title: Health care reform at trauma centers--mortality, complications, and length of stay.
abstract: OBJECTIVE
  The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications.
  
  
  METHODS
  The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity.
  
  
  RESULTS
  Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS.
  
  
  CONCLUSIONS
  Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.
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: Sunni
authors.initials: S
authors.lastname: Barnes
authors.forename: David
authors.initials: D
authors.lastname: Nicewander
authors.forename: David
authors.initials: D
authors.lastname: Ballard
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
authors.forename: Angela M
authors.initials: AM
authors.lastname: Ingraham
authors.forename: Mark
authors.initials: M
authors.lastname: Hemmila
authors.forename: Sandra
authors.initials: S
authors.lastname: Goble
authors.forename: Melanie
authors.initials: M
authors.lastname: Neal
authors.forename: Michael
authors.initials: M
authors.lastname: Pasquale
authors.forename: John J
authors.initials: JJ
authors.lastname: Fildes
authors.forename: Larry M
authors.initials: LM
authors.lastname: Gentilello
mesh_terms: D015998:Abbreviated Injury Scale; D000465:Algorithms; D017046:Cost Savings / Q000191:economics*; D018166:Health Care Reform / Q000191:economics*; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000191:economics*; D016012:Poisson Distribution; D058996:Quality Improvement; D020379:Risk Adjustment; D014193:Trauma Centers / Q000191:economics*; D014481:United States