Then we all fall down: fall mortality by trauma center level

Published:January 06, 2017DOI:



      Ground-level falls (GLFs) are the predominant mechanism of injury in US trauma centers and accompany a spectrum of comorbidities, injury severity, and physiologic derangement. Trauma center levels define tiers of capability to treat injured patients. We hypothesized that risk-adjusted observed-to-expected mortality (O:E) by trauma center level would evaluate the degree to which need for care was met by provision of care.

      Materials and methods

      This retrospective cohort study used National Trauma Data Bank files for 2007-2014. Trauma center level was defined as American College of Surgeons (ACS) level I/II, ACS III/IV, State I/II, and State III/IV for within-group homogeneity. Risk-adjusted expected mortality was estimated using hierarchical, multivariable regression techniques.


      Analysis of 812,053 patients' data revealed the proportion of GLF in the National Trauma Data Bank increased 8.7% (14.1%-22.8%) over the 8 y studied. Mortality was 4.21% overall with a three-fold increase for those aged 60 y and older versus younger than 60 y (4.93% versus 1.46%, P < 0.001). O:E was lowest for ACS III/IV, (0.973, 95% CI: 0.971-0.975) and highest for State III/IV (1.043, 95% CI: 1.041-1.044).


      Risk-adjusted outcomes can be measured and meaningfully compared among groups of trauma centers. Differential O:E for ACS III/IV and State III/IV centers suggests that factors beyond case mix alone influence outcomes for GLF patients. More work is needed to optimize trauma care for GLF patients across the spectrum of trauma center capability.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American College of Surgeons
        National trauma Data Bank user Manual.
        2013 (Available at) (Accessed May 9, 2016)
        • DiMaggio C.
        • Ayoung-Chee P.
        • Shinseki M.
        • et al.
        Traumatic injury in the United States: in-patient epidemiology 2000-2011.
        Injury. 2016; 47: 1393-1403
        • Stevens J.A.
        • Corso P.S.
        • Finkelstein E.A.
        • Miller T.R.
        The costs of fatal and non-fatal falls among older adults.
        Inj Prev. 2006; 12: 290-295
        • Bergeron E.
        • Clement J.
        • Lavoie A.
        • et al.
        A simple fall in the elderly: not so simple.
        J Trauma. 2006; 60: 268-273
        • Spaniolas K.
        • Cheng J.D.
        • Gestring M.L.
        • Sangosanya A.
        • Stassen N.A.
        • Bankey P.E.
        Ground level falls are associated with significant mortality in elderly patients.
        J Trauma. 2010; 69: 821-825
        • Ayoung-Chee P.
        • McIntyre L.
        • Ebel B.E.
        • Mack C.D.
        • McCormick W.
        • Maier R.V.
        Long-term outcomes of ground-level falls in the elderly.
        J Trauma Acute Care Surg. 2014; 76: 498-503
        • Hoyt D.
        • Coimbra R.
        Trauma systems.
        Surg Clin North Am. 2007; 87: 21-35
        • Vassar M.J.
        • Holcroft J.J.
        • Knudson M.M.
        • Kizer K.W.
        Fractures in access to and assessment of trauma systems.
        J Am Coll Surg. 2003; 197: 717-725
        • Inui T.S.
        • Parina R.
        • Chang D.C.
        • Inui T.S.
        • Coimbra R.
        Mortality after ground-level fall in the elderly patient taking oral anticoagulation for atrial fibrillation/flutter: a long-term analysis of risk versus benefit.
        J Trauma. 2014; 76: 642-650
        • Tuunainen E.
        • Rasku J.
        • Jäntti P.
        • Pyykkö I.
        Risk factors of falls in community dwelling active elderly.
        Auris Nasus Larynx. 2014; 41: 10-16
        • Taira T.
        • Morita S.
        • Umebachi R.
        • et al.
        Risk factors for ground-level falls differ by sex.
        Am J Emerg Med. 2015; 33: 640-644
        • Joseph B.
        • Pandit V.
        • Khalil M.
        • et al.
        Managing older adults with ground-level falls admitted to a trauma Service: the effect of frailty.
        J Am Geriatr Soc. 2015; 63: 745-749
        • Cook A.
        • Cade A.
        • King B.
        • Berne J.
        • Fernandez L.
        • Norwood S.
        Ground-level falls: 9-year cumulative experience in a regionalized trauma system.
        Proc (Bayl Univ Med Cent). 2012; 25: 6-12
        • Glance L.G.
        • Osler T.M.
        • Mukamel D.B.
        • Meredith W.
        • Wagner J.
        • Dick A.W.
        TMPM-ICD9: a trauma mortality prediction model based on ICD-9-CM codes.
        Ann Surg. 2009; 249: 1032-1039
        • Barell V.
        • Aharonson-Daniel L.
        • Fingerhut L.A.
        • et al.
        An introduction to the Barell body region by nature of injury diagnosis matrix.
        Inj Prev. 2002; 8: 91-96
        • Cuzick J.A.
        wilcoxon-type test for trend.
        Stat Med. 1985; 4: 543-547
        • Kennedy R.L.
        • Grant P.T.
        • Blackwell D.
        Low-impact falls: demands on a system of trauma management, prediction of outcome, and influence of comorbidities.
        J Trauma. 2001; 51: 717-724
        • Hartholt K.A.
        • Stevens J.A.
        • Polinder S.
        • van der Cammen T.J.
        • Patka P.
        Increase in fall-related hospitalizations in the United States, 2001–2008.
        J Trauma. 2011; 71: 255-258
        • Colby S.L.
        • Ortman J.M.
        Projections of the size and Composition of the US population: 2014 to 2060.
        U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau. 2015; : 25-1143
        • Khuri S.F.
        • Daley J.
        • Henderson W.
        • et al.
        Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study.
        J Am Coll Surg. 1997; 185: 315-327
        • Iezzoni L.I.
        Reasons for risk Adjustment.
        in: Risk Adjustment for Measuring Health Care Outcomes. 3rd ed. Health Administration Press, Chicago2003: 4-5
        • Lehmann R.
        • Beekley A.
        • Casey L.
        • Salim A.
        • Martin M.
        The impact of advanced age on trauma triage decisions and outcomes: a statewide analysis.
        Am J Surg. 2009; 197: 571-575
        • Mangram A.J.
        • Shifflette V.K.
        • Mitchell C.D.
        • et al.
        The creation of a geriatric trauma unit “G-60”.
        Am Surg. 2011; 77: 1144-1146
        • Mann N.C.
        • MacKenzie E.
        • Teitelbaum S.D.
        • Wright D.
        • Anderson C.
        Trauma system structure and viability in the current healthcare environment: a state-by-state assessment.
        J Trauma. 2005; 58: 136-147