Such a low exposure may jeopardize education and clinical competence. We need to rethink our educational strategies both for residents and for continuing medical education. New approaches to training and maintenance of competence must be developed.