Abbreviations: MVC, motor vehicle collision; NA, not applicable.
a Model adjusted for age, sex, insurance status, intent of injury, mechanism of injury, trauma mortality prediction model, severe head injury (head Abbreviated Injury Scale score, ≥3), and Charlson Comorbidity Index.
b Significant at P<.05, comparing patients at low-performing with average-performing and high-performing hospitals, respectively.
c Some categories not shown owing to low cell counts.
d Head Abbreviated Injury Scale score, ≥3.
a If low-performing hospitals improve to average-performing status.
b If low-performing hospitals improve to average-performing status, and average-performing hospitals improve to high-performing status.
c If all hospitals improve to high-performing status.
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Hashmi ZG, Haut ER, Efron DT, Salim A, Cornwell EE, Haider AH. A Target to Achieve Zero Preventable Trauma Deaths Through Quality Improvement. JAMA Surg. 2018;153(7):686–689. doi:10.1001/jamasurg.2018.0159
Trauma remains the leading cause of death in Americans younger than 46 years, leading to nearly 200 000 deaths per year.1 To address this issue, major quality improvement initiatives have been undertaken at the national level to improve care at trauma centers. Although results of these efforts have been generally positive, major variations in outcomes between trauma centers continue to be documented.2 The fact that some hospitals perform better than others suggests that some patients are not receiving the best possible care, which may result in preventable deaths. Recognizing this issue, in its 2016 report, the National Academies of Sciences, Engineering, and Medicine (NASEM) recommended several measures to improve the quality of trauma care, and called for achieving zero preventable deaths after injury.3 Our objective is to determine the number of preventable trauma deaths (PTDs) in US hospitals to provide a specific target for this NASEM mandate.
We used the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample from 2006 to 2014 to determine weighted national estimates of PTDs.4 All individuals aged 16 years or older with blunt or penetrating injuries and an International Classification of Diseases, Ninth Revision, Clinical Modification primary diagnostic code of 800 to 905 were included. Records documenting late effects, superficial injuries, foreign bodies, interhospital transfers, and missing data on variables of interest were excluded. This work was reviewed and approved by the Johns Hopkins institutional review board. This study used deidentified, publicly available administrative data from the Agency for Healthcare Research and Quality; therefore, no individual participant informed consent was required.
National estimates of PTDs were determined using previously described methods.5 Hospitals were first classified as a high-performing hospital (HPH), average-performing hospital (APH), or low-performing hospital (LPH) based on risk-adjusted observed-to-expected in-hospital mortality ratios using standardized benchmarking methods.6 Generalized linear modeling with Poisson distributed mortality was then performed (adjusting for known demographic and injury variables) to estimate the relative risk (RR) of mortality at HPHs and APHs vs LPHs. Weighted national estimates of PTDs were calculated for the following 3 hypothetical quality improvement scenarios:
The conservative model was used if LPHs improved to an average performance: PTDs = OLPH – (OLPH × RRAPH), where O is the number of observed deaths.
The intermediate model was used if LPHs improved to an average performance and APHs improved to a high performance: PTDs = [OLPH – (OLPH × RRAPH)] + [OAPH – (OAPH × RRHPH)].
The best-case model was used if all hospitals improved to a high performance: PTDs = OLPH + APH – (OLPH + APH × RRHPH).
All analyses were performed using Stata, version 12/MP (StataCorp). P < .05 (2-sided) was considered statistically significant.
A total of 18 082 170 patients from 2198 hospitals were analyzed. Performance benchmarking classified 261 facilities (11.9%) as HPHs, 1755 facilities (79.9%) as APHs, and 182 facilities (8.3%) as LPHs (Table 1). More than one-third of patients were treated at LPHs (2 689 177 [14.9%]) and HPHs (3 792 368 [21.0%]). The overall unadjusted mortality rate was 0.4% (n = 64 415); among patients with an Injury Severity Score of 9 or more the mortality rate was 3.8% (n = 52 401 of 1 366 789). Patients at APHs (RR, 0.65; 95% CI, 0.63-0.66) and HPHs (RR, 0.38; 95% CI, 0.37-0.39) had a substantially lower RR of mortality compared with those at LPHs. In addition, LPHs had significantly higher mortality rates across all demographic and injury profiles compared with APHs and HPHs (Table 1).
Table 2 describes the weighted national estimates of PTDs. If all hospitals were to deliver the highest quality of care, an estimated 167 746 (95% CI, 164 534-170 861) lives could potentially be saved.
This nationally representative evaluation of trauma data suggests that if all US hospitals achieved outcomes similar to those at the highest-performing centers, 100 000 lives could be saved in approximately 5 years.
The limitations of this study arise from use of retrospective administrative data, including a lack of information on severity of physiological injury and inability to identify systemic factors to distinguish HPHs and LPHs. In addition, in the absence of specifics of each death, our estimates should be interpreted as potentially preventable deaths.
Although this study focuses on preventable in-hospital trauma deaths (owing to differential quality of care), a substantial proportion of potentially preventable deaths may occur in the prehospital setting (attributable to differential access to care). As efforts are being made to standardize prehospital care and improve access, the fact that thousands of lives could be saved by implementing the existing highest standards of care at our hospitals harkens back to NASEM’s call for “the nation to improve its approach to trauma care.”3(p32) Whereas dedicated initiatives in the last few decades have substantially reduced trauma mortality, future efforts should focus on ensuring that all patients receive the best possible trauma care. The results of this study provide a tangible target for such efforts, and serve as a baseline to evaluate future gains.
Accepted for Publication: January 14, 2018.
Corresponding Author: Adil H. Haider, MD, MPH, Center for Surgery and Public Health, Department of Surgery, Harvard Medical School, 1620 Tremont St, Ste 4-020, Boston, MA 02120 (firstname.lastname@example.org).
Published Online: April 11, 2018. doi:10.1001/jamasurg.2018.0159
Author Contributions: Mr Hashmi and Dr Haider had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Hashmi, Efron, Salim, Cornwell, Haider.
Acquisition, analysis, or interpretation of data: Hashmi, Haut, Haider.
Drafting of the manuscript: Hashmi, Cornwell, Haider.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Hashmi, Haider.
Administrative, technical, or material support: Haider.
Study supervision: Salim, Cornwell, Haider.
Conflict of Interest Disclosures: Dr Haut reported serving as the primary investigator of grant 1R01HS024547-01 from the Agency for Healthcare Research and Quality entitled “Individualized Performance Feedback on Venous Thromboembolism Prevention Practice”; serving as co-investigator of grant 1R21HL129028-01A1 from the National Institutes of Health National Heart, Lung, and Blood Institute entitled “Analysis of the Impact of Missed Doses of Venous Thromboembolism Prophylaxis”; serving as co-investigator of grant HU0001-14-0038 from the Henry M. Jackson Foundation, Uniformed Services University of the Health Sciences entitled “Validation of Training for Cricothyroidotomy”; serving as primary investigator of contract CE-12-11-4489 with PCORI entitled “Preventing Venous Thromboembolism: Empowering Patients and Enabling Patient-Centered Care via Health Information Technology”; serving as primary investigator of contract DI-1603-34596 with PCORI entitled “Preventing Venous Thromboembolism (VTE): Engaging Patients to Reduce Preventable Harm from Missed/Refused Doses of VTE Prophylaxis”; serving as co-investigator of contract PCS-1511-32745 with PCORI entitled “A Randomized Pragmatic Trial Comparing the Complications and Safety of Blood Clot Prevention Medicines Used in Orthopaedic Trauma Patients”; receiving royalties from Lippincott, Williams, and Wilkins for the book Avoiding Common ICU Errors; receiving payment as author of a paper commissioned by the National Academies of Medicine entitled “Military Trauma Care’s Learning Health System: The Importance of Data Driven Decision Making,” which was used to support the report titled “A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury.” Dr Haider reported serving as the primary investigator of contract AD-1306-03980 with the Patient-Centered Outcomes Research Institute (PCORI) entitled “Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity in the ED,” a Harvard Surgery Affinity Research Collaborative Program grant entitled “Mitigating Disparities Through Enhancing Surgeons’ Ability To Provide Culturally Relevant Care,” and a collaborative research grant from the Henry M. Jackson Foundation for the Advancement of Military Medicine in conjunction with the Uniformed Services University of the Health Sciences entitled “The Comparative Effectiveness and Provider Induced Demand Collaboration”; and being a cofounder and equity shareholder of Patient Doctor Technologies Inc, which owns and operates the website https://www.doctella.com. No other disclosures were reported.
Disclaimer: Dr Haider is Deputy Editor of JAMA Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.
Meeting Presentation: This article was presented at the 11th Annual Surgical Congress of the Association for Academic Surgery; February 2, 2016; Jacksonville, Florida.
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