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.
- [show abstract] [hide abstract]
ABSTRACT: Mortality rates vary across designated trauma centers (TC), even after controlling for injury severity. Retrospective analysis of state trauma registry data. Designated Level 1 and 2 TCs in 2003 in a large Southwestern state. Adult trauma patients (n = 18,584) treated at 15 designated Level 1 and 2 TCs. Risk-adjusted survival was calculated for each trauma center using logistic regression analysis to adjust for differences in age, sex, race, injury mechanism, and injury severity. The model was developed using half of the study population and validated in the remaining half. It was then applied to the entire study population, with inclusion of TC identification codes. Observed vs Expected survival ratios were then calculated for each TC. Adjusted odds ratios (OR) for survival at each TC were also calculated. Adjusted OR of survival were significantly different from crude OR at 6 of the 14 TCs, underscoring the importance of risk adjustment when performing quality comparisons. One TC performed significantly worse than the others, 8 achieved significantly better survival, and 5 performed the same as the referent. Observed vs Expected ratios demonstrated that one trauma center had significantly worse severity-adjusted outcomes, some were marginal, some performed as well as expected, and none performed better than expectations. Considerable variations in risk-adjusted mortality rates exist across similarly designated TCs. Such variability in outcomes may reflect variations in quality of care, and reasons for this discrepancy should be explored as the next step in the trauma care quality improvement process.Archives of surgery (Chicago, Ill.: 1960) 02/2009; 144(1):64-8. · 4.32 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Although not directly involved in designation per se, the American College of Surgeons (ACS) Committee on Trauma verification/consultation program in conjunction with has set the national standards for trauma care. This study analyzes the impact of a recent verification process on an academic health center. Performance improvement data were generated monthly from the hospital trauma registry. Forty-seven clinical indicators were reviewed. Three study periods were defined for comparative purposes: PRE (January, June, October 1997), before verification/consultation; CON (April 1999-October 1999), after reorganization; and VER (November 1999-September 2000), from consultation to verification. Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (< 120 minutes) improved in each study section (PRE, 21%; CON, 48%; VER, 76%). Enhanced nursing documentation correlated with improved clinical care such as early acquisition of head computed axial tomographic scans in neurologic injured patients (PRE, 66%; CON, 97%; VER, 95%). Intensive care unit length of stay (< 7 days) decreased (PRE, 87%; VER, 97.8%). Other transformations included increase in institutional morale with recognition of trauma excellence within the hospital and resurgence of the trauma research programs (60 institutional review board-approved projects). The ACS verification/consultation program had a positive influence on this developing academic trauma program. Preparation for ACS verification/consultation resulted in significant improvements in patient care, enhancement of institutional pride, and commitment to care of the injured patient.The Journal of trauma 11/2002; 53(5):811-6. · 2.35 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Selected care processes are increasingly being used to measure hospital quality; however, data regarding the association between hospital process performance and outcomes are limited. To evaluate contemporary care practices consistent with the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations, to examine how hospital performance varied among centers, to identify characteristics predictive of higher guideline adherence, and to assess whether hospitals' overall composite guideline adherence was associated with observed and risk-adjusted in-hospital mortality rates. An observational analysis of hospital care in 350 academic and nonacademic US centers of 64,775 patients enrolled in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) National Quality Improvement Initiative between January 1, 2001, and September 30, 2003, presenting with chest pain and positive electrocardiographic changes or cardiac biomarkers consistent with non-ST-segment elevation acute coronary syndrome (ACS). Use of 9 ACC/AHA class I guideline-recommended treatments and the correlation among hospitals' use of individual care processes as well as overall composite adherence rates. Overall, the 9 ACC/AHA guideline-recommended treatments were adhered to in 74% of eligible instances. There was modest correlation in hospital performance among the individual ACS process metrics. However, composite adherence performance varied widely (median [interquartile range] composite adherence scores from lowest to highest hospital quartiles, 63% [59%-66%] vs 82% [80%-84%]). Composite guideline adherence rate was significantly associated with in-hospital mortality, with observed mortality rates decreasing from 6.31% for the lowest adherence quartile to 4.15% for the highest adherence quartile (P<.001). After risk adjustment, every 10% increase in composite adherence at a hospital was associated with an analogous 10% decrease in its patients' likelihood of in-hospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.84-0.97; P<.001). A significant association between care process and outcomes was found, supporting the use of broad, guideline-based performance metrics as a means of assessing and helping improve hospital quality.JAMA The Journal of the American Medical Association 05/2006; 295(16):1912-20. · 29.98 Impact Factor