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April 2018

Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review

Author Affiliations
  • 1Joint Trauma System, Joint Base San Antonio–Fort Sam Houston, Texas
  • 2Brooke Army Medical Center, Joint Base San Antonio–Fort Sam Houston, Texas
  • 3US Army Medical Department Center and School, Joint Base San Antonio–Fort Sam Houston, Texas
  • 4Armed Forces Medical Examiner System, Dover Air Force Base, Delaware
  • 5Health Affairs, Falls Church, Virginia
JAMA Surg. 2018;153(4):367-375. doi:10.1001/jamasurg.2017.6105
Key Points

Question  What are the methodological differences in military and civilian trauma preventable death studies?

Findings  In this systematic review of 50 studies (8 military and 42 civilian), including 6500 military deaths reviewed and 19 108 civilian deaths reviewed, qualitative assessment of the methods used to determine the preventable death rate in both populations was variable. Similar to civilian studies, the validity and reliability of military preventable death studies are weakened by inconsistent preventable death definitions and criteria, medical and nonmedical evidence reviewed, final determination process, and identification of suboptimal delivery of care.

Meaning  A mixed-methods analytic approach that can integrate qualitative and quantitative analyses into formal preventable death review definitions, guidelines, and standard operating procedures may improve the reliability and reduce bias of preventable death determination.


Importance  Military and civilian trauma experts initiated a collaborative effort to develop an integrated learning trauma system to reduce preventable morbidity and mortality. Because the Department of Defense does not currently have recommended guidelines and standard operating procedures to perform military preventable death reviews in a consistent manner, these performance improvement processes must be developed.

Objectives  To compare military and civilian preventable death determination methods to understand the existing best practices for evaluating preventable death.

Evidence Review  This systematic review followed the PRISMA reporting guidelines. English-language articles were searched from inception to February 15, 2017, using the following databases: MEDLINE (Ovid), Evidence-Based Medicine Reviews (Ovid), PubMed, CINAHL, and Google Scholar. Articles were initially screened for eligibility and excluded based on predetermined criteria. Articles reviewing only prehospital deaths, only inhospital deaths, or both were eligible for inclusion. Information on study characteristics was independently abstracted by 2 investigators. Reported are methodological factors affecting the reliability of preventable death studies and the preventable death rate, defined as the number of potentially preventable deaths divided by the total number of deaths within a specific patient population.

Findings  Fifty studies (8 military and 42 civilian) met the inclusion criteria. In total, 1598 of 6500 military deaths reviewed and 3346 of 19 108 civilian deaths reviewed were classified as potentially preventable. Among military studies, the preventable death rate ranged from 3.1% to 51.4%. Among civilian studies, the preventable death rate ranged from 2.5% to 85.3%. The high level of methodological heterogeneity regarding factors, such as preventable death definitions, review process, and determination criteria, hinders a meaningful quantitative comparison of preventable death rates.

Conclusions and Relevance  The reliability of military and civilian preventable death studies is hindered by inconsistent definitions, incompatible criteria, and the overall heterogeneity in study methods. The complexity, inconsistency, and unpredictability of combat require unique considerations to perform a methodologically sound combat-related preventable death review. As the Department of Defense begins the process of developing recommended guidelines and standard operating procedures for performing military preventable death reviews, consideration must be given to the factors known to increase the risk of bias and poor reliability.

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