Faculty Collaboration Database

The impact of interhospital transfer on mortality benchmarking at Level III and IV trauma centers: A step toward shared mortality attribution in a statewide system. J Trauma Acute Care Surg 2020 Jan;88(1):42-50

Date

09/17/2019

Pubmed ID

31524837

Pubmed Central ID

PMC6923584

DOI

10.1097/TA.0000000000002491

Scopus ID

2-s2.0-85077017131 (requires institutional sign-in at Scopus site)   6 Citations

Abstract

BACKGROUND: Many injured patients presenting to Level III/IV trauma centers will be transferred to Level I/II centers, but how these transfers influence benchmarking at Level III/IV centers has not been described. We hypothesized that the apparent observed to expected (O:E) mortality ratios at Level III/IV centers are influenced by the location at which mortality is measured in transferred patients.

METHODS: We conducted a retrospective study of adult patients presenting to Level III/IV trauma centers in Pennsylvania from 2008 to 2017. We used probabilistic matching to match patients transferred between centers. We used a risk-adjusted mortality model to estimate predicted mortality, which we compared with observed mortality at discharge from the Level III/IV center (O) or observed mortality at discharge from the Level III/IV center for nontransferred patients and at discharge from the Level I/II center for transferred patients (O).

RESULTS: In total, 9,477 patients presented to 11 Level III/IV trauma centers over the study period (90% white; 49% female; 97% blunt mechanism; median Injury Severity Score, 8; interquartile range, 4-10). Of these, 4,238 (44%) were transferred to Level I/II centers, of which 3,586 (85%) were able to be matched. Expected mortality in the overall cohort was 332 (3.8%). A total of 332 (3.8%) patients died, of which 177 (53%) died at the initial Level III/IV centers (O). Including posttransfer mortality for transferred patients in addition to observed mortality in nontransferred patients (O) resulted in worse apparent O:E ratios for all centers and significant differences in O:E ratios for the overall cohort (O:E, 0.53; 95% confidence interval, 0.45-0.61 vs. O:E, 1.00, 95% confidence interval, 0.92-1.11; p < 0.001).

CONCLUSION: Apparent O:E mortality ratios at Level III/IV centers are influenced by the timing of measurement. To provide fair and accurate benchmarking and identify opportunities across the continuum of the trauma system, a system of shared attribution for outcomes of transferred patients should be devised.

Author List

Holena DN, Kaufman EJ, Hatchimonji J, Smith BP, Xiong R, Wasser TE, Delgado MK, Wiebe DJ, Carr BG, Reilly PM

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
Benchmarking
Female
Hospital Mortality
Humans
Injury Severity Score
Male
Middle Aged
Patient Transfer
Pennsylvania
Retrospective Studies
Risk Factors
Time Factors
Trauma Centers
Wounds and Injuries