Today’s trauma units were designed with the intent of saving young patients from dying of major injuries.
Historically, trauma centers have used in-hospital mortality rates as indicators of the quality of trauma care for elderly patients. But a new study challenges this practice and explores the possibility of using a longer-term composite outcome made of multiple post-discharge metrics to change the way physicians evaluate the quality of trauma care in older adults (OAs).
New Trauma-Care Quality Score for Older Adults
“Despite advances in inpatient survival after traumatic injury, longer-term outcomes remain a ‘critical blind spot’ for trauma systems, a reality that is particularly true for the increasing number of older adults aged 65 years or older living in the US,” Cheryl K. Zogg, PhD, MSPH, of the Yale School of Medicine, and colleagues wrote in JAMA Surgery.
The authors noted that today’s trauma units were designed with the intent of saving young patients from dying of major injuries.
“However, emerging research has suggested that in so doing, the current structure of US trauma systems might have inadvertently led to worse outcomes for older trauma patients,” they wrote.
The researchers expanded on the previous ED.TRAUMA study, in which Dr. Zogg developed a composite measurement of 27 post-discharge quality metrics representing significant recovery-related benchmarks. These benchmarks included outcomes at 30-, 90-, and 365-days measuring mortality, healthy days at home, and readmissions among all patients with traumatic injuries, OAs with hip fractures, and OAs with severe traumatic brain injuries. Researchers tested the composite score using Medicare claims data from 573,554 different patients treated at more than 1,200 trauma centers between January 1, 2014, and December 31, 2015. Only hospitals that reported at least 10 instances of each diagnosis were included in the study. Dr. Zogg and colleagues also investigated this system for possible associations with hospital-related factors, and compared the composite score with reliability-adjusted in-hospital mortality.
How the New Score Performed
On average, the patients were 83.1 years old, the researchers reported. Of those, 64.8% were women and 73% were white. The 27 metrics that comprised the composite score were reported to have significantly contributed to the total score, with 1-year mortality, readmission at 30 and 90 days, and average number of healthy days at home 365 days after discharge among all trauma patients being the most important drivers, the authors wrote (each 4.7% of total variance explained; P<0 .001).
A higher outcome on the composite score indicated poorer hospital performance, the researchers wrote. When researchers calculated composite scores for the hospitals included in the study, they reported, 2.9% (n=36) were more than two standard deviations above the mean, indicating that they were clear outliers with especially poor performance, whereas 3.2% (n=39) were more than two standard deviations below the mean, indicating that they were clear outliers with particularly good performance.
Dr. Zogg and colleagues identified several factors associated with worse performance on the composite score. Hospitals that were larger level 1 trauma centers (OR=1.51; 95% CI, 1.48-1.54) or larger level 2 trauma centers (OR=1.63; 95% CI, 1.61-1.66) tended to perform worse compared with non-trauma centers, the researchers reported. Trauma centers that were further away by road from their index hospitals also tended to perform worst (OR=1.14; 95% CI, 1.13-1.62 for top 25% furthest versus total population), as did more rural centers (OR=1.56; 95% CI, 1.51-1.62 for micropolitan versus metropolitan locations),and those that saw lower numbers of older adult patients with traumatic injuries (OR=0.89; 95% CI, 0.88-0.9 for top 25% versus rest of population). Race and ethnicity were an important factor as well, with centers that had fewer patients belonging to ethnic and racial minorities also performing poorly (OR=0.49; 95% CI, 0.48-0.49), the researchers wrote.
The researchers noted that when they investigated why major trauma centers appeared to perform more poorly than non-trauma centers, they determined that level 1 trauma centers had significantly greater short-term mortality than non-trauma centers (absolute difference, 0.6 percentage points; 95% CI, 0.5-0.7 versus 0.5; 95% CI, 0.5-0.6). The gap in performance seemed to wane over time, and at the 1-year mark, level 1 trauma centers appeared to outperform non-trauma centers in terms of 365-day reliability-adjusted mortality, all-cause readmission, and average number of healthy days at home.
“The results challenge historical notions about the adequacy of in-hospital mortality as the single measure of older adult trauma quality and suggest that, when it comes to older adults, decisions about how quality is evaluated can profoundly alter understandings of what constitutes best practices for care,” Dr. Zogg and colleagues concluded.
