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Derivation and validation of a quality indicator for 30-day unplanned hospital readmission to evaluate trauma care

Moore, Lynne PhD; Stelfox, Henry Thomas MD, MSc; Turgeon, Alexis F. MD, MSc; Nathens, Avery B. MD, PhD, MPH; Lavoie, André PhD; Bourgeois, Gilles MD; Lapointe, Jean MD

Journal of Trauma and Acute Care Surgery: May 2014 - Volume 76 - Issue 5 - p 1310–1316
doi: 10.1097/TA.0000000000000202
Original Articles

BACKGROUND Unplanned readmissions represent 20% of all admissions and cost $12 billion annually in the United States. Despite the burden of injuries for the health care system, no quality indicator (QI) based on readmissions is available to evaluate trauma care. The objective of this study was to derive and internally validate a QI for a 30-day unplanned hospital readmission to evaluate trauma care.

METHODS We performed a multicenter retrospective cohort study in a Canadian integrated provincial trauma system. We included adults admitted to any of the 57 provincial trauma centers between 2005 and 2010 (n = 57,524). Data were abstracted from the provincial trauma registry and linked to the hospital discharge database. The primary outcome was unplanned readmission to an acute care hospital within 30 days of discharge. Candidate risk factors were identified by expert consensus and selected for derivation of the risk adjustment model using bootstrap resampling. The validity of the QI was evaluated in terms of interhospital discrimination, construct validity, and forecasting.

RESULTS The risk adjustment model includes patient age, sex, the Injury Severity Score (ISS), region of the most severe injury, and 11 comorbid conditions. The QI discriminates well across trauma centers (coefficient of variation, 0.02) and is correlated with QIs that measure hospital performance in terms of clinical processes (r = −0.38), risk-adjusted mortality (r = 0.32), and complication rates (r = 0.38). In addition, performance in 2005 to 2007 was predictive of performance in 2008 to 2010 (r = 0.59).

CONCLUSION We have developed a QI based on risk-adjusted 30-day rates of unplanned readmission, which can be used to evaluate trauma care with routinely collected data. The QI is based on a comprehensive risk adjustment model with good internal and temporal validity and demonstrates good properties in terms of discrimination, construct validity, and forecasting. This research represents an essential step toward reducing unplanned readmission rates to improve resource use and patient outcomes following injury.

LEVEL OF EVIDENCE Prognostic study, level III.

From the Department of Social and Preventative Medicine (L.M., A.F.T.), and Axe Santé des Populations—Pratiques Optimales en Santé (Population Health—Practice-changing Research Unit) (L.M., A.F.T., A.L.), Traumatologie, Urgence, Soins intensifs (Trauma, Emergency, Critical Care Medicine), Centre de Recherche du Centre Hospitalier Universitaire de Québec (CHU de Québec, Hôpital de l’Enfant-Jésus), Université Laval, Quebec; and Institut national d’excellence en santé et en services sociaux (G.B., J.L.), Montréal, Québec; Department of Critical Care Medicine, Medicine and Community Health Sciences (H.T.), Institute for Public Health, University of Calgary, Calgary, Alberta; and Department of Surgery (A.B.N.), St. Michael’s Hospital, University of Toronto, Toronto, Canada.

Submitted: December 8, 2013, Revised: January 7, 2014, Accepted: January 22, 2014.

This study was supported by the Canadian Institutes of Health Research: New Investigator Award (H.T.S. and L.M.) and research grant (L.M., #110996) and Fonds de la Recherche du Québec—Santé: clinician-scientist award (A.F.T.).

Address for reprints: Lynne Moore, CHU de Québec Research Center (Enfant-Jésus Hospital), Axe Santé des Populations—Pratiques Optimales en Santé (Population Health—Practice-changing Research Unit), Traumatologie, Urgence, Soins intensifs (Trauma, Emergency, Critical Care Medicine), 1401, 18e rue, local H-012a, Québec, Quebec G1J 1Z4; email:

© 2014 Lippincott Williams & Wilkins, Inc.