title: External benchmarking of trauma center performance: have we forgotten our elders?
abstract: OBJECTIVE
  The elderly injured have been identified as a population with unique needs compared with nonelderly trauma patients. We sought to determine whether trauma center (TC) performance is consistent across age groups and to assess whether aggregate evaluations of TC performance capture quality of care among the elderly.
  
  
  BACKGROUND
  The recently launched Trauma Quality Improvement Program utilizes external benchmarking of TC outcomes to identify centers with above-average performance, with the goal of disseminating best practices. If variation exists in TC performance across age groups, such variation might significantly impact on the success of external benchmarking programs in improving quality of care.
  
  
  METHODS
  Study data were derived from the National Trauma Databank (2007), limited to level I and II centers and adults with moderate to severe injuries (injury severity score > 9). Separate logistic regression models were constructed to produce TC risk-adjusted mortality for both the young and the elderly (age > 65 years). Observed-to-expected mortality ratios were used to identify centers with above or below average performance overall, among the young and among the elderly.
  
  
  RESULTS
  We identified 87,754 patients across 132 facilities; 25% were elderly. After adjustment for case mix, 9 centers were identified as above-average performers in the elderly population. Only 2 of these centers were also above-average performers among young patients. Overall, concordance for center performance across age strata evidenced poor agreement (κ, 0.23). In addition, aggregate assessment of center performance did not reliably identify high-performing centers for elderly patients.
  
  
  CONCLUSIONS
  The use of outcome-based benchmarking harbors significant potential for trauma quality improvement. Evaluations of aggregate TC performance may not adequately reflect the care provided to the elderly injured. Elderly trauma patients may warrant special attention in the context of ongoing quality improvement programs.
authors.affiliation: Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. barbara.haas@utoronto.ca
authors.forename: Barbara
authors.initials: B
authors.lastname: Haas
authors.forename: David
authors.initials: D
authors.lastname: Gomez
authors.forename: Wei
authors.initials: W
authors.lastname: Xiong
authors.forename: Najma
authors.initials: N
authors.lastname: Ahmed
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D019985:Benchmarking; D015331:Cohort Studies; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008875:Middle Aged; D012189:Retrospective Studies; D014193:Trauma Centers / Q000458:organization & administration*; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy*; D055815:Young Adult