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A Case for Incorporating Outcome Measures in the Trauma Center Designation Process

Shahid Shafi, MD, MPH; Randall Friese, MD; Larry M. Gentilello, MD

Arch Surg. 2008;143(2):115-119.

Hypothesis  Similarly designated trauma centers do not achieve similar outcomes.

Design  Outcomes study.

Setting  Academic research.

Participants  Forty-seven American College of Surgeons–verified level I trauma centers that contributed more than 1000 patients to the National Trauma Data Bank (from January 1999 to December 2003) were identified.

Main Outcome Measures  Patients were classified into the following 3 injury severity groups using a combination of anatomical and physiological measures: mild (Injury Severity Score [ISS] of <25 with systolic blood pressure [SBP] of 90 mm Hg [n = 184 650]), moderate (ISS of 25 with SBP of 90 mm Hg or ISS of <25 with SBP of <90 mm Hg [n = 22 586]), and severe (ISS of 25 with SBP of <90 mm Hg [n = 4243]). The mean survival for each group was calculated. Individual centers were considered outliers if their patient survival was statistically significantly different from the mean survival for each severity group.

Results  The mean survival of patients with mild, moderate, and severe injuries was 99%, 75%, and 35%, respectively. For mild injuries, survival at 5 centers (11%) was significantly worse than that at their counterpart centers. With increasing injury severity, the percentages of outcome disparities increased (15% of centers for moderate injuries and 21% of centers for severe injuries) and persisted in subgroups of patients with head injuries, patients sustaining penetrating injuries, and older (>55 years) individuals.

Conclusions  When treating patients with similar injury severity, similarly designated level I trauma centers may not achieve similar outcomes, suggesting the existence of a quality chasm in trauma care. Trauma center verification may require the use of outcome measures when determining trauma center status.

Author Affiliations: Division of Burn, Trauma, and Surgical Critical Care, Department of Surgery, University of Texas Southwestern Medical School, Dallas.

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