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National Variation in Outcomes and Costs for Splenic Injury and the Impact of Trauma Systems: A Population-Based Cohort Study

Hamlat, Christian A. MD, MPH*,†; Arbabi, Saman MD, MPH*,†; Koepsell, Thomas D. MD, MPH*,‡,§; Maier, Ronald V. MD*,†; Jurkovich, Gregory J. MD*,†; Rivara, Frederick P. MD, MPH*,§,¶

doi: 10.1097/SLA.0b013e31823840ca
Original Articles

Objective: To measure national variation in splenectomy rates, mortality, and costs for hospitalized patients with splenic injury and the impact of state trauma systems on these outcomes.

Methods: Using the HCUP State Inpatient Database for 2001, 2004, and 2007, all patients hospitalized with splenic injury were identified from 19 participating states. Multivariate regression was performed to compare splenectomy rates, inpatient mortality, and costs between states. Inclusiveness of statewide trauma systems was categorized based on the proportion of hospitals designated as a trauma center.

Results: Of 33,131 patients, 26.2% underwent splenectomy, 6.1% died, and median hospital costs were $14,317. After adjusting for patient, injury, and hospital characteristics, there was a 1.7-fold variation (RR 1.67; 95% CI, 1.39–2.01) among the 19 states in rates of splenectomy. Adjusted inpatient mortality varied more than 2-fold between the highest and lowest states (RR 2.43; 95% CI, 1.76–3.37). Adjusted hospital costs varied over 60% between the highest and lowest states (cost ratio 1.61; 95% CI, 1.41–1.83). States with the most inclusive trauma systems had significantly lower splenectomy rate (RR 0.79; 95% CI, 0.68–0.92) and lower mortality (RR 0.71; 95% CI, 0.58–0.87), but similar hospital costs (CR 1.05; 95% CI, 0.95–1.16) compared to states with exclusive or no trauma systems.

Conclusions: Significant geographic variation in the management, outcome, and costs for splenic injury exists in the United States, and may reflect differences in quality of care. Inclusive trauma systems seem to improve outcomes without increasing hospital costs.

The HCUP State Inpatient Database (SID) was used to detect significant variation in a state-to-state comparison of management and outcomes for 33,131 hospitalized patients with splenic injury. After adjusting for patient, injury, and hospital factors, multivariate regression demonstrated up to a 1.7-fold difference in the use of splenectomy between states, 2.4-fold variation in mortality, and 1.7-fold variation in costs and a significant reduction in splenectomy use and mortality in states with the most inclusive trauma systems.

*Harborview Injury Prevention and Research Center; Departments of



§Health Services

Pediatrics, University of Washington and Harborview Medical Center, Seattle WA.

Reprints: Saman Arbabi, MD, MPH, FACS, Department of Surgery, Harborview Medical Center, 325 9th Ave, Box 359796, Seattle, WA 98104. E-mail:

Disclosure: None of the authors have any relevant financial disclosures for this study.

© 2012 Lippincott Williams & Wilkins, Inc.