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Characteristics of ACS-verified Level I and Level II trauma centers: A study linking trauma center verification review data and the National Trauma Data Bank of the American College of Surgeons Committee on Trauma

Shafi, Shahid MD, MPH; Barnes, Sunni PhD; Ahn, Chul PhD; Hemilla, Mark R. MD; Cryer, H. Gill MD; Nathens, Avery MD; Neal, Melanie MS; Fildes, John MD

Journal of Trauma and Acute Care Surgery: October 2016 - Volume 81 - Issue 4 - p 735–742
doi: 10.1097/TA.0000000000001136
Original Articles

BACKGROUND The Trauma Quality Improvement Project of the American College of Surgeons (ACS) has demonstrated variations in trauma center outcomes despite similar verification status. The purpose of this study was to identify structural characteristics of trauma centers that affect patient outcomes.

METHODS Trauma registry data on 361,187 patients treated at 222 ACS-verified Level I and Level II trauma centers were obtained from the National Trauma Data Bank of ACS. These data were used to estimate each center's observed-to-expected (O-E) mortality ratio with 95% confidence intervals using multivariate logistic regression analysis. De-identified data on structural characteristics of these trauma centers were obtained from the ACS Verification Review Committee. Centers in the lowest quartile of mortality based on O-E ratio (n = 56) were compared to the rest (n = 166) using Classification and Regression Tree (CART) analysis to identify institutional characteristics independently associated with high-performing centers.

RESULTS Of the 72 structural characteristics explored, only 3 were independently associated with high-performing centers: annual patient visits to the emergency department of fewer than 61,000; proportion of patients on Medicare greater than 20%; and continuing medical education for emergency department physician liaison to the trauma program ranging from 55 and 113 hours annually. Each 5% increase in O-E mortality ratio was associated with an increase in total length of stay of one day (r = 0.25; p < 0.001).

CONCLUSIONS Very few structural characteristics of ACS-verified trauma centers are associated with risk-adjusted mortality. Thus, variations in patient outcomes across trauma centers are likely related to variations in clinical practices.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the Office of the Chief Quality Officer (S.S., S.B.), Baylor Scott & White Health, Dallas, Texas; Department of Clinical Science (C.A.), UT Southwestern Medical Center, Dallas, Texas; Department of Surgery (M.R.H.), University of Michigan Health System, Ann Arbor, Michigan; Trauma and Emergency Services Department (H.G.C.), University of California, Los Angeles, California; Division of General Surgery (A.N.), Sunnybrook Health Sciences Centre; Department of Surgery, University of Toronto, Toronto, Canada; American College of Surgeons National Trauma Data Bank (M.N.), Chicago, Illinois; and Department of Surgery (J.F.), University of Nevada School of Medicine, Las Vegas, Nevada.

Submitted: October 21, 2015, Revised: March 16, 2016, Accepted: April 12, 2016, Published online: May 27, 2016.

Address for reprints: Shahid Shafi, MD, MPH, Baylor Scott & White Health, 8080N Central Expressway, Suite 900 Dallas, TX 75206; email:

© 2016 Lippincott Williams & Wilkins, Inc.