Abstract
IntroductionA continuous process of trauma centre evaluation is essential to ensure the development and progression of trauma care at regional, national and international levels. Evaluation may be by comparison between pooled datasets or by direct benchmarking between centres. This study attempts to benchmark mortality at two trauma centres standardising this for multiple case-mix factors, which includes the prevalence of individual background pre-existing diseases within the study population.MethodsTrauma patients with an Injury Severity Score (ISS) >15 admitted to the two centres in 2001 and 2002 were included in the study with the exception of those who died in the emergency department. Patient characteristics were analysed in terms of 18 case-mix factors including Glasgow Coma Scale on arrival, Injury Severity Score and the presence or absence of 9 co-morbidity types, and patient outcome was compared based on in-hospital mortality before and after standardisation.ResultsCrude mortality was greater at UHNS (18.2 vs 14.5%) with a non-significant odds ratio of 1.31 prior to adjusting for case-mix (P = 0.171). Adjustment for case mix using logistic regression analysis altered the odds ratio to 1.64, which was not significant (P = 0.069).DiscussionThis study did not demonstrate any significant difference in the outcome of patients treated at either hospital during the study period. More importantly it has raised several important methodological issues pertinent to researchers undertaking registry based benchmarking studies. Data at the two registries was collected by personnel with differing backgrounds, in formats that were not completely compatible and was collected for patients that met different admissions criteria. The inclusion of a meaningful analysis of pre-existing disease was limited by the availability of robust data and sample size. We suggest greater communication between trauma research coordinators to ensure equivalent data collection and facilitate future benchmarking studies.
Highlights
A continuous process of trauma centre evaluation is essential to ensure the development and progression of trauma care at regional, national and international levels
Crude mortality was greater at University Hospital of North Staffordshire (UHNS) (18.2 versus 14.5%) yielding a crude odds ratio for death of 1.31 (P = 0.171)
This study is the first benchmarking trauma centre comparison to attempt to account for the prevalence of individual pre-existing diseases when calculating mortality rates of severely injured patients
Summary
A continuous process of trauma centre evaluation is essential to ensure the development and progression of trauma care at regional, national and international levels. This study attempts to benchmark mortality at two trauma centres standardising this for multiple case-mix factors, which includes the prevalence of individual background pre-existing diseases within the study population. Adjusting case-mix for this binary indicator of co-morbidity does not accurately allow discrimination between the outcomes of two centres treating patients with a differing prevalence of significant pre-existing diseases, each of which can detrimentally effect the outcome of major trauma to a differing extent, as was demonstrated in a case control study by Morris et al [5]. In this study comparing two major trauma centres, one in the United Kingdom and one in Australia, we have attempted to account for the influence of pre-existing disease on mortality by including the prevalence of individual co-morbid factors within the case-mix adjustment
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