Potential Avoidable Costs of Low-Value Clinical Practices in Acute Injury Care in an Integrated Canadian Provincial Trauma System.

This economic evaluation estimated the direct health care costs associated with 11 low-value clinical practices in acute trauma care in the integrated health care system of Quebec, Canada.

Enteral supplementation with high-dose docosahexaenoic acid on the risk of bronchopulmonary dysplasia in very preterm infants: a collaborative study protocol for an individual participant data meta-analysis.

INTRODUCTION: Severe bronchopulmonary dysplasia (BPD) is a well-known factor consistently associated with impaired cognitive outcomes. Regarding reported benefits on long-term neurodevelopmental outcomes, the potential adverse effects of high-dose docosahexaenoic acid (DHA) supplementation on this short-term neonatal morbidity need further investigations in infants born very preterm. This study will determine whether high-dose DHA enteral supplementation during the neonatal period is associated with the risk of severe BPD at 36 weeks' postmenstrual age (PMA) compared with control, in contemporary cohorts of preterm infants born at less than 29 weeks of gestation. METHODS AND ANALYSIS: As part of an Australian-Canadian collaboration, we will conduct an individual participant data (IPD) meta-analysis of randomised controlled trials targeting infants born at less than 29 weeks of gestation and evaluating the effect of high-dose DHA enteral supplementation in the neonatal period compared with a control. Primary outcome will be severe grades of BPD (yes/no) at 36 weeks' PMA harmonised according to a recent definition that predicts early childhood morbidities. Other outcomes will be survival without severe BPD, death, BPD severity grades, serious brain injury, severe retinopathy of prematurity, patent ductus arteriosus and necrotising enterocolitis requiring surgery, sepsis, combined neonatal morbidities and growth. Severe BPD will be compared between groups using a multivariate generalised estimating equations log-binomial regression model. Subgroup analyses are planned for gestational age, sex, small-for-gestational age, presence of maternal chorioamnionitis and mode of delivery. ETHICS AND DISSEMINATION: The conduct of each trial was approved by institutional research ethics boards and written informed consent was obtained from participating parents. A collaboration and data sharing agreement will be signed between participating authors and institutions. This IPD meta-analysis will document the role of DHA in nutritional management of BPD. Findings will be disseminated through conferences, media interviews and publications to peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42023431063. TRIAL REGISTRATION NUMBER: NCT05915806.

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review.

BACKGROUND: Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs. METHODS: We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria. RESULTS: We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries. CONCLUSION: We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level III.

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review.

OBJECTIVE: To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps. BACKGROUND: Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care. METHODS: We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II." RESULTS: We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning. CONCLUSIONS: We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations.

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Identifying Quality Indicators for the Care of Hospitalized Injured Older Adults: A Scoping Review of the Literature.

OBJECTIVES: Older adults represent more than 50% of trauma admissions in many high-income countries. Furthermore, they are at increased risk for complications, resulting in worse health outcomes than younger adults and a significant health care utilization burden. Quality indicators (QIs) are used to assess the quality of care in trauma systems, but few QIs reflect responses to older patients' specific needs. We aimed to (1) identify QIs used to assess acute hospital care for injured older patients, (2) assess support for identified QIs and, (3) identify gaps in existing QIs. DESIGN: Scoping review of the scientific and gray literature. METHODS: Selection and data extraction were performed by 2 independent reviewers. The level of support was assessed by the number of sources reporting QIs and whether they were developed according to scientific evidence, expert consensus, and patients' perspectives. RESULTS: Of 10,855 identified studies, 167 were eligible. Among 257 different QIs identified, 52% were hip fracture specific. Gaps were identified for head injuries, rib, and pelvic ring fractures. Although 61% of QIs assessed care processes, 21% and 18% focused on structures and outcomes, respectively. Although most QIs were based on literature reviews and/or expert consensus, patients' perspective was rarely accounted for. The 15 QIs with the highest level of support included minimum time between emergency department arrival and ward admission, minimum time to surgery for fractures, assessment by a geriatrician, orthogeriatric review for hip fracture patients, delirium screening, prompt and appropriate analgesia, early mobilizations, and physiotherapy. CONCLUSION AND IMPLICATIONS: Multiple QIs were identified, but their level of support was limited, and important gaps were identified. Future work should focus on achieving consensus for a set of QIs to assess the quality of trauma care to older adults. Such QIs could be used for quality improvement and ultimately improve outcomes for injured older adults.

A Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions to assess the accuracy of prehospital trauma triage protocols: a modified Delphi study.

BACKGROUND: Injury severity scales have traditionally been used to assess the performance of prehospital trauma triage protocols, but they correlate weakly with the urgent needs of specialized trauma care interventions. This study aimed to develop a list of in-hospital urgent and specialized trauma care interventions that require direct transport to the highest-level trauma centre within the catchment area. METHODS: Based on a list of potential participants we obtained using data on training, experience, geographic location, affiliations and role within key trauma organizations, we recruited multidisciplinary trauma experts (including prehospital, emergency, surgery and intensive care clinicians, epidemiologists and clinician/decision-makers) from across Canada to complete a 3-round modified Delphi survey. We conducted a literature review of the criteria used to define urgent and specialized trauma care, and included all diagnostic and therapeutic interventions presented in previously published studies in the list of interventions to present to the panellists. The final list was determined by our advisory committee, 5 clinicians with experience in trauma care. Participants were asked to rate their level of agreement for potentially including the 38 items as urgent and specialized trauma care interventions on a 9-point Likert scale. Interventions were retained if more than 67% of participants moderately or strongly agreed (7-9 on the Likert scale). Interventions that did not reach consensus were presented again in the subsequent round. RESULTS: Twenty-three panellists were recruited. The response rate was 91%, 96% and 83% for the 3 rounds. After the Delphi process, 30 of the 38 interventions, including endotracheal intubation, blood product administration and angioembolization, and abdominal, thoracic, neurosurgical, spinal and/or orthopedic operations (excluding hip or limb surgery, and toe or finger amputation), were selected. Hospital admission to the intensive care unit and/or for observation of brain, spinal, thoracic or abdominal injuries were also retained. CONCLUSION: We developed a Canadian consensus-based list of urgent and specialized in-hospital trauma care interventions requiring direct transportation to a major trauma centre. This list should help standardize assessments of current protocols and derive new triage tools.

Association Between Enteral Supplementation With High-Dose Docosahexaenoic Acid and Risk of Bronchopulmonary Dysplasia in Preterm Infants: A Systematic Review and Meta-analysis.

Importance: High-dose docosahexaenoic acid (DHA), a long-chain polyunsaturated fatty acid, may affect the risk of bronchopulmonary dysplasia (BPD). However, high-level summative evidence supporting such clinical association in very preterm infants is lacking. Objective: To examine the association between enteral supplementation with high-dose DHA during the neonatal period and the risk of BPD in preterm infants born at less than 29 weeks' gestation. Data Sources: PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, medRxiv, and ClinicalTrials.gov were searched from inception to August 1, 2022, for eligible articles with no language restrictions. Study Selection: Randomized clinical trials (RCTs) were eligible for inclusion (1) if their interventions involved direct administration of a minimum DHA supplementation of 40 mg/kg/d or breast milk or formula feeding of at least 0.4% of total fatty acids, and (2) if they reported data on either BPD, death, BPD severity, or a combined outcome of BPD and death. Data Extraction and Synthesis: Two investigators completed independent review of titles and abstracts, full text screening, data extraction, and quality assessment using the Cochrane Risk of Bias 2.0. Risk ratios (RRs) with 95% CIs were pooled using random-effect meta-analyses. Main Outcomes and Measures: Primary outcome was BPD using trial-specific definitions, which was further stratified for RCTs that used a more stringent BPD definition based on systematic pulse oximetry assessment at 36 weeks' postmenstrual age. Other outcomes were BPD, death, BPD severity, or combined BPD and death. Results: Among the 2760 studies screened, 4 RCTs were included, which involved 2304 infants (1223 boys [53.1%]; mean [SD] gestational age, 26.5 [1.6] weeks). Enteral supplementation with high-dose DHA was associated with neither BPD (4 studies [n = 2186 infants]; RR, 1.07 [95% CI, 0.86-1.34]; P = .53; I2 = 72%) nor BPD or death (4 studies [n = 2299 infants]; RR, 1.04 [95% CI, 0.91-1.18]; P = .59; I2 = 61%). However, an inverse association with BPD was found in RCTs that used a more stringent BPD definition (2 studies [n = 1686 infants]; RR, 1.20 [95% CI, 1.01-1.42]; P = .04; I2 = 48%). Additionally, DHA was inversely associated with moderate-to-severe BPD (3 studies [n = 1892 infants]; RR, 1.16 [95% CI, 1.04-1.29]; P = .008; I2 = 0%). Conclusions and Relevance: Results of this study showed that enteral supplementation with high-dose DHA in the neonatal period was not associated overall with BPD, but an inverse association was found in the included RCTs that used a more stringent BPD definition. These findings suggest that high-dose DHA supplementation should not be recommended to prevent BPD in very preterm infants.

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.

High doses of enteral docosahexaenoic acid omega-3 supplementation for prevention of bronchopulmonary dysplasia in very preterm infants: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Docosahexaenoic acid (DHA) supplementation in the neonatal period has been proposed to prevent bronchopulmonary dysplasia (BPD) in very preterm infants. We aim to determine the effects of an enteral supplementation with high doses of DHA on the risk for BPD at 36 weeks' postmenstrual age (PMA) in very preterm infants born less than 29 weeks' gestation compared with a control. METHODS AND ANALYSIS: We will conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) searching PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, MedRxiv, ClinicalTrials.gov (up to 1 November 2021) as well as reference lists and citations of included articles and previous reviews. RCTs targeting infants born less than 29 weeks' gestation and evaluating the effect of high doses of DHA enteral supplementation in the neonatal period compared with a control will be eligible. Primary outcome will be BPD defined as the need for oxygen and/or ventilation at 36 weeks' PMA. Two authors will independently screen for inclusion, extract data and assess data quality using the Cochrane instrument (risk-of-bias tool 2.0). We will perform meta-analysis using random effects models. Prespecified subgroup analyses are planned for the infant gestational age and sex, the marine source of DHA, mode of administration and duration of exposure. Sensitivity analysis will be performed according to the accuracy of the BPD definition (ie, physiological definition) and according to the risk of bias of the RCTs. ETHICS AND DISSEMINATION: This protocol for a systematic review and meta-analysis does not require ethics approval, as no primary data are collected. This study will assess the effectiveness of high doses of enteral DHA supplementation on BPD and provide evidence to clinicians and families for decision-making. Findings will be disseminated through conferences, media interviews and publications to peer review journals. PROSPERO REGISTRATION NUMBER: CRD42021286705.

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.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review.

INTRODUCTION: Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix. ETHICS AND DISSEMINATION: Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers. PROSPERO REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (CRD42021226934).

Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care.

Importance: The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective: To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, Setting, and Participants: This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main Outcomes and Measures: Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results: Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and Relevance: In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.

Intensity of hospital resource use following traumatic brain injury: a multicentre cohort study, 2013-2016.

BACKGROUND: The knowledge gap regarding acute care resource use for patients with traumatic brain injury (TBI) impedes efforts to improve the efficiency and quality of the care of these patients. Our objective was to evaluate interhospital variation in resource use for patients with TBI, identify determinants of high resource use and assess the association between hospital resource use and clinical outcomes. METHODS: We conducted a multicentre retrospective cohort study including patients aged 16 years and older admitted to the inclusive trauma system of Quebec following TBI, between 2013 and 2016. We estimated resource use using activity-based costs. Clinical outcomes included mortality, complications and unplanned hospital readmission. Interhospital variation was evaluated using intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs). Correlations between hospital resource use and clinical outcomes were evaluated using correlation coefficients on weighted, risk-adjusted estimates with 95% CIs. RESULTS: We included 6319 patients. We observed significant interhospital variation in resource use for patients discharged alive, which was not explained by patient case mix (ICC 0.052, 95% CI 0.043 to 0.061). Adjusted mean resource use for patients discharged to long-term care was more than twice that of patients discharged home. Hospitals with higher resource use tended to have a lower incidence of mortality (r -0.347, 95% CI -0.559 to -0.087) and unplanned readmission (r -0.249, 95% CI -0.481 to 0.020) but a higher incidence of complications (r 0.491, 95% CI 0.255 to 0.666). CONCLUSION: Resource use for TBI varies significantly among hospitals and may be associated with differences in mortality and morbidity. Negative associations with mortality and positive associations with complications should be interpreted with caution but suggest there may be a trade-off between adverse events and survival that should be evaluated further.

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.

Value of repeat CT for nonoperative management of patients with blunt liver and spleen injury: a systematic review.

PURPOSE: To evaluate the effectiveness of routine repeat computed tomography (CT) for nonoperative management (NOM) of adults with blunt liver and/or spleen injury. METHODS: We conducted a systematic review of randomized and non-randomized controlled trials (RCTs), quasi-experimental and observational studies of repeat CT in adult patients with blunt abdominal injury. We searched Medline, Embase, Web of Science, and Cochrane Central from their inception to October 2020 using Cochrane guidelines. Primary outcomes were change in clinical management (e.g., emergency surgery, embolization, blood transfusion, clinical surveillance), mortality, and complications. Secondary outcomes were hospital readmission and length of stay. RESULTS: Search results yielded 1611 studies of which 28 studies including 2646 patients met our inclusion criteria. The majority reported on liver (n = 9) or spleen injury (n = 16) or both (n = 3). No RCTs were identified. Meta-analyses were not possible because no study performed direct comparisons of study outcomes across intervention groups. Only seven of the twenty-eight studies reported whether repeat CT was routine or prompted by clinical indication. In these 7 studies, among the 254 repeat CT performed, 188 (74%) were routine and 8 (4%) of these led to a change in clinical management. Of the 66 (26%) repeated CT prompted by clinical indication, 31 (47%) led to a change in management. We found no data allowing comparison of any other outcomes across intervention groups. CONCLUSION: Routine repeat CT without clinical indication is not useful in the management of patients with liver and/or spleen injury. However, effect estimates were imprecise and included studies were of low methodological quality. Given the risks of unnecessary radiation and costs associated with repeat CT, future research should aim to estimate the frequency of such practices and assess practice variation. LEVEL OF EVIDENCE: Systematic reviews and meta-analyses, Level II.

Effectiveness of trauma centre verification: a systematic review and meta-analysis.

Background: There is a growing trend toward verification of trauma centres, but its impact remains unclear. This systematic review aimed to synthesize available evidence on the effectiveness of trauma centre verification. Methods: We conducted a systematic search of the CINAHL, Embase, HealthStar, MEDLINE and ProQuest databases, as well as the websites of key injury organizations for grey literature, from inception to June 2019, without language restrictions. Our population consisted of injured patients treated at trauma centres. The intervention was trauma centre verification. Comparison groups comprised nonverified trauma centres, or the same centre before it was first verified or re-verified. The primary outcome was in-hospital mortality; secondary outcomes included adverse events, resource use and processes of care. We computed pooled summary estimates using random-effects meta-analysis. Results: Of 5125 citations identified, 29, all conducted in the United States, satisfied our inclusion criteria. Mortality was the most frequently investigated outcome (n = 20), followed by processes of care (n = 12), resource use (n = 12) and adverse events (n = 7). The risk of bias was serious to critical in 22 studies. We observed an imprecise association between verification and decreased mortality (relative risk 0.74, 95% confidence interval 0.52 to 1.06) in severely injured patients. Conclusion: Our review showed mixed and inconsistent associations between verification and processes of care or patient outcomes. The validity of the published literature is limited by the lack of robust controls, as well as any evidence from outside the US, which precludes extrapolation to other health care jurisdictions. Quasiexperimental studies are needed to assess the impact of trauma centre verification. Systematic reviews registration: PROSPERO no. CRD42018107083.

Contexte: Le processus d'audit des centres de traumatologie gagne en popularité, mais ses effets concrets ne sont pas bien connus. La présente revue systématique a cherché à résumer les données probantes disponibles sur l'efficacité de l'audit des centres de traumatologie. Méthodes: Nous avons effectué des recherches systématiques dans les bases de données CINAHL, Embase, HealthSTAR, MEDLINE et ProQuest, de même qu'une recherche dans la littérature grise sur les sites Web d'organisations majeures du domaine des traumas, de leur création à juin 2019, sans restriction de langue. La population à l'étude était l'ensemble des patients blessés traités en centre de traumatologie. L'intervention était l'audit du centre de traumatologie. Les groupes de comparaison correspondaient aux centres de traumatologie n'ayant pas subi d'audit, ou le même centre, avant son premier audit ou un audit subséquent. Le principal résultat à l'étude était la mortalité en milieu hospitalier; les résultats secondaires étaient les événements indésirables, l'utilisation des ressources et les processus de soins. Nous avons calculé des estimations sommaires par méta-analyse à effets aléatoires sur données groupées. Résultats: Sur les 5125 citations retenues, 29 publications sur des études menées aux États-Unis répondaient à nos critères d'inclusion. La mortalité était le résultat le plus souvent à l'étude (n = 20), puis suivaient les processus de soins (n = 12), l'utilisation des ressources (n = 12) et les événements indésirables (n = 7). Le risque de biais était important ou critique dans 22 études. Nous avons observé une association imprécise entre l'audit et une baisse de la mortalité (risque relatif 0,74; intervalle de confiance à 95 % 0,52 à 1,06) chez les patients ayant subi un trauma grave. Conclusion: Notre revue a conclu qu'il y avait des associations mitigées et manquant d'uniformité entre l'audit et les processus de soins ou les issues pour les patients. La validité des données à l'étude était limitée par un manque de contrôles fiables, ainsi que par l'absence de données provenant d'autres pays que les États-Unis, ce qui empêche l'extrapolation à d'autres systèmes de santé. Des études quasi expérimentales devront être menées pour évaluer les effets de l'audit des centres de traumatologie. Enregistrement de la revue systématique: Registre PROSPERO, numéro CRD42018107083.

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.

Strategies aimed at preventing chronic opioid use in trauma and acute care surgery: a scoping review protocol.

INTRODUCTION: Globally every year, millions of patients sustain traumatic injuries and require acute care surgeries. A high incidence of chronic opioid use (up to 58%) has been documented in these populations with significant negative individual and societal impacts. Despite the importance of this public health issue, optimal strategies to limit the chronic use of opioids after trauma and acute care surgery are not clear. We aim to identify existing strategies to prevent chronic opioid use in these populations. METHODS AND ANALYSIS: We will perform a scoping review of peer-reviewed and non-peer-reviewed literature to identify studies, reviews, recommendations and guidelines on strategies aimed at preventing chronic opioid use in patients after trauma and acute care surgery. We will search MEDLINE, EMBASE, PsycINFO, CINHAL, Cochrane Central Register of Controlled Trials, Web of Science, ProQuest and websites of trauma and acute care surgery, pain, government and professional organisations. Databases will be searched for papers published from 1 January 2005 to a maximum of 6 months before submission of the final manuscript. Two reviewers will independently evaluate studies for eligibility and extract data from included studies using a standardised data abstraction form. Preventive strategies will be classified according to their types and targeted trauma populations and acute care surgery procedures. ETHICS AND DISSEMINATION: Research ethics approval is not required as this study is based on the secondary use of published data. This work will inform research and clinical stakeholders on the required next steps towards the uptake of effective strategies aimed at preventing chronic opioid use in trauma and acute care surgery patients.