Lucky number 13: Association between center-specific chest wall stabilization volumes and patient outcomes

Abstract

BACKGROUND:Chest wall stabilization (CWS) improves outcomes for patients with chest wall injury (CWI). We hypothesized that patients treated at centers with higher annual CWS volumes experience superior outcomes. METHODS:A retrospective study of adults with acute CWI undergoing surgical stabilization of rib or sternal fractures within the 2019 Trauma Quality Improvement Program database, excluding those with 24-hour mortality or any Abbreviated Injury Scale body region of six, was conducted. Hospitals were grouped in quartiles by annual CWS volume. Our primary outcome was a composite of in-hospital mortality, ventilator-associated pneumonia, acute respiratory distress syndrome, sepsis, and unplanned intubation or intensive care unit readmission. Regression was controlled for age, sex, Injury Severity Scale, flail chest, medical comorbidities, and Abbreviated Injury Scale chest. We performed cut-point analysis and compared patient outcomes from high-and low-volume centers. RESULTS:We included 3,207 patients undergoing CWS at 430 hospitals with annual volumes ranging from 1 to 66. There were no differences between groups in age, sex, or Injury Severity Scale. Patients in the highest volume quartile (Q4) experienced significantly lower rates of the primary outcome (Q4, 14%; Q3, 18.4%; Q2, 17.4%; Q1, 22.1%) and significantly shorter hospital and intensive care unit lengths of stay. Q4 versus Q1 had lower adjusted odds of the primary outcome (odds ratio, 0.58; 95% confidence interval, 0.43-0.80). An optimal cut point of 12.5 procedures annually was used to define high-and low-volume centers. Patients treated at high-volume centers experienced significantly lower rates of the primary composite outcome, in-hospital mortality, and deep venous thrombosis with shorter lengths of stay and higher rates of home discharge. CONCLUSION:Center-specific CWS volume is associated with superior in-hospital patient outcomes. These findings support efforts to establish CWI centers of excellence. Further investigation should explore the impact of center-specific volume on patient-reported outcomes including pain and postdischarge quality of life.

Surgical stabilization of rib fractures for flail chest: Analysis of center-based variability in practice and outcomes

“…We chose a threshold of 12 cases/year to define a high-volume center based on previous studies demonstrating improved outcomes at centers that met this criterion. 7…”

“…While strong associations between SSRF and improved patient outcomes were seen in previous observational studies, results of randomized controlled trials have not been consistent. 7,8,[11][12][13][14]33 These discrepant results raise concern for residual confounding in observational studies, since patients anticipated to have a positive outcome may have been more likely to undergo SSRF. Our analysis' use of an instrumental variable analysis mitigates this concern as in this approach patients are putatively "pseudorandomized" to receive SSRF based on the tendencies of the hospital at which they are treated.…”

“…We included the following covariates in each model: age, sex, race/ethnicity, insurance status, number of comorbidities, presence of severe brain, abdominal or spinal injury, shock on presentation, interfacility transfer, ISS, hospital teaching status, trauma center level, center size (number of beds), high-volume center (>12 SSRF procedures annually), mechanism of injury and year of admission. We chose a threshold of 12 cases/year to define a high-volume center based on previous studies demonstrating improved outcomes at centers that met this criterion 7 …”

“…Over the past two decades, a growing body of evidence has developed in support of surgical stabilization of rib fractures (SSRF). 7,8 Large observational studies have demonstrated strong associations between SSRF and improved mortality, which has led to increasingly liberal selection criteria for the procedure. 8 The Chest Wall Injury Society and Eastern Association of the Surgery of Trauma both recommend SSRF in the presence of a flail segment.…”

“…Conservative management has historically been the cornerstone of management of flail chest. Over the past two decades, a growing body of evidence has developed in support of surgical stabilization of rib fractures (SSRF) 7,8 . Large observational studies have demonstrated strong associations between SSRF and improved mortality, which has led to increasingly liberal selection criteria for the procedure 8 .…”