Schubert Finn D, Gabbe Laura J, Bjurlin Marc A, Renson Audrey
Department of Clinical Research, New York University Langone Hospital-Brooklyn, Brooklyn, NY, USA.
Department of Urology, New York University Langone Hospital-Brooklyn, Brooklyn, NY, USA.
Injury. 2019 Jan;50(1):186-191. doi: 10.1016/j.injury.2018.09.038. Epub 2018 Sep 21.
Traumatic injury is a leading cause of deaths worldwide, and designated trauma centers are crucial to preventing these. In the US, trauma centers can be designated as level I-IV by states and/or the American College of Surgeons (ACS), reflecting the resources available for care. We examined whether state- and ACS-verified facilities of the same level (I-IV) had differences in mortality, complications, and disposition, and whether differences varied by center level.
Using all admissions reported to the National Trauma Data Bank 2010-2015, we estimated risk ratios for the association between current ACS verification (vs. state designation) and patient mortality and complications, adjusting for trauma level and facility, injury, and demographic characteristics. We tested the interaction between trauma level and ACS verification, stratifying by trauma level in the presence of significant statistical interaction.
Overall, patients admitted to ACS-verified vs state-designated facilities had similar adjusted mortality risk [RR 1.00; 95% CI 0.91-1.03] and lower risk of discharge to intermediate care facilities [RR 0.58; 95% CI 0.44 to 0.78]. However, Level III and IV facilities had lower adjusted mortality risk when ACS-verified, with much lower mortality risk in ACS-verified Level IV facilities [RR 0.25; 95% CI 0.12 to 0.54].
Findings suggest that while outcomes are similar between ACS-verified and state-designated Level I and II centers, state-designated Level III and particularly Level IV centers show poorer outcomes relative to their ACS-verified counterparts. Further research could explore mechanisms for these differences, or inform potential changes to state designation processes for lower-level centers.
创伤性损伤是全球死亡的主要原因之一，指定的创伤中心对于预防此类死亡至关重要。在美国，创伤中心可由各州和/或美国外科医师学会（ACS）指定为I - IV级，这反映了可用于治疗的资源情况。我们研究了相同级别（I - IV级）的经州和ACS认证的机构在死亡率、并发症和处置方面是否存在差异，以及这些差异是否因中心级别而异。
利用2010 - 2015年向国家创伤数据库报告的所有入院病例，我们估计了当前ACS认证（相对于州指定）与患者死亡率和并发症之间关联的风险比，并对创伤级别、机构、损伤和人口统计学特征进行了调整。我们测试了创伤级别与ACS认证之间的相互作用，在存在显著统计相互作用时按创伤级别进行分层。
总体而言，入住经ACS认证机构与州指定机构的患者调整后的死亡风险相似[风险比1.00；95%置信区间0.91 - 1.03]，且转至中级护理机构的风险较低[风险比0.58；95%置信区间0.44至0.78]。然而，III级和IV级机构在经ACS认证时调整后的死亡风险较低，经ACS认证的IV级机构的死亡风险更低[风险比0.25；95%置信区间0.12至0.54]。
研究结果表明，虽然经ACS认证的I级和II级中心与州指定的中心在结局方面相似，但州指定的III级中心，尤其是IV级中心相对于经ACS认证的同类中心表现出较差的结局。进一步的研究可以探索这些差异的机制，或为较低级别中心的州指定流程的潜在变化提供信息。
