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Shahid Shafi, MD, MPH; Ronald M. Stewart, MD; Avery B. Nathens, MD, PhD; Randall S. Friese, MD; Heidi Frankel, MD; Larry M. Gentilello, MD

Arch Surg. 2009;144(1):64-68.

Hypothesis  Mortality rates vary across designated trauma centers (TC), even after controlling for injury severity.

Design  Retrospective analysis of state trauma registry data.

Setting  Designated Level 1 and 2 TCs in 2003 in a large Southwestern state.

Patients  Adult trauma patients (n = 18 584) treated at 15 designated Level 1 and 2 TCs.

Main Outcome Measures  Risk-adjusted survival was calculated for each trauma center using logistic regression analysis to adjust for differences in age, sex, race, injury mechanism, and injury severity. The model was developed using half of the study population and validated in the remaining half. It was then applied to the entire study population, with inclusion of TC identification codes. Observed vs Expected survival ratios were then calculated for each TC. Adjusted odds ratios (OR) for survival at each TC were also calculated.

Results  Adjusted OR of survival were significantly different from crude OR at 6 of the 14 TCs, underscoring the importance of risk adjustment when performing quality comparisons. One TC performed significantly worse than the others, 8 achieved significantly better survival, and 5 performed the same as the referent. Observed vs Expected ratios demonstrated that one trauma center had significantly worse severity-adjusted outcomes, some were marginal, some performed as well as expected, and none performed better than expectations.

Conclusions  Considerable variations in risk-adjusted mortality rates exist across similarly designated TCs. Such variability in outcomes may reflect variations in quality of care, and reasons for this discrepancy should be explored as the next step in the trauma care quality improvement process.

Author Affiliations: Department of Surgery, Division of Burns, Trauma, and Critical Care, University of Texas Southwestern Medical School, Dallas, Texas (Drs Shafi, Friese, Frankel, and Gentilello); Department of Surgery, Division of Trauma, University of Texas Health Sciences Center at San Antonio, Texas (Dr Stewart); and Department of Surgery, University of Toronto, Toronto, Ontario (Dr Nathens).

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