Comparison of Hospital Mortality Rates After Burn Injury in New York State: A Risk-Adjusted Population-Based Observational Study
Department of Surgery, University of Vermont, Colchester, Vermont 05446, USA. The Journal of trauma
(Impact Factor: 2.96).
05/2011; 71(4):1040-7. DOI: 10.1097/TA.0b013e318217866f
Severity-adjusted mortality is an unequivocal measure of burn care success. Hospitals can be compared on this metric using administrative data because information required for calculating statistically adjusted risk of mortality is routinely collected on hospital admission.
The New York State Department of Health provided information on all 13,113 thermally injured patients hospitalized at 1 of 194 hospitals between 2004 and 2008. We compared hospital survival rates using a random effects logistic model of mortality that incorporated age and several predictors that were present on admission and captured as International Classification of Diseases-9 codes: burn surface area, inhalation injury, three measures of physiologic compromise, and four medical comorbidities. Hospitals were compared on the adjusted odds of death and the number of excess deaths.
Overall mortality was 3.2%. Nine high-volume hospitals (>100 patients/year) cared for 83% of patients with burn injuries. Overall variability of the odds of mortality among these high-volume centers was modest (median odds ratio=1.2) and we found little evidence for differences in the adjusted odds of mortality. A secondary analysis of the 185 low-volume hospitals that cared for 2,235 patients disclosed only 24 deaths. When examined in aggregate, these hospitals had better than predicted risk-adjusted mortality; a logical explanation is judicious case selection.
Administrative hospital discharge data are extensive and comparably enough collected to allow comparison of the performance of burn centers. Risk-adjusted models show that patients have statistically indistinguishable risk-adjusted odds of mortality regardless of which hospital in New York State cared for them.
Available from: Moustafa Elmasry
- "It therefore served as an excellent base and a source of inspiration for the present work. Our aim was to evaluate the predictive value of the sum of age and TBSA% (the Baux score as it is used in the present study), compared with a selection of other more advanced models for the prediction of mortality after burns, and to find out whether data from a five-year period  from a single burn centre is enough to obtain significant differences in SMR. We also wanted to discuss in depth the value of the variables included in the different models. "
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ABSTRACT: Standardised Mortality Ratio (SMR) based on generic mortality predicting models is an established quality indicator in critical care. Burn-specific mortality models are preferred for the comparison among patients with burns as their predictive value is better. The aim was to assess whether the sum of age (years) and percentage total body surface area burned (which constitutes the Baux score) is acceptable in comparison to other more complex models, and to find out if data collected from a separate burn centre are sufficient for SMR based quality assessment. The predictive value of nine burn-specific models was tested by comparing values from the area under the receiver-operating characteristic curve (AUC) and a non-inferiority analysis using 1% as the limit (delta). SMR was analysed by comparing data from seven reference sources, including the North American National Burn Repository (NBR), with the observed mortality (years 1993-2012, n=1613, 80 deaths). The AUC values ranged between 0.934 and 0.976. The AUC 0.970 (95% CI 0.96-0.98) for the Baux score was non-inferior to the other models. SMR was 0.52 (95% CI 0.28-0.88) for the most recent five-year period compared with NBR based data. The analysis suggests that SMR based on the Baux score is eligible as an indicator of quality for setting standards of mortality in burn care. More advanced modelling only marginally improves the predictive value. The SMR can detect mortality differences in data from a single centre.
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To analyze trends in incidence and treatment of thermal injuries over the last two decades.
We retrospectively reviewed our local single center database of patients with thermal injuries admitted to the burn intensive care unit (BICU) of the Cologne-Merheim Medical Center (University Hospital of Witten/Herdecke). The cohort was divided into two groups according to the decade of admission and the epidemiology and clinical course of the patient sample admitted during the period 1991-2000 (n=911) was compared to that of 2001-2010 (n=695).
The following variables were significantly different in the bivariate analysis: mean age (39.8 years vs. 44.0 years), burn size of total body surface area (23.2% vs. 18.0%) and size of 3rd degree burns (9.6% vs. 14.9%). The incidence of inhalation injury was significantly lower in the last decade (33.3% vs. 13.7%) and was associated with a shorter duration of mechanical ventilation (10.8 days vs. 8.5 days). The ABSI-score as an indicator of burn severity declined in the second period (6.3 vs. 6.0) contributing partially to the decline of BICU length of stay (19.1 days vs. 18.8 days) and to the mortality rate decrease (18.6% vs. 15.0%).
The severity of burn injuries during the last two decades declined, probably reflecting the success of prevention campaigns. Concerning mortality, the chance of dying for a given severity of injury has decreased.
Available from: Andreas Becker
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