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Original Investigation
July 2016

Derivation and Validation of a Quality Indicator to Benchmark In-Hospital Complications Among Injury Admissions

Author Affiliations
  • 1Department of Social and Preventive Medicine, Université Laval, Quebec, Quebec, Canada
  • 2Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Quebec, Quebec, Canada
  • 3Department of Medicine, Université Laval, Quebec, Quebec, Canada
  • 4Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
  • 5Department of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 6Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  • 7Division of General Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
  • 8Division of Critical Care, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
  • 9Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
  • 10Department of Family Medicine, Université Laval, Quebec, Quebec, Canada
  • 11Department of Surgery, Université Laval, Quebec, Quebec, Canada
  • 12Institut National d’Excellence en Santé et en Services Sociaux, Quebec, Quebec, Canada
  • 13Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec, Quebec, Canada
JAMA Surg. 2016;151(7):622-630. doi:10.1001/jamasurg.2015.5484
Abstract

Importance  The rate of complications among injury admissions has been estimated to be more than 3 times that observed for general admissions, and complications have been targeted as an important quality-of-care metric. Despite the negative effect of complications on resource use and patient mortality and morbidity, there is no standardized method to benchmark trauma centers in terms of in-hospital complications, to our knowledge.

Objectives  To develop a quality indicator (QI) for in-hospital complications that can be used to evaluate the quality of acute injury care and to assess its validity.

Design, Setting, and Participants  Multicenter retrospective cohort study. The setting was a well-established inclusive trauma system in Canada. Participants included all 66 048 moderate or major injury admissions to an adult trauma center between April 1, 2006, and March 31, 2012. The dates of the analysis were January to April 2015.

Main Outcomes and Measures  The primary outcome was the occurrence of at least 1 in-hospital complication. We selected risk-adjustment variables by expert consultation and bootstrap resampling. We evaluated internal validity using measures of discrimination, construct validity, and forecasting.

Results  The study cohort comprised 66 048 patients. Their mean (SD) age was 59 (22) years, and 48.0% were female. Fifteen percent of patients had at least 1 in-hospital complication. The risk-adjustment model has excellent discrimination (area under the curve, 0.81) and calibration. The QI was correlated with the risk-adjusted incidence of mortality (r = 0.71), unplanned readmission (r = 0.43), and mean length of stay (r = 0.68). Hospital performance on the QI from 2007 to 2009 was predictive of performance from 2010 to 2012 (r = 0.82).

Conclusions and Relevance  We developed a QI to benchmark trauma centers on in-hospital complications among injury admissions. The QI is based on data that are routinely collected in most trauma systems and demonstrates good internal validity. The integration of this QI in trauma quality improvement programs will facilitate the identification of quality problems, the implementation of solutions, and the evaluation of their effectiveness. Therefore, the QI has the potential to lead to reductions in mortality, morbidity, and resource use after injury.

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