Surgeon- and System-Based Influences on Trauma Mortality | Emergency Medicine | JAMA Surgery | JAMA Network
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Original Article
August 14, 2009

Surgeon- and System-Based Influences on Trauma Mortality

Author Affiliations

Author Affiliations: Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland (Drs Haut, Chang, Hayanga, Efron, and Haider); and Department of Surgery, Howard University School of Medicine, Washington, DC (Dr Cornwell).

Arch Surg. 2009;144(8):759-764. doi:10.1001/archsurg.2009.100

Hypothesis  The mechanism by which trauma systems improve mortality is unknown. Outcomes may be influenced by experienced trauma surgeons treating more patients (surgeon effect) or improving the overall system of care (system effect). We hypothesized that mortality is lower in patients treated by a fellowship-trained senior trauma program director (experienced) vs first-year general surgery attending surgeon (novice) and that patient mortality for novice surgeons would improve after adding a new senior trauma director.

Design  Retrospective cohort study.

Setting  Academic level I trauma center.

Patients  Individuals who had experienced trauma.

Main Outcome Measures  We concurrently compared mortality in trauma patients treated by an experienced trauma surgeon with those admitted by novice surgeons during 5½ years. We also compared mortality in patients treated by novice surgeons before vs after implementation of a more structured trauma program. The χ2 test and multiple logistic regression analysis were used to compare the groups. Odds ratios (95% confidence intervals) for death were examined.

Results  Concurrent comparison of patients treated by novice surgeons vs experienced trauma surgeons demonstrated no difference in mortality (odds ratio, 1.33; 95% confidence interval, 0.82-2.15). At unadjusted univariate analysis, mortality in patients treated by novice surgeons significantly improved over time in the blunt trauma group and all emergency department survivor subgroups. Multivariate analysis demonstrated significantly improved mortality over time in patients treated by novice surgeons (odds ratio, 0.56; 95% confidence interval, 0.37-0.85).

Conclusions  In a structured trauma program, there is no mortality difference between novice surgeons and their experienced trauma director. The organized trauma program and senior surgical mentoring overpower any influence of individual surgeon inexperience.