Beyond In-hospital Mortality: Use of Postdischarge Quality-Metrics Provides a More Complete Picture of Older Adult Trauma Care.

Abstract

To identify the distributions of and extent of variability among 3 new sets of postdischarge quality-metrics measured within 30/90/365 days designed to better account for the unique health needs of older trauma patients: mortality (expansion of the current in-hospital standard), readmission (marker of health-system performance and care coordination), and patients' average number of healthy days at home (marker of patient functional status). Traumatic injuries are a leading cause of death and loss of independence for the increasing number of older adults living in the United States. Ongoing efforts seek to expand quality evaluation for this population. Using 100% Medicare claims, we calculated hospital-specific reliability-adjusted postdischarge quality-metrics for older adults aged 65 years or older admitted with a primary diagnosis of trauma, older adults with hip fracture, and older adults with severe traumatic brain injury. Distributions for each quality-metric within each population were assessed and compared with results for in-hospital mortality, the current benchmarking standard. A total of 785,867 index admissions (305,186 hip fracture and 92,331 severe traumatic brain injury) from 3692 hospitals were included. Within each population, use of postdischarge quality-metrics yielded a broader range of outcomes compared with reliance on in-hospital mortality alone. None of the postdischarge quality-metrics consistently correlated with in-hospital mortality, including death within 1 year [ r =0.581 (95% CI, 0.554-0.608)]. Differences in quintile-rank revealed that when accounting for readmissions (8.4%, κ=0.029) and patients' average number of healthy days at home (7.1%, κ=0.020), as many as 1 in 14 hospitals changed from the best/worst performance under in-hospital mortality to the completely opposite quintile rank. The use of new postdischarge quality-metrics provides a more complete picture of older adult trauma care: 1 with greater room for improvement and better reflection of multiple aspects of quality important to the health and recovery of older trauma patients when compared with reliance on quality benchmarking based on in-hospital mortality alone.