title: Benchmarking trauma center performance in traumatic brain injury: the limitations of mortality outcomes.
abstract: BACKGROUND
  Trauma centers (TCs) generally use mortality to gauge performance. However, differences in mortality outcomes might reflect different approaches or philosophies toward end-of-life care. We postulate that discharge home (DH) as a proxy for functional outcome may be a more useful measure of quality and may have significant implications on the assessment of TC performance and external benchmarking efforts.
  
  
  METHODS
  Data were derived from the National Trauma Data Bank (2007-2009). We included patients (18 years or older) with isolated, severe blunt head injuries who were admitted to Level I and Level II TCs. Observed-to-expected (O/E) mortality ratios were calculated and used to rank TC performance by mortality and then DH. Concordance between performance measures was calculated using a weighted kappa statistic.
  
  
  RESULTS
  In total, 19,705 patients in 240 TCs were identified. Crude mortality ranged from 4% to 60%, whereas rates of DH ranged from 3% to 66%. When O/E ratios for mortality were evaluated, five centers were identified as high performers. Of these five centers, only two were also high performers for DH. The concordance of outlier status and correlation across O/E ratios between mortality and DH high performers was 0.16 (poor).
  
  
  CONCLUSIONS
  Centers that are characterized as high performers when evaluating mortality are not high performers for functional outcome as evaluated by DH. DH may provide an alternative way of assessing quality of care delivered to patients with traumatic brain injury.
  
  
  METHODS
  Care management study, level III.
authors: Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario, Canada. sunjay.sharma@gmail.com
authors: Sunjay
authors: S
authors: Sharma
authors: Charles
authors: C
authors: de Mestral
authors: Marvin
authors: M
authors: Hsiao
authors: David
authors: D
authors: Gomez
authors: Barbara
authors: B
authors: Haas
authors: James
authors: J
authors: Rutka
authors: Avery B
authors: AB
authors: Nathens
mesh_terms: D000328:Adult; D000368:Aged; D019985:Benchmarking / Q000706:statistics & numerical data*; D001930:Brain Injuries / Q000401:mortality*; D016208:Databases, Factual; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014193:Trauma Centers