EBQ:A national evaluation of the effect of trauma-center care on mortality

Complete Journal Club Article

MacKenzie E. et el.. "A national evaluation of the effect of trauma-center care on mortality". NEJM. 2006. 354(4):366-78.
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Clinical Question

Is there a difference in mortality between trauma patients treated at level 1 trauma centers vs non-trauma centers?

Conclusion

The risk of death is significantly lower for patients treated at a trauma center than at non-trauma center.

Major Points

• This was the first national-level study to demonstrate that trauma center care reduces mortality compared to non-trauma center care
• Patients treated at Level I trauma centers had a 25% lower odds of death compared to those treated at non-trauma centers
• The mortality benefit was most pronounced in patients with severe injuries (ISS >15)
• Results provided strong evidence supporting regionalized trauma care systems and triage protocols to direct severely injured patients to trauma centers

Study Design

Prospective cohort study.

Population

Inclusion Criteria

• Age 18-84
• Arrived alive at the hospital
• At least one injury with a score ≥3 on the Abbreviated Injury Scale

Exclusion Criteria

• Arrived at hospital without vital signs and pronounced dead within 30 min of arrival
• Sought treatment >24 hr after injury
• Age ≥65 years with first listed diagnosis as hip fracture
• Neither English- nor Spanish-speaking
• Non-US residents
• Incarcerated or homeless at the time of injury

Interventions

• No specific intervention; retrospective comparison of outcomes at trauma centers vs non-trauma centers
• Trauma center designation was based on American College of Surgeons verification levels
• Outcomes were compared using propensity-score matching to control for patient and injury characteristics

Outcomes

Primary Outcome

Mortality

Secondary Outcomes

None

Subgroup analysis

None

Criticisms

• Retrospective, observational study cannot establish causation
• Relied on administrative data from the National Study on Costs and Outcomes of Trauma (NSCOT), which may have coding inaccuracies
• Selection bias: sicker patients may have been preferentially transported to trauma centers
• Did not account for prehospital time differences between groups
• Results may not generalize to all trauma systems, particularly those in rural settings

Funding

• Agency for Healthcare Research and Quality (AHRQ)
• Centers for Disease Control and Prevention (CDC)