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

Shahid Shafi, Sunni Barnes, David Nicewander, David Ballard, Avery B. Nathens, Angela M. Ingraham, Mark Hemmila, Sandra Goble, Melanie Neal, Michael Pasquale, John J. Fildes, Larry M. Gentilello

Research output: Contribution to journalArticle

21 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)1367-1371
Number of pages5
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume69
Issue number6
DOIs
StatePublished - Dec 2010

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Health Care Reform
Trauma Centers
Length of Stay
Mortality
Wounds and Injuries
Quality Improvement
Cost Savings
Comorbidity
Abbreviated Injury Scale
Risk Adjustment
Gunshot Wounds
Injury Severity Score
Insurance Coverage
Brain Injuries
Intensive Care Units
Shock
Databases

Keywords

  • Health care reform
  • Trauma core measures
  • Trauma quality improvement

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Shafi, S., Barnes, S., Nicewander, D., Ballard, D., Nathens, A. B., Ingraham, A. M., ... Gentilello, L. M. (2010). Health care reform at trauma centers-mortality, complications, and length of stay. Journal of Trauma - Injury, Infection and Critical Care, 69(6), 1367-1371. https://doi.org/10.1097/TA.0b013e3181fb785d

Health care reform at trauma centers-mortality, complications, and length of stay. / Shafi, Shahid; Barnes, Sunni; Nicewander, David; Ballard, David; Nathens, Avery B.; Ingraham, Angela M.; Hemmila, Mark; Goble, Sandra; Neal, Melanie; Pasquale, Michael; Fildes, John J.; Gentilello, Larry M.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 69, No. 6, 12.2010, p. 1367-1371.

Research output: Contribution to journalArticle

Shafi, S, Barnes, S, Nicewander, D, Ballard, D, Nathens, AB, Ingraham, AM, Hemmila, M, Goble, S, Neal, M, Pasquale, M, Fildes, JJ & Gentilello, LM 2010, 'Health care reform at trauma centers-mortality, complications, and length of stay', Journal of Trauma - Injury, Infection and Critical Care, vol. 69, no. 6, pp. 1367-1371. https://doi.org/10.1097/TA.0b013e3181fb785d
Shafi, Shahid ; Barnes, Sunni ; Nicewander, David ; Ballard, David ; Nathens, Avery B. ; Ingraham, Angela M. ; Hemmila, Mark ; Goble, Sandra ; Neal, Melanie ; Pasquale, Michael ; Fildes, John J. ; Gentilello, Larry M. / Health care reform at trauma centers-mortality, complications, and length of stay. In: Journal of Trauma - Injury, Infection and Critical Care. 2010 ; Vol. 69, No. 6. pp. 1367-1371.
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abstract = "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.",
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AU - Ingraham, Angela M.

AU - Hemmila, Mark

AU - Goble, Sandra

AU - Neal, Melanie

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N2 - 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.

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