title: The effect of dead-on-arrival and emergency department death classification on risk-adjusted performance in the American College of Surgeons Trauma Quality Improvement Program.
abstract: BACKGROUND
  The American College of Surgeons' Trauma Quality Improvement Program is focused on identifying variations in outcomes across trauma centers for the purposes of performance improvement. In previous analyses, patients who died in the emergency department were excluded. We investigated the effect of inclusion and exclusion of emergency department (ED) deaths (dead on arrival [DOA] and died in ED [DIE]) on analyses of overall risk-adjusted trauma center performance.
  
  
  METHODS
  Data for patients admitted to 65 Trauma Quality Improvement Program hospitals during the 2009 calendar year was used. A logistic regression model was developed to estimate risk-adjusted mortality. Trauma centers were then ranked based on their observed-to-expected (O/E) mortality ratio with 90% confidence intervals (CIs) and classified by outlier status: low outliers/high performers had a 90% CI for O/E mortality ratio of less than 1, and high outliers/low performers had a 90% CI for O/E mortality ratio of greater than 1. Changes in outlier status, rank, and quartile were examined with and without DOA and DIE patients included in the analyses to discern the impact of such exclusions on overall risk-adjusted center-specific performance.
  
  
  RESULTS
  Thirty-one trauma centers (48%) reported no DOA patients in 2009, while 6 centers (9%) reported more than 10. Of 224 patients, 14 (6.2%) had a documented time of death of more than 30 minutes after ED arrival despite being recorded as DOA. Forty-one trauma centers (63%) changed rank by three positions or less. Ten trauma centers changed their quartile ranking by a single quartile, but no centers were found to change quartile rank more than one quartile. Changes in outlier status occurred for 6 trauma centers (9%).
  
  
  CONCLUSIONS
  The relative frequency of patients classified as DOA varies greatly between trauma centers. Misclassification of patients as DOA occurs. Inclusion of ED deaths in risk-adjusted analysis of mortality results in a small but insignificant change in predicting the outcome results of a trauma center. This change is less than the rate of finding a center to be a high or low outlier by chance alone using the 90% CI. Inclusion of DOA and DIE patients in risk-adjusted analysis of mortality is appropriate and eliminates the bias introduced by exclusion of ED deaths owing to misuse of the DOA classification.
  
  
  METHODS
  Prognostic/epidemiologic study, level III.
authors.affiliation: Department of Surgery, University of Virginia, Charlottesville, Virginia 22908, USA. calland@virginia.edu
authors.forename: James Forrest
authors.initials: JF
authors.lastname: Calland
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Young
authors.forename: Melanie L
authors.initials: ML
authors.lastname: Neal
authors.forename: Sandra
authors.initials: S
authors.lastname: Goble
authors.forename: Jonathan
authors.initials: J
authors.lastname: Abelson
authors.forename: John J
authors.initials: JJ
authors.lastname: Fildes
authors.forename: Mark R
authors.initials: MR
authors.lastname: Hemmila
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D020379:Risk Adjustment; D014481:United States; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D055815:Young Adult