Introduction
Trauma patients have greater rates of complications than general surgery patients;
however, existing surgical pay-for-performance (P4P) guidelines have yet to be adapted
for trauma care. To better understand whether current P4P measures are applicable
to trauma, this study used nationally representative data to determine the mortality
and attributable costs associated with the presence or absence of both Centers for
Medicare and Medicaid Services–recognized complications (urinary tract infections,
surgical site infections [SSIs], and pneumonia) and other major trauma-related complications.
Methods
Trauma admissions were extracted from the 2008 National Inpatient Sample using primary
ICD-9-CM diagnosis codes (range, 800–905, 910–939, 950–958). Patients aged 18–65 years
with a duration of hospital stay of >3 days and isolated complications were included.
To account for differences in patient factors, coarsened-exact matching was used to
create comparable cohorts of adult patients with and without complications. Multivariable
regression was then performed within matched groups to determine differences in cost
and mortality, controlling for hospital characteristics and wage index.
Results
Of 493,372 trauma patients, 78,156 met inclusion criteria, of whom 24.4% had an isolated
complication. Consistent with surgical P4P guidelines, SSI, urinary tract infections,
and pneumonia had the greatest incidence (8.0%, 5.2%, and 4.4%, respectively); however,
mortality in matched patients with complications was greatest for sepsis (odds ratio
[OR], 9.76; 95% CI, 3.84–24.80), myocardial infarction (MI; OR, 4.21; 95% CI, 1.70–10.44)
and stroke (OR, 3.02; 95% CI, 1.40–6.52). Excess costs associated with a complication
were similarly greatest for sepsis (relative cost, 1.84; 95% CI, 1.57–2.17), followed
by acute respiratory distress syndrome (ARDS; relative cost, 1.84; 95% CI, 1.7–1.99)
and MI (relative cost, 1.73; 95% CI, 1.51–1.99).
Conclusion
Consideration of attributable costs and mortality suggest that additional complications
have a substantial impact among trauma patients, beyond the conditions used in general
surgery P4P guidelines. These aspects of trauma should be prioritized to capture the
influence of complications in trauma that the incidence of frequent but less costly
conditions overlooks.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- National health expenditure fact sheet [Internet]. Centers for Medicare & Medicaid Services, Baltimore2014 ([updated May 6; cited 2014 Sep 5]. Available from:)
- Incidence and lifetime costs of injuries in the United States.Inj Prev. 2006; 12: 212-218
- The five most costly conditions, 1996 and 2006: estimates for the U.S. civilian noninstitutionalized population.Medical Expenditure Panel Survey; Agency for Healthcare Research and Quality, Rockville (MD)2009
- Pay-for-performance: will the latest payment trend improve care?.JAMA. 2007; 297: 740-744
- Pay for performance in critical care: a position paper by the Society of Critical Care Medicine.Pay for Performance Task Force of the Advocacy Committee; Society of Critical Care Medicine, Mount Prospect (IL)2009
- National cost of trauma care by payer status.J Surg Res. 2013; 184: 444-449
- Patient safety indicators (PSI) parameter estimates version 4.5 (with corrected PSI #90).Agency for Healthcare Research and Quality, Rockville (MD)2013
- Pay for performance in commercial HMOs.N Engl J Med. 2006; 355: 1895-1902
- Process versus outcome indicators in the assessment of quality of health care.Int J Quality Health Care. 2001; 13: 475-480
- Acute hospital costs of trauma in the United States: implications for regionalized systems of care.J Trauma. 1990; 30: 1096-1101
- The complications of trauma and their associated costs in a Level I trauma center.Arch Surg. 1997; 132: 920-924
- Hospital costs associated with surgical complications: a report from the private-sector national surgical quality improvement program.J Am Coll Surg. 2004; 199: 531-537
- Hospital quality and the cost of inpatient surgery in the United States.Ann Surg. 2012; 255: 1-5
- The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients.Ann Surg. 2011; 254: 907-913
- Linking compensation to quality—Medicare payments to physicians.N Engl J Med. 2005; 353: 870-872
- Females have fewer complication and lower mortality following trauma than similarly injured males: a risk adjusted analysis of adults in the National Trauma Data Bank.Surgery. 2009; 146: 308-315
- Comparative effectiveness of inhospital resuscitation at a French trauma center and matched patients in the United States.Ann Surg. 2013; 258: 178-183
- Association between race and age in survival after trauma.JAMA Surgery. 2014; 149: 642-647
- Exploring robust methods for evaluating treatment and comparison groups in chronic care management programs.Popul Health Manag. 2013; 18: 35-45
- Deaths from heart failure: using coarsened exact matching to correct cause-of-death statistics.Popul Health Metr. 2010; 8: 6
- 2006 Medicare physician payment update and claims processing—questions and answers.J Okla Med Assoc. 2006; 99: 136
- Paying physicians for high-quality care.N Engl J Med. 2004; 350: 406-410
- Paying physicians for quality: evidence and themes from the field.Jt Comm Qual Patient Saf. 2006; 32: 443-451
- Position statement of the American College of Physicians on pay-for-performance.Subcommittee on Pay-for-Performance, Institute of Medicine, Philadelphia2005
- Principles for the construct of pay-for-performance programs.Joint Commission (JACHO), Washington (DC)2004
- The Affordable Care Act, section by section [Internet]. US Department of Health & Human Services, Washington (DC)2014 ([updated Sep 6; cited 2014 Sep 6]. Available from:)
- Regional variations in cost of trauma care in the United States: who is paying more?.J Trauma Acute Care Surg. 2012; 73: 516-522
- Complications and costs after high-risk surgery: where should we focus quality improvement initiatives?.J Am Coll Surg. 2003; 196: 671-678
- Who pays for poor surgical quality? Building a business case for quality improvement.J Am Coll Surg. 2006; 202: 933-937
- Rates and patterns of death after surgery in the United States, 1996 and 2006.Surgery. 2012; 151: 171-182
Article info
Publication history
Published online: April 18, 2015
Accepted:
February 27,
2015
Footnotes
Conflicts of Interest and Source of Funding: None of the authors have financial disclosures or conflicts of interest.
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
