SAN FRANCISCO – Trauma centers are ranked on the basis of in-hospital mortality rates, but pay-for-performance programs will benchmark them based on in-hospital complications – and there’s not good concordance between the two measures, a study of data from 248 trauma centers suggests.
Investigators used data on 449,743 patients aged 16 years or older who had blunt/penetrating injuries and an Injury Severity Score of 9 or higher to generate risk-adjusted, observed-to-expected mortality rates for each trauma center They ranked each facility based on mortality rate as a high-performing, average, or low-performing center and used complication rates to rank them again based on observed-to-expected morbidity ratios.
Only 40% of centers received the same benchmark using these two measures, Dr. Zain G. Hashmi and his associates reported at the annual meeting of the American Association for the Surgery of Trauma.
Dividing each performance ranking into quintiles, the two rankings diverged by at least one quintile for 79% of trauma centers. Only 21% were assigned the same quintile rank in the mortality benchmarking as in the morbidity benchmarking. A two-quintile divergence in rankings was noted in 21%, and a three-quintile difference in 23%, said Dr. Hashmi, a research fellow at Johns Hopkins University, Baltimore.
Overall, the unadjusted mortality rate was 7% and the morbidity rate was 10%. The most frequent complications were pneumonia in 4%, acute respiratory distress syndrome in 2%, and deep venous thrombosis in 2%.
The complications used for the morbidity benchmarking included pneumonia, deep venous thrombosis, acute respiratory distress syndrome, acute renal failure, sepsis, pulmonary embolism, decubitus ulcer, surgical site infection, myocardial infarction, cardiac arrest, unplanned intubation, and stroke.
The Centers for Medicare and Medicaid Services is implementing pay-for-performance programs in the public health sector nationwide under the Affordable Care Act to incentivize high quality of care and penalize low quality of care. The programs may soon be extended to trauma care, which could incorrectly penalize centers that are the best performers based on mortality benchmarks, he said.
"We need to develop more appropriate measures of trauma quality before pay-for-performance" programs come to trauma centers, perhaps using multiple quality indicators such as mortality, length of stay, complications, and failure to rescue, he said.
Data for the study came from the National Trauma Data Bank for 2007-2010.
Dr. Hashmi reported having no financial disclosures.
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