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Home > Blogs > Trauma Research Blog > The Survival Measurement and Reporting Trial for Trauma (SMARTT): Background and Study Design.

PubMed ID: 20068485
J Trauma. 2010 Jan 9. [Epub ahead of print]
Authors: Glance LG, Osler TM, Dick AW, Mukamel DB, Meredith W.

Abstract:

BACKGROUND:: This report describes a project funded by the Agency for Healthcare Research and Quality to evaluate the impact of providing hospitals with nonpublic report cards on trauma outcomes. The Survival Measurement and Reporting Trial for Trauma explores the feasibility of using the National Trauma Data Bank as a platform for measuring and improving trauma outcomes. METHODS:: We identified a cohort of 125 hospitals in the National Trauma Data Bank with annual hospital volumes of 250 or more trauma cases meeting specific minimum criteria for data quality. The performance of hospitals in this cohort was evaluated using hierarchical logistic regression model. The effect of each hospital on trauma mortality was captured by a shrinkage coefficient, which is exponentiated to yield an adjusted odds ratio. This adjusted odds ratio represents the likelihood that a trauma patient treated at a specific hospital is more or less likely to die compared with a patient treated at an "average" hospital. RESULTS:: The initial hospital cohort includes 125 hospitals and 157,045 patients admitted in 2006. Most hospitals are either level I (36%) or level II (34%) trauma centers. Patients admitted to the worst-performing hospitals were at least 50% more likely to die than patients admitted to the average hospital, after adjusting for injury severity. CONCLUSION: The initial findings of this trial suggest that there is significant variability in trauma mortality across centers caring for injured patients after adjusting for differences in patient casemix. This variation in risk-adjusted mortality presents an opportunity for improvement. The Survival Measurement and Reporting Trial for Trauma study is designed to test the hypothesis that nonpublic report cards can lead to improved population mortality for injured patients. The results of this study may have substantial implications in the future design and implementation of a national effort to report and improve trauma outcomes in the United States.

Notes & Commentary:

This wide variability in outcomes at different hospitals is mirrored by other studies of injury care at individual institutions.   The Trauma Audit & Research Network iregularly collates this data for hospitals in England & Wales:

TARN trauma outcomes
(Source)

What is more concerning is that, unlike the UK figures, the hospitals in this study are mainly trauma centres and therefore should be meeting designated performance standards in order to maintain their trauma centre status.  It'd be interesting to see if there is similar variability between hospitals accredited under American College of Surgeons criteria for designation, rather than state or local criteria.

There are problems with this form of modelling.  Hospital's whose case mix varies from the national average may have skewed results (positively or negatively).  Additionally the relationship between statistical modelling of unexpected deaths or survivors has not yet been validated against assessment of the quality of clinical care.

Interesting also is that these are non-reported data.  TARN data is available to the general public, so you can see how your local hospital performs compared to the national average.  Here's part of our page from the Royal London Hospital.

Royal London Hospital TARN outcomes

There's nothing like public opinion to make hospitals up their game.

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