title: Then we all fall down: fall mortality by trauma center level.
abstract: Ground-level falls (GLFs) are the predominant mechanism of injury in US trauma centers and accompany a spectrum of comorbidities, injury severity, and physiologic derangement. Trauma center levels define tiers of capability to treat injured patients. We hypothesized that risk-adjusted observed-to-expected mortality (O:E) by trauma center level would evaluate the degree to which need for care was met by provision of care.
  
  
  
  This retrospective cohort study used National Trauma Data Bank files for 2007-2014. Trauma center level was defined as American College of Surgeons (ACS) level I/II, ACS III/IV, State I/II, and State III/IV for within-group homogeneity. Risk-adjusted expected mortality was estimated using hierarchical, multivariable regression techniques.
  
  
  
  Analysis of 812,053 patients' data revealed the proportion of GLF in the National Trauma Data Bank increased 8.7% (14.1%-22.8%) over the 8 y studied. Mortality was 4.21% overall with a three-fold increase for those aged 60 y and older versus younger than 60 y (4.93% versus 1.46%, P < 0.001). O:E was lowest for ACS III/IV, (0.973, 95% CI: 0.971-0.975) and highest for State III/IV (1.043, 95% CI: 1.041-1.044).
  
  
  
  Risk-adjusted outcomes can be measured and meaningfully compared among groups of trauma centers. Differential O:E for ACS III/IV and State III/IV centers suggests that factors beyond case mix alone influence outcomes for GLF patients. More work is needed to optimize trauma care for GLF patients across the spectrum of trauma center capability.
authors.affiliation: Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas.
authors.forename: Daniel
authors.initials: D
authors.lastname: Roubik
authors.affiliation: Department of Surgery, Chandler Regional Medical Center, Chandler, Arizona. Electronic address: adcookmd@gmail.com.
authors.forename: Alan D
authors.initials: AD
authors.lastname: Cook
authors.affiliation: Department of Surgery, Chandler Regional Medical Center, Chandler, Arizona.
authors.forename: Jeanette G
authors.initials: JG
authors.lastname: Ward
authors.affiliation: Department of Surgery, Chandler Regional Medical Center, Chandler, Arizona.
authors.forename: Kristina M
authors.initials: KM
authors.lastname: Chapple
authors.affiliation: Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Sheldon
authors.initials: S
authors.lastname: Teperman
authors.affiliation: Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Melvin E
authors.initials: ME
authors.lastname: Stone
authors.affiliation: Department of Surgery, Trauma and Acute Care Surgery, Lancaster General Hospital, Lancaster, Pennsylvania.
authors.forename: Brian
authors.initials: B
authors.lastname: Gross
authors.affiliation: Department of Surgery, Chandler Regional Medical Center, Chandler, Arizona.
authors.forename: Forrest O
authors.initials: FO
authors.lastname: Moore
mesh_terms: D000058:Accidental Falls / Q000401:mortality*; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: Comparative assessment; Ground-level fall; Outcomes; Risk adjustment; Trauma center level