Wednesday, March 01, 2006

Practice Makes Perfect V ......
From the January 26th issue of the New England Journal of Medicine:A National Evaluation of the Effect of Trauma-Center Care on Mortality. The abstract:
Background Hospitals have difficulty justifying the expense of maintaining trauma centers without strong evidence of their effectiveness. To address this gap, we examined differences in mortality between level 1 trauma centers and hospitals without a trauma center (non-trauma centers).

Methods Mortality outcomes were compared among patients treated in 18 hospitals with a level 1 trauma center and 51 hospitals non-trauma centers located in 14 states. Patients 18 to 84 years old with a moderate-to-severe injury were eligible. Complete data were obtained for 1104 patients who died in the hospital and 4087 patients who were discharged alive. We used propensity-score weighting to adjust for observable differences between patients treated at trauma centers and those treated at non-trauma centers.

Results After adjustment for differences in the case mix, the in-hospital mortality rate was significantly lower at trauma centers than at non–trauma centers (7.6 percent vs. 9.5 percent; relative risk, 0.80; 95 percent confidence interval, 0.66 to 0.98), as was the one-year mortality rate (10.4 percent vs. 13.8 percent; relative risk, 0.75; 95 percent confidence interval, 0.60 to 0.95). The effects of treatment at a trauma center varied according to the severity of injury, with evidence to suggest that differences in mortality rates were primarily confined to patients with more severe injuries.

Conclusions Our findings show that the risk of death is significantly lower when care is provided in a trauma center than in a non-trauma center and argue for continued efforts at regionalization.
One caveat the authors put forth:
Caution is needed in generalizing our results. Because the NSCOT is a study of the effectiveness of trauma centers in urban and suburban America, our results cannot readily be extrapolated to rural areas of the country. In addition, we did not address the relative effectiveness of intermediate levels (2, 3, or 4) of trauma care.
Ask and ye shall receive. From the Journal of the American College of Surgeons:Relationship Between American College of Surgeons Trauma Center Designation and Mortality in Patients with Severe Trauma (Injury Severity Score > 15):
We studied the association of the American College of Surgeons (ACS) trauma center designation and mortality in adult patients with severe trauma (Injury Severity Score > 15). ACS designation of trauma centers into different levels requires substantial financial and human resources commitments. There is very little work published on the association of ACS trauma center designation and outcomes in severe trauma.

Study design
National Trauma Data Bank study including all adult trauma admissions (older than 14 years of age) with Injury Severity Score (ISS) > 15. The relationship between ACS level of trauma designation and survival outcomes was evaluated after adjusting for age, mechanism of injury, ISS, hypotension on admission, severe liver trauma, aortic, vena cava, iliac vascular, and penetrating cardiac injuries.

A total of 130,154 patients from 256 trauma centers met the inclusion criteria. Adjusted mortality in ACS-designated Level II centers and undesignated centers was notably higher than in Level I centers (adjusted odds ratio, 1.14; 95% CI, 1.09−120; p <> 15 treated in ACS Level I trauma centers have considerably better survival outcomes than those treated in ACS Level II centers
The unadjusted mortality rates were better at level 1 centers versus level 2 centers (14.9 vs. 15.4 percent). But adjustments by logistic regression were required to achieve statistical significance.
So level 1 centers do better with particularly nasty injuries (severe liver trauma, aortic, vena cava, iliac vascular, and penetrating cardiac injuries). However level 1 centers are hard to come by. Viewing the listing here, one notices the absence of verified ACS trauma centers of ANY level in Alabama, Florida, Georgia, South Carolina, or Tennessee.
Currently in Georgia legislature is forming a study committee to work on establishing a statewide trauma network. Safe America has launched an awareness program that includes public service announcements


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