Gomez David, Haas Barbara, Hemmila Mark, Pasquale Michael, Goble Sandra, Neal Melanie, Mann N Clay, Meredith Wayne, Cryer Henry G, Shafi Shahid, Nathens Avery B
Division of Trauma, Department of Surgery, Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
J Trauma. 2010 Nov;69(5):1037-41. doi: 10.1097/TA.0b013e3181f65387.
Trauma centers (TCs) vary in the inclusion of patients with isolated hip fractures (IHFs) in their registries. This inconsistent case ascertainment may have significant implications on the assessment of TC performance and external benchmarking efforts.
Data were derived from the National Trauma Data Bank (2007-8.1). We included patients (aged 16 years or older) with Injury Severity Score value ≥ 9 who were admitted to Level I and II TCs. To ensure data quality, we limited the study to TC that routinely reported comorbidities and Abbreviated Injury Scale codes. IHF were defined as patients, aged 65 years or older, injured as a result of falls, with Abbreviated Injury Scale codes for hip fracture and without other significant injuries. TCs were stratified according to their reported inclusion of IHF in their registry. Observed-to-expected mortality ratios were used to rank TC performance first with and then, without the inclusion of patients with IHF.
In total, 91,152 patients in 132 TCs were identified; 5% (n = 4,448) were IHF. The proportion of IHF per TC varied significantly, ranging from 0% to 31%. When risk-adjusted mortality was evaluated, excluding patients with IHF had significant effects: 37% (n = 49) of TCs changed their performance rank by ≥ 3 (range, 1-25) and 12% of centers changed their performance quintile. The greatest change in rank performance was evident in centers that routinely include IHF in their registries.
Given the fact that IHFs in the elderly significantly influence risk-adjusted outcomes and are variably reported by TCs, these patients should be excluded from subsequent benchmarking efforts.
创伤中心（TCs）在其登记册中纳入单纯性髋部骨折（IHFs）患者的情况各不相同。这种病例确定的不一致可能对创伤中心绩效评估和外部基准化努力产生重大影响。
数据来源于国家创伤数据库（2007 - 8.1）。我们纳入了入住一级和二级创伤中心、损伤严重程度评分值≥9分的16岁及以上患者。为确保数据质量，我们将研究局限于常规报告合并症和简明损伤定级代码的创伤中心。单纯性髋部骨折定义为65岁及以上因跌倒受伤、有髋部骨折简明损伤定级代码且无其他严重损伤的患者。创伤中心根据其登记册中报告的单纯性髋部骨折纳入情况进行分层。观察到的与预期的死亡率比值用于首先对创伤中心的绩效进行排名，然后在不纳入单纯性髋部骨折患者的情况下进行排名。
总共在132个创伤中心识别出91,152名患者；5%（n = 4,448）为单纯性髋部骨折患者。每个创伤中心的单纯性髋部骨折患者比例差异显著，范围从0%到31%。在评估风险调整后的死亡率时，排除单纯性髋部骨折患者有显著影响：37%（n = 49）的创伤中心绩效排名变化≥3（范围为1 - 25），12%的中心绩效五分位数发生变化。排名绩效变化最大的是那些在登记册中常规纳入单纯性髋部骨折患者的中心。
鉴于老年人的单纯性髋部骨折对风险调整后的结果有显著影响，且创伤中心对其报告存在差异这些患者应被排除在后续的基准化努力之外。
