The ability to objectively measure and compare the quality and long-term outcomes of trauma care nationwide will be imperative under the new health-care payment models that are evolving, UC Davis Institute for Population Health Improvement Director Kenneth W. Kizer told attendees of the Trauma Quality Improvement Program (TQIP) meeting of the American College of Surgeons last month.
Inconsistencies in the quality and capacity of the country’s trauma care systems require a comprehensive effort to define systems-level quality and outcomes standards, he said.
Kizer delivered the remarks during his keynote address to nearly 600 attendees at the TQIP national meeting in Phoenix on Nov. 18, providing a historical context and an overview of the quality of health care and trauma care nationally and making recommendations for trauma care in the emerging value-based health-care economy.
“There is compelling evidence that seriously injured persons are significantly more likely to survive if treated at trauma centers, compared to non-trauma centers. Yet more than a third of serious traumatic injuries occur in areas not having a designated trauma-care system,” Kizer said.
“Studies conducted during the past 10 years also have shown that many seriously injured persons are not treated at trauma centers even when their injuries occur within the catchment areas of designated trauma-care systems,” he said.
For example, a study of trauma care in California co-authored by Kizer in 2003, showed that only 56 percent of patients who were seriously injured within a designated trauma center’s catchment area received treatment in a trauma center. Other more recent studies have identified similar under-triage (an inappropriately low treatment priority level) of major trauma patients to trauma centers, he said.
“Under-triage of patients to trauma centers is especially a problem among older persons and among those with brain injuries,” said Kizer. “Unfortunately, our ability to understand why under-triage occurs so often is hampered by fragmentation in the systems of care, inadequate data management systems and lack of trauma care performance reporting by non-trauma center hospitals.”
“Under-triage of patients to trauma centers is especially a problem among older persons and among those with brain injuries. Unfortunately, our ability to understand why under-triage occurs so often is hampered by fragmentation in the systems of care, inadequate data management systems and lack of trauma care performance reporting by non-trauma center hospitals.”
— Kenneth W. Kizer
Another concern, Kizer said, is that too many trauma patients treated at designated trauma centers do not receive recommended care and that medical errors are more common among critically ill trauma patients.
To improve the national trauma care system, Kizer believes that systems-level performance measures need to be explicitly defined and validated, in addition to performance measures for trauma centers, and that trauma systems need to be assessed for their long-term outcomes.
“Assessing trauma-care quality has historically occurred at the local level using locally developed quality indicators,” Kizer said. “As a result, we have relatively little information about the quality of trauma care regionally or nationally. Despite the exemplary efforts of the American College of Surgeons Committee on Trauma, there still is no comprehensive national trauma care data bank, nor a common language or taxonomy for trauma-care quality improvement.”
Kizer noted that the lack of information is compounded by the proliferation of trauma centers – more than 200 new trauma centers have been designated since 2009 – and that there are ongoing questions about the net value of having so many designated trauma centers in light of the sizable expense of staffing and maintaining these specialized facilities.
“The trauma-care community needs to build upon its pioneering historical focus on evidence-based performance assessment and work with the National Quality Forum to establish a trauma-care quality improvement taxonomy and nationally endorsed performance measures that can be used for both internal quality improvement purposes and public reporting of quality,” he said. “In the emerging value-based health-care economy these efforts must have a national focus.”
Kizer also recommended that a concerted effort be made to:
- define high-quality trauma care for the several different types of major trauma
- conduct research to understand how values, culture, emotional climate and other components of a center’s ‘invisible architecture’ contribute to high-quality trauma care and how these factors can be replicated
- adopt a more systems-based and population-health approach to assessing the value of trauma care