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Attribution: whose complication is it?
Jason Murry1, Greg Hambright, Nimesh Patel
1From the Department of Surgery, Methodist Dallas Medical Center, Dallas, Texas.
Insights
Attributing complications in trauma care is often inaccurate. A refined process involving physician input is crucial for correct assignment of responsibility and improved patient outcomes.
Area of Science:
- Trauma Surgery
- Healthcare Quality Improvement
- Patient Safety
Background:
- Accurate attribution of medical complications is essential for quality improvement programs like accountable care organizations.
- Traditional attribution to the admitting physician may misidentify responsibility, particularly in complex trauma cases with multiple providers.
- Existing methods for attributing complications in trauma patients are hypothesized to be inadequate.
Purpose of the Study:
- To evaluate the adequacy of traditional complication attribution methods in trauma patients.
- To compare traditional attribution with a refined method involving trauma and accountable care organization leadership.
- To identify the impact of different surgical services on complications in trauma care.
Main Methods:
- A retrospective review of all trauma admissions over a 12-month period, excluding single-system trauma.
- Analysis of the trauma database for injury mechanisms, complications, and readmissions.
- Complications were attributed by trauma and accountable care organization directors and compared to hospital-assigned attributions.
Main Results:
- Of 1,019 reviewed trauma patients, 73 experienced 125 complications.
- Traditional attribution assigned all complications to acute care surgery.
- The refined method attributed complications to neurosurgery (36%), acute care surgery (34%), and orthopedic surgery (22%).
- Orthopedic surgery was also implicated in most unexpected readmissions (6 of 7).
Conclusions:
- Traditional complication attribution in trauma care is inadequate and can lead to significant misattribution.
- A critical review process with physician input is necessary to refine complication attribution.
- Accurate attribution is vital for fair physician comparison and effective quality improvement in trauma care.
Background:
To improve quality, programs such as accountable care organizations need to determine the part of the health care system most "responsible" for a complication. This is referred to as attribution. This provides a framework to compare physicians for patients and third-party payers. Traditionally, the attribution of complications has been to the admitting physician. This may misidentify the physician "responsible" for the complication. This is especially difficult in trauma patients who have multiple providers. We hypothesized that the current mechanism for attributing complications in trauma patients is inadequate and will need to be modernized.
Methods:
All trauma admissions during a 12-month period were reviewed. Patients with single-system trauma were excluded. We reviewed our trauma database for mechanism of injury, complications, and readmissions. The trauma director and the medical director of our accountable care organizations reviewed all complications and attributed them to the appropriate health care provider. These were compared with the hospital decisions using the traditional definition.
Results:
The trauma service had 1,526 admissions. After exclusions, 1,019 patients were reviewed. One hundred twenty-five complications occurred in 73 patients. Using the traditional definition, the acute care surgery service was assigned all 125 complications. Using the trauma director and medical director method, the neurosurgical attending accounted for 36% (45 of 125) of complications. The acute care surgery attending was responsible for 34% (43 of 125) of complications, and orthopedic surgery was identified as the causative factor in 22% (27 of 125). The remaining 8% (10 of 125) were attributed to various other services. Seven patients had unexpected readmissions. Most (6 of 7) of these were related to orthopedics.
Conclusion:
Hospital complications are now being assigned to individual surgeons. Which physician is responsible for each complication will be a controversial matter. Without a critical review process with physician input, up to two thirds of complications could be attributed incorrectly. The attribution process needs to be refined.
Level Of Evidence:
Epidemiologic study, level IV.
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