Quantifying the Drivers of Survival: A Matched Cohort Study of Trauma Center-Level Differences

Tertiary trauma centers (levels I and II) offer comprehensive care and are equipped to manage complex injuries. Trauma patients treated at tertiary centers have better survival outcomes. However, the specific interventions driving this advantage remain unknown. This study aimed to identify interventions contributing to differences in short-term mortality between tertiary trauma centers (TTCs) and nontertiary trauma centers (NTCs).

This was a retrospective cohort study using Trauma Quality Improvement Program data reported between 2017 and 2022. Propensity score matching (1:1, exact) based on injury severity measures paired 12,423 major trauma patients aged 18-54 y, directly admitted from the injury scene to TTCs, with an equal number treated at NTCs. The Oaxaca-Blinder decomposition method was then used to quantify interventions explaining the difference in 7-d mortality between TTCs and NTCs.

In the propensity-matched sample, the 7-d in-hospital mortality was significantly higher at NTCs (7.04%) than tertiary centers (5.65%), with a risk ratio of 1.25 (95% confidence interval [CI]: 1.13-1.37; P = 0.001). The mortality difference of 1.39 percentage points was explained by a higher proportion of massive blood transfusion (45.67%; 95% CI: 27.98-63.35), airway procedure (44.40%; 95% CI 29.06-49.75), hemorrhage control via laparotomy (30.13%; 95% CI: 16.70-43.56), and other cardiac procedures (4.58%; 95% CI: 2.94-6.21), collectively accounting for 55% of the observed mortality difference.

This study suggests that, for similarly injured patients, massive transfusion, airway management, hemorrhage control via laparotomy, and other cardiac procedures performed at TTCs explain most of the observed survival benefit for patients treated at TTCs.