title: More operations, more deaths? Relationship between operative intervention rates and risk-adjusted mortality at trauma centers.
abstract: BACKGROUND
  The Trauma Quality Improvement Project has demonstrated significant variations in risk-adjusted mortality rates across the designated trauma centers. It is not known whether the outcome differences are related to provider-level clinical decision making. We hypothesized that centers with good outcomes undertake critical operative interventions aggressively, thereby avoiding complications and deaths.
  
  
  METHODS
  The previously validated Trauma Quality Improvement Project risk-adjustment algorithm was used to measure observed-to-expected mortality rates (O/E with 90% confidence intervals [CI]) for 152 Level I and II trauma centers participating in the National Trauma Data Bank (version 7.0). Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Scale score >or=3) were included (N = 135,654). Operative intervention rates for solid organ injuries (spleen, liver, and kidney) were compared between the centers classified as high mortality (O/E with CI > 1, n = 35 centers) versus low mortality (O/E with CI < 1, n = 37 centers) using nonparametric tests.
  
  
  RESULTS
  Low- and high-mortality trauma centers were similar in designation level, hospital and intensive care unit beds, teaching status, and number of trauma, orthopedic, and neurosurgeons. Despite a similar incidence and severity of solid organ injuries, low-mortality centers were less likely to undertake operative interventions.
  
  
  CONCLUSIONS
  Trauma centers with higher risk-adjusted mortality rates are more likely to undertake operative interventions for solid organ injuries. Hence, there is a need to focus quality improvement efforts on medical decision-making and perioperative processes of care.
authors.affiliation: Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, Texas 76051, USA. shahid.shafi@baylorhealth.edu
authors.forename: Shahid
authors.initials: S
authors.lastname: Shafi
authors.forename: Jennifer
authors.initials: J
authors.lastname: Parks
authors.forename: Chul
authors.initials: C
authors.lastname: Ahn
authors.forename: Larry M
authors.initials: LM
authors.lastname: Gentilello
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D000007:Abdominal Injuries / Q000401:mortality / Q000601:surgery*; D000328:Adult; D016001:Confidence Intervals; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007668:Kidney / Q000293:injuries; D008099:Liver / Q000293:injuries; D008297:Male; D008875:Middle Aged; D020379:Risk Adjustment / Q000706:statistics & numerical data; D013154:Spleen / Q000293:injuries; D014193:Trauma Centers / Q000706:statistics & numerical data; D016896:Treatment Outcome