Inter‐hospital variation in surgical intensity for trauma admissions: A multicentre cohort study

Abstract

Background: Guidelines for injury care are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. We aimed to assess inter-hospital variation in surgical intensity for injury admissions and evaluate the correlation between hospital surgical intensity and mortality/complications. Methods: We included adults admitted for major trauma between 2006 and 2016 in a Canadian provincial trauma system. Analyses were stratified for orthopaedic (n = 16 887), neurological (n = 12 888) and torso injuries (n = 9816). Surgical intensity was quantified with the number of surgical procedures <72 hours. Inter-hospital variation was assessed with the intra-class correlation coefficient (ICC). We assessed the correlation between the risk-adjusted mean number of surgical procedures and risk-adjusted incidence of mortality and complications using Pearson correlation coefficients (r). Results: Moderate inter-hospital variation was observed for orthopaedic surgery (ICC = 14.0%) whereas variation was low for torso surgery (ICC = 2.7%) and neurosurgery (ICC = 0.8%). Surgical intensity was negatively correlated with hospital mortality for torso injury (r = −.32, P = .02) and neurotrauma (r = −.65, P = .08). A strong positive correlation was observed with hospital complications for orthopaedic injuries (r = .36, P = .006) whereas the opposite was observed for neurotrauma (r = −.71, P = .05). Conclusions: Results should be interpreted with caution as they may be a result of residual confounding. However, they may suggest that there are opportunities for quality improvement in surgical care for injury admissions, particularly for orthopaedic injuries. Moving forward, we should aim to prospectively evaluate adherence to guidelines on non-operative management and their impact on mortality and morbidity.

Low‐value injury care in the adult orthopaedic trauma population: A systematic review

“…First, we may have missed important low value practices that were not identified in the scoping review or suggested by clinical experts. For example, no practices related to surgical procedures were identified although significant variability in orthopaedic surgical intensity among trauma centres was reported in a recent study 92 . Second, by using a staged approach for the inclusion of studies with the most rigorous evidence, we may have missed some relevant studies.…”

“…For example, no practices related to surgical procedures were identified although significant variability in orthopaedic surgical intensity among trauma centres was reported in a recent study. 92 Second, by using a staged approach for the inclusion of studies with the most rigorous evidence, we may have missed some relevant studies. However, for practices with associated systematic reviews or RCTs, we also included studies with a lower level of evidence that were published more recently.…”

Low value Injury Care in the Adult Orthopaedic Trauma Population: A Systematic Review

“…For example, no practices related to surgical procedures were identified although significant variability in orthopedic surgical intensity among trauma centres was reported in a recent study. 92 Second, by using a staged approach for the inclusion of studies with the most rigorous evidence, we may have missed some relevant studies. However, for practices with associated systematic reviews or RCTs, we also included studies with a lower level of evidence that were published more recently.…”