Frequency of adoption of practice management guidelines at trauma centers

Use of performance reports among trauma medical directors and programme managers in the American College of Surgeons' Trauma Quality Improvement Program: a qualitative analysis

BACKGROUND

The American College of Surgeons' Trauma Quality Improvement Program (TQIP) provides trauma centres with performance reports on their processes and outcomes of care relative to their peers. This study explored how performance reports are used by trauma centre leaders to engage in performance improvement and perceived barriers to use.

STUDY DESIGN

Qualitative focus group study with trauma medical directors (TMDs) and trauma programme managers (TPMs) in US trauma centres. Consistent with qualitative descriptive analysis, data collection and interpretation were inductively and iteratively completed. Major themes were derived using a constant comparative technique.

RESULTS

Six focus groups were conducted involving 22 TMDs and 22 TPMs. Three major themes were captured: (1) technical uses of performance reports; (2) cultural uses of performance reports; (3) opportunities to enhance the role and value of TQIP. First, technical uses included using reports to assess data collection procedures, data quality and areas of poor performance relative to peers. In this domain, barriers to report use included not trusting others' data quality and challenges with report interpretation. Second, reports were used to influence practice change by fostering inter-specialty discussions, leveraging resources for quality improvement, community engagement and regional collaboratives. Perceived lack of specialist engagement was viewed as an impediment in this domain. Lastly, identified opportunities for TQIP to support report use involved clarifying the relationship between verification and performance reports, and increasing partnerships with nursing associations.

CONCLUSION

Trauma centre improvement leaders indicated practical and social uses of performance reports that can affect intention and ability to change. Recommendations to optimise programme participation include a focus on data quality, adequate resource provision and enhanced support for regional collaboratives.

The impact of individual physicians on outcomes after trauma: is it the system or the surgeon?

BACKGROUND

Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma.

METHODS

Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size.

RESULTS

There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon.

CONCLUSIONS

At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management.