title: Beyond incidence: Costs of complications in trauma and what it means for those who pay.
abstract: BACKGROUND
  Trauma patients have greater rates of complications than general surgery patients; however, existing surgical pay-for-performance (P4P) guidelines have yet to be adapted for trauma care. To better understand whether current P4P measures are applicable to trauma, this study used nationally representative data to determine the mortality and attributable costs associated with the presence or absence of both Centers for Medicare and Medicaid Services-recognized complications (urinary tract infections, surgical site infections [SSIs], and pneumonia) and other major trauma-related complications.
  
  
  METHODS
  Trauma admissions were extracted from the 2008 National Inpatient Sample using primary ICD-9-CM diagnosis codes (range, 800-905, 910-939, 950-958). Patients aged 18-65 years with a duration of hospital stay of >3 days and isolated complications were included. To account for differences in patient factors, coarsened-exact matching was used to create comparable cohorts of adult patients with and without complications. Multivariable regression was then performed within matched groups to determine differences in cost and mortality, controlling for hospital characteristics and wage index.
  
  
  RESULTS
  Of 493,372 trauma patients, 78,156 met inclusion criteria, of whom 24.4% had an isolated complication. Consistent with surgical P4P guidelines, SSI, urinary tract infections, and pneumonia had the greatest incidence (8.0%, 5.2%, and 4.4%, respectively); however, mortality in matched patients with complications was greatest for sepsis (odds ratio [OR], 9.76; 95% CI, 3.84-24.80), myocardial infarction (MI; OR, 4.21; 95% CI, 1.70-10.44) and stroke (OR, 3.02; 95% CI, 1.40-6.52). Excess costs associated with a complication were similarly greatest for sepsis (relative cost, 1.84; 95% CI, 1.57-2.17), followed by acute respiratory distress syndrome (ARDS; relative cost, 1.84; 95% CI, 1.7-1.99) and MI (relative cost, 1.73; 95% CI, 1.51-1.99).
  
  
  CONCLUSIONS
  Consideration of attributable costs and mortality suggest that additional complications have a substantial impact among trauma patients, beyond the conditions used in general surgery P4P guidelines. These aspects of trauma should be prioritized to capture the influence of complications in trauma that the incidence of frequent but less costly conditions overlooks.
authors.affiliation: Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham & Women's Hospital, Boston, MA; Department of Surgery, Brigham & Women's Hospital, Boston, MA. Electronic address: ahhaider@partners.org.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.affiliation: The Massachusetts Institute of Technology Sloan School of Management, Cambridge, MA.
authors.forename: Sonia
authors.initials: S
authors.lastname: Gupta
authors.affiliation: Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham & Women's Hospital, Boston, MA; Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Cheryl K
authors.initials: CK
authors.lastname: Zogg
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Mehreen T
authors.initials: MT
authors.lastname: Kisat
authors.affiliation: Center for Surgery and Public Health, Harvard Medical School and Harvard School of Public Health, Brigham & Women's Hospital, Boston, MA; Department of Surgery, Brigham & Women's Hospital, Boston, MA.
authors.forename: Alexander
authors.initials: A
authors.lastname: Schupper
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: David T
authors.initials: DT
authors.lastname: Efron
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.affiliation: Department of Surgery, Howard University College of Medicine, Washington, DC.
authors.forename: Augustine C
authors.initials: AC
authors.lastname: Obirieze
authors.affiliation: Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.affiliation: Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronvost
authors.affiliation: Department of Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: MacKenzie
authors.affiliation: Department of Surgery, Howard University College of Medicine, Washington, DC.
authors.forename: Edward E
authors.initials: EE
authors.lastname: Cornwell
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012052:Reimbursement, Incentive / Q000191:economics*; D014481:United States; D014947:Wounds and Injuries / Q000150:complications* / Q000191:economics*; D055815:Young Adult