Faculty Collaboration Database

High-Performance Trauma Centers in a Single-State Trauma System : Big Saves or Marginal Gains? Am Surg 2020 Jul;86(7):766-772

Date

07/30/2020

Pubmed ID

32723186

DOI

10.1177/0003134820934415

Scopus ID

2-s2.0-85090550964 (requires institutional sign-in at Scopus site)   2 Citations

Abstract

BACKGROUND: Trauma centers with low observed:expected (O:E) mortality ratios are considered high performers; however, it is unknown whether improvements in this ratio are due to a small number of unexpected survivors with high mortality risk (big saves) or a larger number of unexpected survivors with moderate mortality risk (marginal gains). We hypothesized that the highest-performing centers achieve that status via larger numbers of unexpected survivors with moderate mortality risk.

METHODS: We calculated O:E ratios for trauma centers in Pennsylvania for 2016 using a risk-adjusted mortality model. We identified high and low performers as centers whose 95% CIs did not cross 1. We visualized differences between these centers by plotting patient-level observed and expected mortality; we then examined differences in a subset of patients with a predicted mortality of ≥10% using the chi-squared test.

RESULTS: One high performer and 1 low performer were identified. The high performer managed a population with more blunt injuries (97.2% vs 93.6%, P < .001) and a higher median Injury Severity Score (14 vs 11, P < .001). There was no difference in survival between these centers in patients with an expected mortality of <10% (98.0% vs 96.7%, P = .11) or ≥70% (23.5% vs 10.8%, P = .22), but there was a difference in the subset with an expected mortality of ≥10% (77.5% vs 43.1%, P < .001).

CONCLUSIONS: Though patients with very low predicted mortality do equally well in high-performing and low-performing centers, the fact that performance seems determined by outcomes of patients with moderate predicted mortality favors a "marginal gains" theory.

Author List

Hatchimonji JS, Kaufman EJ, Young AJ, Smith BP, Xiong R, Reilly PM, Holena DN

Author

Daniel N. Holena MD Professor in the Surgery department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Adult
Aged
Aged, 80 and over
Female
Hospital Mortality
Humans
Injury Severity Score
Male
Middle Aged
Pennsylvania
Retrospective Studies
Survival Analysis
Trauma Centers
Wounds and Injuries