Uncovering Cultural Barriers to Quality Improvement Learning in a Trauma Program: An Ethnographic Study.

OBJECTIVE: Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center. STUDY DESIGN: An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences. SETTING: University of Toronto and Sunnybrook Health Sciences Center. PARTICIPANTS: Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees. RESULTS: All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons. CONCLUSION: Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change.

Medical Costs of Delayed Hip Fracture Surgery.

BACKGROUND: Waiting for hip fracture surgery is associated with complications. The objective of this study was to determine whether waiting for hip fracture surgery is associated with health-care costs. METHODS: We conducted a population-based, propensity-matched cohort study of patients treated between 2009 and 2014 in Ontario, Canada. The primary exposure was early hip fracture surgery, performed within 24 hours after arrival at the emergency department. The primary outcome was direct medical costs, estimated for each patient in 2013 Canadian dollars, from the payer perspective. The costs in the early and delayed groups were then compared using a difference-in-differences approach: the baseline cost in the year prior to the hip fracture that had been accrued by patients with early surgery was subtracted from the cost in the first year following the surgery (first difference), and the difference was then compared with the same difference among propensity-score-matched patients who had received delayed surgery (second difference). The secondary outcome was the postoperative length of stay (in days). RESULTS: The study included 42,230 patients who received hip fracture surgery from a total of 522 different surgeons at 72 hospitals. The mean cost (and standard deviation) attributed to the hip fracture was $39,497 ± $46,645 per person. The matched patients who underwent surgery after 24 hours had direct 1-year medical costs that were an average of $2,638 higher (95% confidence interval [CI] = $1,595 to $3,680, p < 0.0001) and a postoperative length of stay that was an average of 0.610 day longer (95% CI = 0.1749 to 1.0331 days, p = 0.0058) compared with those who underwent surgery within 24 hours. CONCLUSIONS: Waiting >24 hours for hip fracture surgery was associated with increased medical costs and length of stay. Costs incurred by waiting may provide a financial incentive to mitigate delays in hip fracture surgery. LEVEL OF EVIDENCE: Economic Level III. Please see Instructions for Authors for a complete description of levels of evidence.

Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs Ground Emergency Medical Services.

IMPORTANCE: Time to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes. OBJECTIVE: To evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle. MAIN OUTCOME AND MEASURE: In-hospital mortality. RESULTS: Of the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR, 0.45; 95% CI, 0.36-0.56) and stab wound (OR, 0.32; 95% CI, 0.20-0.52) subgroups. CONCLUSIONS AND RELEVANCE: Private vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

Direct medical costs of motorcycle crashes in Ontario.

BACKGROUND: There is no reliable estimate of costs incurred by motorcycle crashes. Our objective was to calculate the direct costs of all publicly funded medical care provided to individuals after motorcycle crashes compared with automobile crashes. METHODS: We conducted a population-based, matched cohort study of adults in Ontario who presented to hospital because of a motorcycle or automobile crash from 2007 through 2013. For each case, we identified 1 control absent a motor vehicle crash during the study period. Direct costs for each case and control were estimated in 2013 Canadian dollars from the payer perspective using methodology that links health care use to individuals over time. We calculated costs attributable to motorcycle and automobile crashes within 2 years using a difference-in-differences approach. RESULTS: We identified 26 831 patients injured in motorcycle crashes and 281 826 injured in automobile crashes. Mean costs attributable to motorcycle and automobile crashes were $5825 and $2995, respectively (p < 0.001). The rate of injury was triple for motorcycle crashes compared with automobile crashes (2194 injured annually/100 000 registered motorcycles v. 718 injured annually/100 000 registered automobiles; incidence rate ratio [IRR] 3.1, 95% confidence interval [CI] 2.8 to 3.3, p < 0.001). Severe injuries, defined as those with an Abbreviated Injury Scale ≥ 3, were 10 times greater (125 severe injuries annually/100 000 registered motorcycles v. 12 severe injuries annually/100 000 registered automobiles; IRR 10.4, 95% CI 8.3 to 13.1, p < 0.001). INTERPRETATION: Considering both the attributable cost and higher rate of injury, we found that each registered motorcycle in Ontario costs the public health care system 6 times the amount of each registered automobile. Medical costs may provide an additional incentive to improve motorcycle safety.

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures.

BACKGROUND: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. METHODS: From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. RESULTS: Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. CONCLUSIONS: Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

Nationwide Assessment of Trends in Choledocholithiasis Management in the United States From 1998 to 2013.

Importance: There are currently 2 widely accepted treatment strategies for patients presenting to the hospital with choledocholithiasis. However, the rate of use for each strategy in the United States has not been evaluated, and their trends over time have not been described. Furthermore, an optimal management strategy for choledocholithiasis has yet to be defined. Objective: To evaluate secular trends in the management of choledocholithiasis in the United States and to compare hospital length of stay between patients with choledocholithiasis treated with endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (ERCP+LC) vs laparoscopic common bile duct exploration with laparoscopic cholecystectomy (LCBDE+LC). Design, Setting, and Participants: In this cohort study, we studied patients with a primary diagnosis of choledocholithiasis that were included in the National Inpatient Sample between 1998 and 2013 from a representative sample of acute care hospitals in the United States. Patients with cholangitis or pancreatitis were excluded. Main Outcomes and Measures: Unadjusted and risk-adjusted median hospital length of stay. Results: Of the 37 207 patients included in our analysis, 36 048 (96.9%) were treated with ERCP+LC and 1159 (3.1%) were treated with LCBDE+LC. The mean (SD) age of patients treated with ERCP+LC was 50.7 (21.1) years and was 51.9 (20.9) years for those treated with LCBDE+LC; 25 788 (69.3%) were female. Analysis of the National Inpatient Sample data indicates that there are an average of 26 158 patients with choledocholithiasis admitted in the United States each year. The overall use of CBDE for patients with choledocholithiasis decreased from 39.8% of admissions in 1998 to 8.5% in 2013 (P < .001). A decrease was also seen for open CBDE (30.6% vs 5.5%; P < .001) and laparoscopic CBDE (9.2% vs 3.0%; P < .001) independently. Rates of management with LCBDE+LC decreased from 5.3% to 1.5% (P < .001), while rates of ERCP+LC increased from 52.8% to 85.7% (P < .001). The unadjusted median hospital length of stay was shorter for patients treated with LCBDE+LC than for those treated with ERCP+LC (3.0 vs 4.0 days; P < .001). After risk-adjustment, the median length of stay remained 0.5 days shorter for patients treated with LCBDE+LC than with ERCP+LC (3.5 vs 4.0 days; P < .001). Conclusions and Relevance: This study highlights the marked decline in the use of both open and laparoscopic CBDE in the United States as well as the benefit to the length of stay LCBDE+LC has over ERCP+LC. Despite a persistent need for CBDE and the potential benefits of LCBDE+LC over ERCP+LC for managing choledocholithiasis, if current trends continue, CBDE may be at risk of disappearing from the surgical armamentarium.

Early Cholecystectomy for Acute Cholecystitis Offers the Best Outcomes at the Least Cost: A Model-Based Cost-Utility Analysis.

BACKGROUND: The application of early cholecystectomy for acute cholecystitis remains inconsistent across hospitals worldwide. Given the constrained nature of health care spending, careful consideration of costs relative to the clinical consequences of alternative treatments should support decision making. We present a cost-utility analysis comparing alternative time frames of cholecystectomy for acute cholecystitis. STUDY DESIGN: A Markov model with a 5-year time horizon was developed to compare costs and quality-adjusted life-years (QALY) gained from 3 alternative management strategies for the treatment of acute cholecystitis: early cholecystectomy (within 7 days of presentation), delayed elective cholecystectomy (8 to 12 weeks from presentation), and watchful waiting, where cholecystectomy is performed urgently only if recurrent symptoms arise. Model inputs were selected to reflect patients with uncomplicated acute cholecystitis-without concurrent common bile duct obstruction, pancreatitis, or severe sepsis. Real-world outcome probability and cost estimates included in the model were derived from analysis of population-based administrative databases for the province of Ontario, Canada. The QALY values were derived from utilities identified in published literature. Parameter uncertainty was evaluated through probabilistic sensitivity analyses. RESULTS: Early cholecystectomy was less costly (C$6,905 per person) and more effective (4.20 QALYs per person) than delayed cholecystectomy (C$8,511; 4.18 QALYs per person) or watchful waiting (C$7,274; 3.99 QALYs per person). Probabilistic sensitivity analysis showed early cholecystectomy was the preferred management in 72% of model iterations, given a cost-effectiveness threshold of C$50,000 per QALY. CONCLUSIONS: This cost-utility analysis suggests early cholecystectomy is the optimal management of uncomplicated acute cholecystitis. Furthermore, deferring surgery until recurrent symptoms arise is associated with the worst clinical outcomes.

Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality.

BACKGROUND: Economic evaluations provide a unique opportunity to identify the optimal strategies for the diagnosis and management of traumatic brain injury (TBI), for which uncertainty is common and the economic burden is substantial. OBJECTIVE: The objective of this study was to systematically review and examine the quality of contemporary economic evaluations in the diagnosis and management of TBI. METHODS: Two reviewers independently searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, Health Technology Assessment Database, EconLit, and the Tufts CEA Registry for comparative economic evaluations published from 2000 onward (last updated on August 30, 2013). Data on methods, results, and quality were abstracted in duplicate. The results were summarized quantitatively and qualitatively. RESULTS: Of 3539 citations, 24 economic evaluations met our inclusion criteria. Nine were cost-utility, five were cost-effectiveness, three were cost-minimization, and seven were cost-consequences analyses. Only six studies were of high quality. Current evidence from high-quality studies suggests the economic attractiveness of the following strategies: a low medical threshold for computed tomography (CT) scanning of asymptomatic infants with possible inflicted TBI, selective CT scanning of adults with mild TBI as per the Canadian CT Head Rule, management of severe TBI according to the Brain Trauma Foundation guidelines, management of TBI in dedicated neurocritical care units, and early transfer of patients with TBI with nonsurgical lesions to neuroscience centers. CONCLUSIONS: Threshold-guided CT scanning, adherence to Brain Trauma Foundation guidelines, and care for patients with TBI, including those with nonsurgical lesions, in specialized settings appear to be economically attractive strategies.

Blunt splenic injury and severe brain injury: a decision analysis and implications for care.

BACKGROUND: The initial nonoperative management (NOM) of blunt splenic injuries in hemodynamically stable patients is common. In soldiers who experience blunt splenic injuries with concomitant severe brain injury while on deployment, however, NOM may put the injured soldier at risk for secondary brain injury from prolonged hypotension. METHODS: We conducted a decision analysis using a Markov process to evaluate 2 strategies for managing hemodynamically stable patients with blunt splenic injuries and severe brain injury--immediate splenectomy and NOM--in the setting of a field hospital with surgical capability but no angiography capabilities. We considered the base case of a 40-year-old man with a life expectancy of 78 years who experienced blunt trauma resulting in a severe traumatic brain injury and an isolated splenic injury with an estimated failure rate of NOM of 19.6%. The primary outcome measured was life expectancy. We assumed that failure of NOM would occur in the setting of a prolonged casualty evacuation, where surgical capability was not present. RESULTS: Immediate splenectomy was the slightly more effective strategy, resulting in a very modest increase in overall survival compared with NOM. Immediate splenectomy yielded a survival benefit of only 0.4 years over NOM. CONCLUSION: In terms of overall survival, we would not recommend splenectomy unless the estimated failure rate of NOM exceeded 20%, which corresponds to an American Association for the Surgery of Trauma grade III splenic injury. For military patients for whom angiography may not be available at the field hospital and who require prolonged evacuation, immediate splenectomy should be considered for grade III-V injuries in the presence of severe brain injury.

CONTEXTE: La gestion non chirurgicale (GNC) initiale des traumatismes spléniques fermés chez les patients hémodynamiquement stables est fréquente. Toutefois, dans les cas de traumatismes spléniques fermés accompagnés de graves lésions cérébrales concomitantes durant leur déploiement, la GNC peut exposer les soldats blessés à un risque de lésion cérébrale secondaire par suite d'une hypotension prolongée. MÉTHODES: Nous avons appliqué un modèle de Markov à l'analyse décisionnelle pour évaluer 2 stratégies de prise en charge des patients hémodynamiquement stables porteurs de traumatismes spléniques fermés et de graves lésions cérébrales, soit la splénectomie immédiate et la GNC, dans le contexte d'un hôpital de campagne doté d'installations chirurgicales mais non d'installations angiographiques. Nous avons étudié le scénario de référence d'un homme de 40 ans ayant une espérance de vie de 78 ans, victime d'un traumatisme fermé entraînant une lésion cérébrale grave et un traumatisme splénique isolé, avec un taux estimé d'échec de la GNC de 19,6 %. Le principal paramètre mesuré était l'espérance de vie. Nous avons présumé que l'échec de la GNC surviendrait dans le contexte d'une évacuation prolongée des blessés en l'absence d'installations chirurgicales. RÉSULTANTS: La splénectomie immédiate s'est révélée être une stratégie légèrement plus efficace, entraînant une augmentation très modeste de la survie globale comparativement à la GNC. La splénectomie immédiate a produit un avantage de 0,4 an seulement au plan de la survie par rapport à la GNC. CONCLUSION: Au plan de la survie globale, nous ne recommanderions pas la splénectomie, à moins que le taux d'échec estimé de la GNC n'excède 20 %, ce qui correspond à un traumatisme splénique de grade III selon l'American Association for the Surgery of Trauma. Pour le personnel militaire blessé chez qui il est impossible de procéder à une angiographie dans un hôpital de campagne, et qui requiert une évacuation prolongée, il faut envisager une splénectomie immédiate pour les traumatisme de grade III V en présence de graves lésions cérébrales.

Acute nontraumatic general surgical conditions on a combat deployment.

BACKGROUND: Literature is lacking on acute surgical problems that may be encountered on military deployment; even less has been written on whether or not any of these surgical problems could have been avoided with more focused predeployment screening. We sought to determine the burden of illness attributable to acute nontraumatic general surgical problems while on deployment and to identify areas where more rigorous predeployment screening could be implemented to decrease surgical resource use for nontraumatic problems. METHODS: We studied all Canadian Armed Forces (CAF) members deployed to Afghanistan between Feb. 7, 2006, and June 30, 2011, who required treatment for a nontraumatic general surgical condition. RESULTS: During the study period 28 990 CAF personnel deployed to Afghanistan; 373 (1.28%) were repatriated because of disease and 100 (0.34%) developed an acute general surgical condition. Among those who developed an acute surgical illness, 42 were combat personnel (42%) and 58 were support personnel (58%). Urologic diagnoses (n = 34) were the most frequent acute surgical conditions, followed by acute appendicitis (n = 18) and hernias (n = 12). We identified 5 areas where intensified predeployment screening could have potentially decreased the incidence of in-theatre acute surgical illness. CONCLUSION: Our findings suggest that there is a significant acute care surgery element encountered on combat deployment, and surgeons tasked with caring for this population should be prepared to treat these patients.

CONTEXTE: Il y a un manque de données sur les problèmes chirurgicaux aigus qui peuvent survenir lors de déploiements militaires, et encore moins sur la question de savoir si on aurait pu éviter ces problèmes en faisant un dépistage plus ciblé avant le déploiement. Nous avons tenté de déterminer le fardeau de la maladie attribuable à des problèmes non traumatiques aigus de chirurgie générale pendant le déploiement, puis d'identifier les domaines où un dépistage préalable plus rigoureux pourrait être mis en oeuvre pour réduire l'utilisation des ressources chirurgicales pour les problèmes non traumatiques. MÉTHODES: Notre étude a porté sur tous les membres des Forces armées canadiennes (FAC) déployés en Afghanistan entre le 7 février 2006 et le 30 juin 2011 et qui ont eu besoin de traitement pour un état chirurgical général non traumatique. RÉSULTANTS: Pendant la période de l'étude, 28 990 membres des FAC ont été déployés en Afghanistan; 373 (1,28 %) ont été rapatriés en raison de maladie et 100 (0,34 %) ont développé un état chirurgical général aigu. Parmi ces derniers, 42 faisaient partie du personnel de combat (42 %) et 58 faisaient partie du personnel de soutien (58 %). Les diagnostics urologiques (n = 34) constituaient les états chirurgicaux aigus les plus fréquents, suivis de l'appendicite aiguë (n = 18) et des hernies (n = 12). Nous avons identifié 5 domaines où un dépistage intensifié, préalable au déploiement, aurait possiblement réduit l'incidence des états chirurgicaux aigus en théâtre d'opérations. CONCLUSION: Il ressort de nos conclusions que les missions de combat comportent un important élément de soins chirurgicaux aigus et que les chirurgiens chargés de soigner cette population devraient être préparés à traiter ces patients.

A geospatial analysis of the relationship between neighbourhood socioeconomic status and adult severe injury in Greater Vancouver.

BACKGROUND: Every year, injuries cost the Canadian healthcare system billions of dollars and result in thousands of emergency room visits, hospitalisations and deaths. The purpose of this study was to explore the relationship between neighbourhood socioeconomic status (NSES) and the rates of all-cause, unintentional and intentional severe injury in Greater Vancouver adults. A second objective was to determine whether the identified associations were spatially consistent or non-stationary. METHODS: Severe injury cases occurring between 2001 and 2006 were identified using the British Columbia's Coroner's Service records and the British Columbia Trauma Registry, and mapped by census dissemination areas using a geographical information system. Descriptive statistics and exploratory spatial data analysis methods were used to gain a better understanding of the data sets and to explore the relationship between the rates of severe injury and two measures of NSES (social and material deprivation). Ordinary least squares and geographically weighted regression were used to model these relationships at the global and local levels. RESULTS: Inverse relationships were identified between both measures of NSES and the rates of severe injury with the strongest associations located in Greater Vancouver's most socioeconomically deprived neighbourhoods. Social deprivation was found to have a slightly stronger relationship with the rates of severe injury than material deprivation. CONCLUSIONS: Results of this study suggest that policies and programmes aimed at reducing the burden of severe injury in Greater Vancouver should take into account social and material deprivation, and should target the most socioeconomically deprived neighbourhoods in Greater Vancouver.

Trauma Non-Technical Training (TNT-2): the development, piloting and multilevel assessment of a simulation-based, interprofessional curriculum for team-based trauma resuscitation.

Medical error is common during trauma resuscitations. Most errors are nontechnical, stemming from ineffective team leadership, nonstandardized communication among team members, lack of global situational awareness, poor use of resources and inappropriate triage and prioritization. We developed an interprofessional, simulation-based trauma team training curriculum for Canadian surgical trainees. Here we discuss its piloting and evaluation.

Economic evaluation of decompressive craniectomy versus barbiturate coma for refractory intracranial hypertension following traumatic brain injury.

OBJECTIVES: Decompressive craniectomy and barbiturate coma are often used as second-tier strategies when intracranial hypertension following severe traumatic brain injury is refractory to first-line treatments. Uncertainty surrounds the decision to choose either treatment option. We investigated which strategy is more economically attractive in this context. DESIGN: We performed a cost-utility analysis. A Markov Monte Carlo microsimulation model with a life-long time horizon was created to compare quality-adjusted survival and cost of the two treatment strategies, from the perspective of healthcare payer. Model parameters were estimated from the literature. Two-dimensional simulation was used to incorporate parameter uncertainty into the model. Value of information analysis was conducted to identify major drivers of decision uncertainty and focus future research. SETTING: Trauma centers in the United States. SUBJECTS: Base case was a population of patients (mean age = 25 yr) who developed refractory intracranial hypertension following traumatic brain injury. INTERVENTIONS: We compared two treatment strategies: decompressive craniectomy and barbiturate coma. MEASUREMENTS AND MAIN RESULTS: Decompressive craniectomy was associated with an average gain of 1.5 quality-adjusted life years relative to barbiturate coma, with an incremental cost-effectiveness ratio of $9,565/quality-adjusted life year gained. Decompressive craniectomy resulted in a greater quality-adjusted life expectancy 86% of the time and was more cost-effective than barbiturate coma in 78% of cases if our willingness-to-pay threshold is $50,000/quality-adjusted life year and 82% of cases at a threshold of $100,000/quality-adjusted life year. At older age, decompressive craniectomy continued to increase survival but at higher cost (incremental cost-effectiveness ratio = $197,906/quality-adjusted life year at mean age = 85 yr). CONCLUSIONS: Based on available evidence, decompressive craniectomy for the treatment of refractory intracranial hypertension following traumatic brain injury provides better value in terms of costs and health gains than barbiturate coma. However, decompressive craniectomy might be less economically attractive for older patients. Further research, particularly on natural history of severe traumatic brain injury patients, is needed to make more informed treatment decisions.

Sustaining a coordinated, regional approach to trauma and emergency care is critical to patient health care needs.

Trauma systems provide an organized approach to the care of injured patients within a defined geographic region. When fully operational, the systems ensure a continuum of care involving public access through 911 calls, emergency medical services, timely triage and transport to acute care, and transfer to rehabilitation services. Substantial progress has been made in establishing statewide trauma systems, which are seen as the prototype for regionalized care for other time-sensitive, emergency conditions such as stroke. Trauma systems provide a model of care that is consistent with the goals of the Affordable Care Act, which authorizes $100 million in annual grants to ensure the continued availability of trauma services. Full funding of these provisions is needed to stabilize statewide systems that are struggling to survive. We describe the components of a regionalized trauma system, review the evidence in support of this approach, and discuss the challenges to sustaining systems that are accountable and affordable.

Evolution of the incidence, management, and mortality of blunt thoracic aortic injury: a population-based analysis.

BACKGROUND: In the last decade, CT angiography has become the dominant diagnostic modality for blunt aortic injury and endovascular repair has become the leading aortic repair strategy. The impact of these shifts on incidence, aortic repair rate, and mortality remains poorly characterized. Our objective was to perform a population-based analysis of secular trends in the incidence, management, and in-hospital mortality of blunt thoracic aortic injury. STUDY DESIGN: From the population-based Canadian National Trauma Registry, we identified a cohort of all adults hospitalized between April 2002 and March 2010 with a diagnosis of thoracic aortic injury after blunt trauma. Trends over time in the incidence of hospitalization, frequency and type of aortic repair, as well as risk-adjusted in-hospital mortality, were evaluated. RESULTS: A total of 487 incident cases of blunt thoracic aortic injury were identified. During the study period, the incidence of hospitalization for blunt thoracic aortic injury remained stable (trend p = 0.16). Although the proportion of repairs undertaken via an endovascular approach increased (11% to 78% of repairs; trend p < 0.001), the frequency of any repair (endovascular or open) declined (55% to 36%; trend p = 0.003). Across all patients, when controlling for age, sex, mechanism of injury, and presence of severe extrathoracic injuries, mortality remained unchanged during the study period (odds ratio = 0.92 per 1 year; 95% CI, 0.82-1.03). However, in patients managed nonoperatively, risk-adjusted mortality decreased over time (odds ratio = 0.85 per 1 year; 95% CI, 0.80-0.98). CONCLUSIONS: The increasing frequency of patients managed nonoperatively and decreasing risk-adjusted mortality in these patients suggests that defining the evolving role of nonoperative management should be a major focus of research in the endovascular era.

A population-based analysis of the discrepancy between potential and realized access to trauma center care.

OBJECTIVE: To explore whether a discrepancy between the availability of trauma services (potential access) and trauma center utilization rates (realized access) exists, with the aim of informing strategies to improve access. BACKGROUND: Lack of access to trauma center care has frequently been attributed to the geographic distribution of trauma centers. Alternatively, impeded access to trauma center care might be due to suboptimal triage practices in the setting of appropriate resources. METHODS: Population-based retrospective cohort study of severely injured adult patients (2002-2010). Potential access to trauma center care was evaluated using network-based spatial analysis of census data and was defined as residing within 1 hour of a trauma center. Realized access to trauma center care was evaluated using population-based data sources and was defined as direct transport from the scene of injury to a trauma center. Concordance between potential and realized access (high, moderate, or low) was evaluated at the county level. RESULTS: Of the population in the study region, 7,340,711 persons (60%) had potential access to trauma center care; persons in 11 counties (22%) had high potential access. Of 26,861 severely injured patients, 10,237 (38%) had realized access to trauma center care; patients in only 4 counties (8%) had high realized access. The concordance between potential and realized access was moderate (weighted κ = 0.49); 63% of counties (n = 7) with high potential access performed worse than expected and had moderate or low realized access. CONCLUSIONS: There is limited concordance between potential and realized access. Regions with high potential access had low realized access, and vice versa. This evaluation suggests that strategies to improve access must be based on understanding the distribution of centers and the triage practices used to access trauma care.

Variation in quality of care after emergency general surgery procedures in the elderly.

BACKGROUND: The elderly (age ≥65 years) comprise an increasing proportion of patients undergoing emergency general surgery (EGS) procedures and have distinct needs compared with the young. We postulated that the needs of the elderly require different processes of care than those required for the young to assure optimal outcomes. To explore this hypothesis, we evaluated 30-day outcomes following EGS procedures in the young and the elderly and determined whether hospital performance was consistent across these 2 age strata. STUDY DESIGN: With data from the American College of Surgeons National Surgical Quality Improvement Program (2005 to 2008), regression models were constructed for serious morbidity and mortality for all patients undergoing EGS procedures and separately for young and elderly patients. These models allowed for estimation of the risk of adverse outcomes associated with advanced age and the generation of hospital-level observed to expected (O/E) ratios. We evaluated the correlation between hospital O/E ratios for the young and the elderly and the concordance of outlier status (hospitals with CIs of O/E ratios excluding 1) with weighted κ across these 2 age groups. RESULTS: Among 68,003 procedures at 186 hospitals, elderly patients had a higher crude and adjusted risk for serious morbidity (27.9% versus 9.7%, p < 0.0001; odds ratio 1.17, 95% CI 1.10 to 1.24) and mortality (15.2% versus 2.5%, p < 0.0001; odds ratio 2.29, 95% CI 2.09 to 2.51). When outcomes for elderly versus younger patients were compared, there was fair to moderate agreement on hospital performance for serious morbidity (r = 0.43; κ = 0.30) but not for mortality (r = 0.10; κ = 0.17). CONCLUSIONS: Elderly patients are at substantially greater risk for adverse events following EGS procedures. Hospitals had only slight agreement in mortality outcomes in the elderly compared with those in young patients. Processes of care that may account for this disparity should be further investigated.

Health care reform at trauma centers--mortality, complications, and length of stay.

OBJECTIVE: The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications. METHODS: The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity. RESULTS: Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS. CONCLUSION: Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

Survival of the fittest: the hidden cost of undertriage of major trauma.

BACKGROUND: Injured patients cared for in trauma centers have a lower risk of death than those cared for in nontrauma centers. However, many patients are transported to a non-trauma center after injury (undertriaged) and require transfer to trauma center care. Previous analyses of undertriage focused only on survivors to trauma center care and were potentially subject to survivor bias. Using a novel population-based design, we evaluated the true mortality cost of undertriage. STUDY DESIGN: We used a retrospective cohort design and included all severely injured patients surviving to reach an emergency department within the province of Ontario, Canada. Those patients who were triaged to a non-trauma center as their first hospital exposure were the Undertriage cohort. Undertriage cohort patients were either transferred to a trauma center (Transfer cohort) or died before transfer could be accomplished (emergency department-death cohort). Patients that were transported directly from the scene of injury to a trauma center represented the Direct cohort. Thirty-day mortality in undertriaged patients was analyzed using two approaches: allowing for survivor bias (Transfer versus Direct) and without survivor bias (Undertriage versus Direct). RESULTS: Among 11,398 patients, 66% were transported directly to a trauma center and 30% were transferred. Four percent died before transfer (22% of all deaths). Reproducing approaches that ignore survivor bias, mortality in the Transfer and Direct cohorts was equivalent. However, unbiased assessment demonstrated that mortality was significantly higher in the Undertriage cohort than the Direct cohort (odds ratio = 1.24; 95% CI, 1.10-1.40). CONCLUSIONS: Undertriage after major trauma is associated with substantial mortality. These data suggest a need to design strategies to improve triage to trauma center.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.