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Interfacility variation in trauma care costs without differences in mortality: A national retrospective cohort study
Troy Coaston1, Saad Mallick, Zihan Gao
1Center for Advanced Surgical & Interventional Technology (T.C., S.M., Z.G., S.H., G.P., Z.T., P.B.), David Geffen School of Medicine at University of California, Los Angeles, California; Department of Surgery (A.T., P.B.), David Geffen School of Medicine at University of California, Los Angeles, California.
Background:
Trauma care costs have risen nationally, yet whether higher inpatient spending translates into better outcomes remains unclear. We evaluated contemporary interhospital variation in trauma hospitalization costs and mortality and assessed whether higher-cost hospitals achieved lower risk-adjusted mortality.
Methods:
This was a retrospective cohort study of hospitalizations entailing traumatic injury identified in the 2016-2021 National Inpatient Sample. The primary outcomes were interfacility variation in hospitalization costs and mortality. Estimated hospitalization costs were derived using cost-to-charge ratios and inflation-adjusted to 2021 dollars. Hierarchical linear and logistic regression models were used to quantify hospital-attributable variation in costs and mortality via intraclass correlation coefficients. Costs were log-transformed for modeling, and hospitals in the highest decile of risk-adjusted costs were designated High-Cost Centers (HCCs). Multivariable models assessed associations of HCC status with inpatient mortality and length of stay (LOS). A subgroup analysis examined patients with severe injuries [Injury Severity Score (ISS) ≥15].
Results:
Among an estimated 10,661,449 admissions, 8.1% were at HCC. Intraclass correlation coefficient analysis demonstrated that hospital effects accounted for 13% of the variation in inpatient costs but only 3% of the variation in mortality. HCC treated a higher-acuity case mix (ISS: 5 [1-16] vs. 3 [1-9], |SMD|=0.22) and were more commonly metropolitan teaching centers (50.2 vs. 37.4%, p<0.001). After adjustment, HCC status was not associated with inpatient mortality (adjusted odds ratio, 1.02; 95% CI, 0.98-1.07) but was associated with longer LOS (β, 0.77; 95% CI, 0.64-0.90). In severe injuries (ISS ≥15), hospital effects explained 12% of cost variation and 2% of mortality variation, and HCC status remained unassociated with mortality (adjusted odds ratio, 0.95; 95% CI, 0.90-1.00).
Conclusions:
Trauma hospitalization costs vary substantially across US hospitals, whereas hospital-level variation in mortality is minimal. High-cost hospitals cared for higher-acuity patients and had longer LOS, yet did not demonstrate improved risk-adjusted survival, highlighting opportunities to improve value through system-level efficiency efforts.
Level Of Evidence:
Prognostic/Epidemiological; Level III.