Several indicators of quality pediatric trauma care have been proposed including low in-hospital mortality, nonoperative management of blunt splenic injury, use of intracranial pressure monitors after severe traumatic brain injury, and craniotomy for children with severe subdural or epidural hematomas. It is not known if center-level performance is consistent in each of these metrics. We evaluated whether center performance in one area of quality predicted similar performance in other areas of quality.
We reviewed patients 18 years or younger who were hospitalized with an injury Abbreviated Injury Scale (AIS) score of 2 or greater from 2010 to 2011 at trauma centers (n = 150) participating in the Trauma Quality Improvement Program. Random-intercept multilevel modeling was used to generate center-specific adjusted odds ratios for each quality indicator. We evaluated correlations between center-specific adjusted odds ratios of each quality indicator and mortality using Pearson correlation coefficients. Weighted κ statistics were used to test multiple pairwise agreements between indicators and the overall agreement across all four indicators.
Among 84,880 children identified for analysis, 3,603 had blunt splenic injury, 3,503 had severe traumatic brain injury, and 1,286 had an epidural or subdural hematoma. A negative correlation between center-specific odds of mortality and craniotomy was present (Pearson correlation coefficient, −0.18; p = 0.03). There were no significant correlations between other indicators. Although κ statistics showed slight agreement for the pairwise comparison of odds of mortality and craniotomy (0.17, 0.02–0.32), there was no agreement for all other pairwise comparisons or the overall comparison of all four indicators (−0.01, −0.07 to 0.06).
Our findings demonstrate a lack of concordance in center-level performance across the four pediatric trauma quality indicators we evaluated. These findings should be considered by pediatric trauma quality improvement initiatives to allow for comprehensive measurement of hospital quality as opposed to benchmarking using a single indicator.
From the Division of General Surgery (C.S., P.J.K., P.W.W., A.B.N.), Department of Surgery, and Institute of Health Policy, Management, and Evaluation (C.S., P.J.K., D.C.S., A.B.N.), University of Toronto; Sunnybrook Research Institute (P.J.K., W.X., A.B.N.), and Division of General Surgery (P.J.K., A.B.N.), Department of Surgery, and Department of Critical Care Medicine (D.C.S.), Sunnybrook Health Sciences Center; Division of General and Thoracic Surgery (P.W.W.), Hospital for Sick Children; and Li Ka Shing Knowledge Institute (A.B.N.), St. Michael’s Hospital, Toronto, Ontario, Canada; Division of General and Thoracic Surgery (R.S.B.), Children’s National Health System, Washington, District of Columbia; and Division of General and Thoracic Surgery (M.L.N.), Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania.
Submitted: December 1, 2014, Revised: March 24, 2015, Accepted: March 25, 2015.
This work was presented as a poster at the 28th Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 13–17, 2015, in Lake Buena Vista, Florida. Furthermore, this work was selected as the winner of the Canadian Resident Trauma paper competition on September 20, 2014.
The funding sources had no role in the study design; data collection, analysis, and interpretation; or decision for publication. The opinions, results, and conclusions of this study are those of the authors alone.
Address for reprints: Chethan Sathya, MD, Division of General Surgery, Department of Surgery, University of Toronto, Sunnybrook Health Sciences, 2075 Bayview Ave, Suite D574, Toronto, Ontario, M4N 3M5, Canada; email: firstname.lastname@example.org.