Hospital Quality and Performance of a Complex Surgical Procedure after Traumatic Digit Amputation

Traumatic digit amputations are prevalent injuries that have long-term disabling consequences. Although replantation after traumatic digit amputation is a complex procedure, the aesthetic, functional, and long-term economic benefits of replantation render it preferable to revision amputation when clinically indicated. The authors adapted the Donabedian quality-of-care conceptual framework to examine the association between hospital outcome quality measured by observed-to-expected mortality ratio and the treatment received after traumatic digit amputation. The authors hypothesized that the probability of undergoing replantation is higher in hospitals with lower observed-to-expected mortality ratios.

Data from 106 qualified Level I and II trauma centers included in the 2007 to 2012 National Trauma Data Bank were used to estimate hospital-specific observed-to-expected mortality ratio. The authors then used a two-level logistic hierarchical model, adjusting for patient, clinical, and hospital characteristics, to examine whether observed-to-expected mortality ratio, as one of the commonly used hospital quality measures, is a predictor of the treatment received for 4169 patients with traumatic digit amputation.

Compared with trauma centers with high observed-to-expected mortality ratios, the probability of undergoing replantation was substantially higher in trauma centers with low observed-to-expected mortality ratios (OR, 5.09; 95 percent CI, 2.51 to 10.30; p < 0.001). Seeking care at hospitals with more than 400 beds increased the probability of digit replantation (OR, 2.08; 95 percent CI, 1.08 to 4.01; p = 0.029). Having no insurance decreased the odds of undergoing replantation (OR, 0.70; 95 percent CI, 0.53 to 0.91; p = 0.009).

Hospital observed-to-expected mortality ratio was the greatest predictor of undergoing replantation after digit amputation injury. The observed-to-expected mortality ratio, as an outcome measure of hospital quality, is an important predictor of the treatment received.