Centers for Medicare and Medicaid services quality indicators do not correlate with risk-adjusted mortality at trauma centers.
ABSTRACT The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital compliance with evidence-based processes of care as quality indicators. We hypothesized that compliance with CMS quality indicators would correlate with risk-adjusted mortality rates in trauma patients.
A previously validated risk-adjustment algorithm was used to measure observed-to-expected mortality ratios (O/E with 95% confidence interval) for Level I and II trauma centers using the National Trauma Data Bank data. Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Score >or=3) were included (127,819 patients). Compliance with CMS quality indicators in four domains was obtained from Hospital Compare website: acute myocardial infarction (8 processes), congestive heart failure (4 processes), pneumonia (7 processes), surgical infections (3 processes). For each domain, a single composite score was calculated for each hospital. The relationship between O/E ratios and CMS quality indicators was explored using nonparametric tests.
There was no relationship between compliance with CMS quality indicators and risk-adjusted outcomes of trauma patients.
CMS quality indicators do not correlate with risk-adjusted mortality rates in trauma patients. Hence, there is a need to develop new trauma-specific process of care quality indicators to evaluate and improve quality of care in trauma centers.
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ABSTRACT: Object Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. Methods This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. Results The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). Conclusions Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.Journal of Neurosurgery 01/2014; · 3.15 Impact Factor
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ABSTRACT: To examine the association between hospital self-reported compliance with the National Quality Forum patient safety practices and trauma outcomes in a nationally representative sample of level I and level II trauma centers. Retrospective cohort study using the Nationwide Inpatient Sample. Level I and level II trauma centers. Trauma patients. Multivariate logistic regression models were estimated to examine the association between clinical outcomes (in-hospital mortality and hospital-associated infections) and the National Quality Forum patient safety practices. We controlled for patient demographic characteristics, injury severity, mechanism of injury, comorbidities, and hospital characteristics. The total score on the Leapfrog Safe Practices Survey was not associated with either mortality (adjusted odds ratio [aOR], 0.92; 95% confidence interval [CI], 0.79-1.06) or hospital-associated infections (1.03; 0.82-1.29). Full implementation of computerized physician order entry was not associated with reduced mortality (aOR, 1.03; 95% CI, 0.75-1.42) or with a lower risk of hospital-associated infections (0.94; 0.57-1.56). Full implementation of intensive care unit physician staffing was also not predictive of mortality (aOR, 1.13; 95% CI, 0.90-1.28) or of hospital-associated infections (1.04; 0.76-1.42). In this nationally representative sample of level I and level II trauma centers, we were unable to detect evidence that hospitals reporting better compliance with the National Quality Forum patient safety practices had lower mortality or a lower incidence of hospital-associated infections.Archives of surgery (Chicago, Ill.: 1960) 10/2011; 146(10):1170-7. · 4.32 Impact Factor
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ABSTRACT: Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data. Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data. There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.Journal of the American College of Surgeons 02/2012; 214(5):756-68. · 4.50 Impact Factor