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Evaluating a pediatric trauma program: effectiveness versus preventable death rate
D E Wesson1, J I Williams, L R Salmi
1Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Effectiveness (E) better assesses trauma program quality than preventable death rate (PDR). PDR is sensitive to patient case mix, not just care quality, impacting its reliability for evaluating trauma outcomes.
Area of Science:
- Trauma surgery
- Medical quality assessment
- Public health
Background:
- Evaluating trauma care quality is crucial for improving patient outcomes.
- Effectiveness (E) and preventable death rate (PDR) are metrics used to assess trauma program performance.
- Understanding the limitations of each metric is essential for accurate evaluation.
Purpose of the Study:
- To compare the effectiveness (E) and preventable death rate (PDR) in assessing trauma program performance over three years.
- To determine which metric, E or PDR, is more reliable for evaluating trauma care quality.
- To investigate the influence of patient case mix on PDR calculations.
Main Methods:
- Severely injured patients (Abbreviated Injury Score >= 4) were categorized as salvageable or nonsalvageable.
- Effectiveness (E) was calculated as the proportion of salvageable patients who survived.
- Preventable Death Rate (PDR) was calculated over three consecutive 1-year periods, analyzing deaths among salvageable patients.
Main Results:
- No significant difference in Effectiveness (E) was observed across the three study years.
- Preventable Death Rate (PDR) appeared to improve, but this was due to an increase in deaths among nonsalvageable patients.
- The number of deaths among salvageable patients decreased over the study period.
Conclusions:
- Effectiveness (E) provides a more stable and reliable measure of trauma program quality than PDR.
- Preventable Death Rate (PDR) is significantly influenced by patient case mix, limiting its utility as a sole quality indicator.
- Trauma program assessment should prioritize metrics like E that are less susceptible to variations in patient severity.
Abstract:
We compared effectiveness (E), the proportion of severely injured patients who were salvageable and survived, to the preventable death rate (PDR) over three consecutive 1-year periods. Severely injured patients were those with at least one injury with an Abbreviated Injury Score (AIS) of greater than or equal to 4. Those with one fatal injury (AIS greater than or equal to 6), a critical head injury (AIS greater than or equal to 5) apart from acute epidural hematoma, or massive multiple injuries (Injury Severity Score greater than 59) were considered nonsalvageable; the remainder were considered salvageable. In the first year, six of 74 salvageable patients died, in the second year five of 76, and in the third year one of 69. The PDR rates were 0.32 (6/19), 0.23 (5/22), and 0.06 (1/17), respectively. There was no significant difference in the E of our trauma program over the 3 years. The apparent improvement in PDR in the second and third years resulted from an increased number of deaths among nonsalvageable patients and fewer deaths among salvageable patients. This finding demonstrates that PDR is sensitive to case mix and not just quality of care, and confirms the superiority of E over PDR for assessing a trauma program.