Cameron Willis

Interpreting process indicators in trauma care: Construct validity versus confounding by indication

OBJECTIVE Quality indicators (QIs) are routinely used in health systems, often on the assumption that they provide a valid reflection of the outcome of care. This study investigated the construct validity of 14 trauma QIs through their ability to identify patients at risk of poor outcomes, including increased mortality, longer lengths of stay and greater use of the intensive care unit (ICU). METHODS Data were analysed from the Victorian State Trauma Registry from January 2001 to March 2006. Patients included blunt trauma, injury severity score >15 and aged >16 years. Univariate analyses and logistic regression modeling were used to adjust for significant covariates. RESULTS The study included 5104 cases. Three QIs were associated with increased mortality (abdominal surgery >24 h after arrival, blunt compound tibial fracture treatment >8 h after arrival and non-fixation of femoral diaphyseal fracture) and three with increased lengths of stay (cranial or abdominal surgery >24 h after arrival and patients developing deep vein thromboses, pulmonary emboli or decubitus ulcers, the latter also associated with increased ICU use). All remaining QIs exhibited reduced risks of poor outcomes or no significant associations. CONCLUSION The investigated QIs generally demonstrated poor construct validity and limited usefulness in predicting outcomes. Although QIs associated with poor patient outcomes may represent an avenue for further refinement, additional investigation of QIs in comparative trauma systems could provide insight into the utility of these measures at the system level.

Predicting trauma patient mortality: ICD [or ICD-10-AM] versus AIS based approaches

Background:  The International Classification of Diseases Injury Severity Score (ICISS) has been proposed as an International Classification of Diseases (ICD)‐10‐based alternative to mortality prediction tools that use Abbreviated Injury Scale (AIS) data, including the Trauma and Injury Severity Score (TRISS). To date, studies have not examined the performance of ICISS using Australian trauma registry data. This study aimed to compare the performance of ICISS with other mortality prediction tools in an Australian trauma registry.

Use of rFVIIa for critical bleeding in cardiac surgery: dose variation and patient outcomes

Background and Objectives  Recombinant activated factor VIIa (rFVIIa) is increasingly being used in non‐haemophiliac patients for the treatment of severe bleeding refractory to standard interventions. Optimal dosing regimens remain debated in cardiac surgery. Therefore, this study investigated the use of different rFVIIa dosing practices on response to bleeding and patient outcomes in cardiac surgery patients using data from the Haemostasis Registry.

Applying composite performance measures to trauma care.

BACKGROUND To investigate the association between a number of hospital level composite index methodologies developed from trauma indicators with inhospital mortality. METHODS Data from January 2001 to December 2006 were extracted from the Victorian State Trauma Registry (Australia) and the Trauma Audit and Research Network (United Kingdom). Three composite methods were explored, including two denominator-based weight approaches and a factor analysis technique. The association between the composite measures and the count of inhospital mortality was investigated using Poisson regression models adjusting for expected deaths per hospital using the Trauma Injury Severity Score methodology. RESULTS Composite scores were calculated per hospital, per year. The composite score was entered in statistical models as a raw score, and the mortality difference across the central 50% of the composite index was ascertained. In total, 9,218 patients were included and were distributed across 14 hospitals. Composite scores demonstrated an inverse relationship with risk-adjusted inhospital mortality. From the 25th to the 75th percentile of each composite, mortality decreased by 11.99%, 13.58%, and 16.13% (p < 0.05). CONCLUSION Trauma composite indices demonstrate construct validity when used as measures of hospital level process and represent potentially useful methods of analyzing and reporting quality indicators.

Variation in the use of recombinant activated factor VII in critical bleeding.

Background:  Recombinant activated factor VII (rFVIIa) is being increasingly used as a treatment option in settings of uncontrolled bleeding. Despite this, national practice guidelines are lacking, resulting in widespread practice variation between providers. This investigation aimed to describe the differences in use of rFVIIa across Australian and New Zealand hospitals.

Clinical guidelines and off‐license recombinant activated factor VII: content, use, and association with patient outcomes

Summary.  Background: Recombinant activated factor VII (rFVIIa) is increasingly being used off‐license for treating critical bleeding. Guidelines may therefore be useful for improving processes and outcomes. Little is known regarding guidelines for off‐license rFVIIa or their association with patient outcomes. Objectives: To investigate the availability of hospital guidelines for off‐license rFVIIa use and the association between these guidelines and mortality. Methods: Data were extracted from the Haemostasis Registry, which collects all cases of off‐license rFVIIa use in participating institutions in Australia and New Zealand. Contributing hospitals were requested to supply a copy of the institutional guideline relating to off‐license rFVIIa administration. The characteristics of patients treated in accordance with all elements of the guidelines were compared with those of patients for who one or more guideline elements had been violated. The relationship between guideline‐directed treatment and 28‐day mortality was investigated using stepwise logistic regression. Results: Two thousand five hundred and fifty‐one patients in 75 hospitals were available for analysis. Of these hospitals, 58 provided a guideline for analysis. Patients complying with all guideline elements (n = 530) did not differ from patients receiving care that violated guidelines (n = 1035) regarding age, size of dose, or gender. Guideline‐directed treatment was not found to have an association with 28‐day mortality following logistic regression. Conclusions: Few patients are treated in accordance with the criteria of rFVIIa guidelines, despite their availability in the majority of hospitals. Moreover, 28‐day mortality does not appear to be associated with the use of guidelines in this patient group. Refinement of guidelines relating to the off‐license use of rFVIIa is therefore required.