Impact of hospital volume on mortality in patients with severe torso injury

Trauma Patient Volume and the Quality of Care: A Scoping Review

BACKGROUND

Healthcare stakeholders in the Netherlands came to an agreement in 2022 to deal with present and future challenges in healthcare. Among others, this agreement contains clear statements regarding the concentration of trauma patients, including the minimal required number of annual severe trauma patients for Major Trauma Centers. This review investigates the effects of trauma patient volumes on several domains of the quality of healthcare.

METHODS

PubMed was searched; studies published during the last 10 years reporting quantitative data on trauma patient volume and quality of healthcare were included. Results were summarized and categorized into the quality domains of healthcare.

RESULTS

Seventeen studies were included with a total of 1,517,848 patients. A positive association between trauma patient volume and survival was observed in 11/13 studies with adjusted analyses. Few studies addressed other quality domains: efficiency (n = 5), safety (n = 2), and time aspects of care (n = 4). None covered people-centeredness, equitability, or integrated care.

CONCLUSIONS

Most studies showed a better survival of trauma patients when treated in high-volume hospitals compared to lower volume hospitals. However, the ideal threshold could not be determined. The association between trauma volume and other domains of the quality of healthcare remains unclear.

Operative trauma volume is not related to risk-adjusted mortality rates among Pennsylvania trauma centers

BACKGROUND

Higher center-level operative volume is associated with lower mortality after complex elective surgeries, but this relationship has not been robustly demonstrated for operative trauma. We hypothesized that trauma centers in Pennsylvania with higher operative trauma volumes would have lower risk-adjusted mortality rates than lower volume institutions.

METHODS

We queried the Pennsylvania Trauma Outcomes Study database (2017-2019) for injured patients 18 years or older at Level I and II trauma centers who underwent an International Classification of Diseases, Tenth Revision (ICD-10), procedure code -defined operative procedure within 6 hours of admission. The primary exposure was tertile of center-level operative volume. The primary outcome of interest was inpatient mortality. We entered factors associated with mortality in univariate analysis (age, injury severity, mechanism, physiology) into multivariable logistic regression models with tertiles of volume accounting for center-level clustering. We conducted secondary analyses varying the form of the association between the volume and mortality to including dichotomous and fractional polynomial models.

RESULTS

We identified 3,650 patients at 29 centers meeting the inclusion criteria. Overall mortality was 15.9% (center-level range, 6.7-34.2%). Operative procedure types were cardiopulmonary (7.3%), vascular (20.1%), abdominopelvic (24.3%), and multiple (48.3%). The mean annual operative volume over the 3 years of data was 10 to 21 operations for low-volume centers, 22 to 47 for medium-volume centers, and 47 to 158 for high-volume centers. After controlling for patient demographics, physiology, and injury characteristics, there was no significant difference in mortality between highest and lowest tertile centers (odds ratio, 0.92; confidence interval, 0.57-1.49). Secondary analyses similarly demonstrated no relationship between center operative volume and mortality in key procedure subgroups.

CONCLUSION

In a mature trauma system, we found no association between center-level operative volume and mortality for patients who required early operative intervention for trauma. Efforts to standardize the care of seriously injured patients in Pennsylvania may ensure that even lower-volume centers are prepared to generate satisfactory outcomes.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Impact of Hospital Volume on the Outcomes of Renal Trauma Management

Background

Some health care systems have set up referral trauma centers to centralize expertise to improve trauma management. There is scant and controversial evidence regarding the impact of provider’s volume on the outcomes of trauma management.

Objective

To evaluate the impact of hospital volume on the outcomes of renal trauma management in a European health care system.

Design, setting, and participants

A retrospective multicenter study, including all patients admitted for renal trauma in 17 French hospitals between 2005 and 2015, was conducted.

Intervention

Nephrectomy, angioembolization, or nonoperative management.

Outcome measurements and statistical analysis

Four quartiles according to the caseload per year: low volume (eight or fewer per year), moderate volume (nine to 13 per year), high volume (14–25/yr), and very high volume (≥26/yr). The primary endpoint was failure of nonoperative management defined as any interventional radiology or surgical procedure needed within the first 30 d after admission.

Results and limitations

Of 1771 patients with renal trauma, 1704 were included. Nonoperative management was more prevalent in the very-high- and low-volume centers (p = 0.02). In a univariate analysis, very high hospital volume was associated with a lower risk of nonoperative management failure than low (odds ratio [OR] = 0.54; p = 0.05) and moderate (OR = 0.48; p = 0.02) hospital volume. There were fewer nephrectomies in the high- and very-high-volume groups (p = 0.003). In a multivariate analysis, very high volume remained associated with a lower risk of nonoperative management failure than low (OR = 0.48; p = 0.04) and moderate (OR = 0.42; p = 0.01) volume. Study limitations include all the shortcomings inherent to its retrospective multicenter design.

Conclusions

In this multicenter study, management of renal trauma varied according to hospital volume. There were lower rates of nephrectomy and failure of nonoperative management in very-high-volume centers. These results raise the question of centralizing the management of renal trauma, which is currently not the case in our health care system.

Patient summary

In this study, management of renal trauma varied according to hospital volume. Very-high-volume centers had lower rates of nephrectomy and failure of nonoperative management.

Current status of trauma surgery at a Japanese prefectural academic institute: improved organization in a regional prefecture

PURPOSES

Balancing scheduled surgery and trauma surgery is difficult with a limited number of surgeons. To address the issues and systematize education, we analyzed the current situation and the effectiveness of having a trauma team in the ER of a regional hospital.

METHODS

This retrospective study analyzed the demographics, traumatic variables, procedures, postoperative morbidities, and outcomes of 110 patients who underwent trauma surgery between 2012 and 2019. The trauma team was established in 2016 and our university hospital Emergency Room (ER) opened in 2012.

RESULTS

Blunt trauma accounted for 82% of the trauma injuries and 39% of trauma victims were transported from local centers to our institute. The most frequently injured organs were in the digestive tract and about half of the interventions were for hemostatic surgery alone. Concomitant treatments for multiple organ injuries were performed in 31% of the patients. The rates of postoperative severe complications (over Clavien-Dindo IIIb) and mortality were 10% and 13%, respectively. Fourteen (12.7%) of 24 patients who underwent damage-control surgery died, with multiple organ injury being the predominant cause of death.

CONCLUSION

Systematic education or training of medical students and general surgeons, as well as the co-operation of the team at the regional academic institute, are necessary to overcome the limited human resources and save trauma patients.

Volume-outcome relationship in severe operative trauma surgery: A retrospective cohort study using a Japanese nationwide administrative database

BACKGROUND

The relationship between hospital case volume and in-hospital mortality, often referred to as the volume-outcome relationship, has been studied in various types of surgery. Despite its usefulness in policymaking, it has not been reported in operative trauma surgery. This study aimed to identify the volume-outcome relationship in severe operative trauma surgery.

METHODS

A retrospective cohort study was conducted using a risk adjustment method based on the International Classification of Diseases 10th Revision Codes in a Japanese nationwide administrative database. Patients discharged from July 1, 2010, to March 31, 2015, who underwent severe operative trauma surgery, defined as having a mortality rate equal to or greater than 10%, were included. A logistic regression model with random effects was used for analysis. Annual hospital case volume was categorized into 4 groups: <6 (reference group), 6 to 11, 12 to 17, and ≥18. Subgroup analysis on head and torso trauma surgery was conducted.

RESULTS

The study population consisted of 18,382 patients from 964 hospitals. Overall mortality was 19.7%. The adjusted odds ratio for mortality did not reduce significantly in the higher hospital case volume category. Subgroup analysis revealed that the adjusted odds ratio reduced significantly in the subgroup of torso surgery (<6 cases/y [reference] vs ≥6 cases/y; adjusted odds ratio, 0.55; 95% confidence interval, 0.42-0.73), but not in the operative head trauma surgery subgroup.

CONCLUSION

A volume-outcome relationship was not identified in severe operative trauma surgery but was observed in the operative torso trauma surgery subgroup.