Background: Comparisons across trauma systems are key to identifying opportunities to improve trauma care. We aimed to compare trauma service structures, processes and outcomes between the English National Health Service (NHS) and the province of Quebec, Canada.
Methods: We conducted a multicentre cohort study including admissions of patients aged older than 15 years with major trauma to major trauma centres (MTCs) from 2014/15 to 2016/17. We compared structures descriptively, and time to MTC and time in the emergency department (ED) using Wilcoxon tests. We compared mortality, and hospital and intensive care unit (ICU) length of stay (LOS) using multilevel logistic regression with propensity score adjustment, stratified by body region of the worst injury.
Results: The sample comprised 36 337 patients from the NHS and 6484 patients from Quebec. Structural differences in the NHS included advanced prehospital medical teams (v. “scoop and run” in Quebec), helicopter transport (v. fixed-wing aircraft) and trauma team leaders. The median time to an MTC was shorter in Quebec than in the NHS for direct transports (1 h v. 1.5 h, p < 0.001) but longer for transfers (2.5 h v. 6 h, p < 0.001). Time in the ED was longer in Quebec than in the NHS (6.5 h v. 4.0 h, p < 0.001). The adjusted odds of death were higher in Quebec for head injury (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.09–1.51) but lower for thoracoabdominal injuries (OR 0.69, 95% CI 0.52–0.90). The adjusted median hospital LOS was longer for spine, torso and extremity injuries in the NHS than in Quebec, and the median ICU LOS was longer for spine injuries.
Conclusion: We observed significant differences in the structure of trauma care, delays in access and risk-adjusted outcomes between Quebec and the NHS. Future research should assess associations between structures, processes and outcomes to identify opportunities for quality improvement.
Injuries are a major public health issue. They represent the primary cause of death for people younger than 40 years, as well as loss of active life years and temporary or permanent disability for all age groups in North America, Europe and Australia.1,2 In terms of health care costs, injuries are second only to cardiovascular diseases in Canada and the United States.1,3
To reduce the burden of injuries, many regions in North America, Europe and Australia have introduced integrated trauma systems, defined as organized, regional and multidisciplinary structures with the objective of ensuring adequate and optimal management of patients with major trauma.4,5 Trauma systems have been associated with reductions in mortality, disabilities and costs after injury.6,7 Quality-improvement programs based on internal benchmarking have been implemented in trauma systems in many high-income countries, including the US (American College of Surgeons Trauma Quality Improvement Program, https://www.facs.org/quality-programs/trauma/quality/trauma-quality-improvement-program/), Australia (Victorian State Trauma Outcomes Registry and Monitoring Group [VSTORM], https://www.monash.edu/medicine/sphpm/vstorm/home) and the United Kingdom (The Trauma Audit & Research Network, https://www.tarn.ac.uk/). These programs allow comparisons of risk-adjusted outcomes across hospitals within a system. Comparisons across trauma systems are key to identifying further opportunities to improve trauma care.8
The Trauma and Injury Severity Score made it possible to conduct international comparisons of trauma centres/systems. However, this score is now outdated and is based on a risk-adjustment model with important limits, which may lead to some hospitals’ being wrongly labelled as outliers.9 Furthermore, this method is based solely on mortality, and its validity may be questioned when the patient population or the health care system under evaluation is different from that observed in the US. Other investigators have directly compared trauma systems by looking separately at mortality, adherence to a single clinical process, or the degree of maturity of trauma system structures.10,11 To our knowledge, studies comparing structures, processes and outcomes across trauma systems are currently lacking. The primary goal of this study was to compare mortality and hospital and intensive care unit (ICU) length of stay (LOS) between Quebec, Canada, and England by means of propensity score analysis. Secondary objectives were to compare system structures and processes related to access to major trauma centres (MTCs).
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)