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The impact of individual physicians on outcomes after trauma: is it the system or the surgeon?

Published:April 16, 2018DOI:https://doi.org/10.1016/j.jss.2018.02.051

      Abstract

      Background

      Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma.

      Methods

      Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size.

      Results

      There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon.

      Conclusions

      At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management.

      Keywords

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      References

        • Shafi S.
        • Friese R.
        • Gentilello L.M.
        Moving beyond personnel and process: a case for incorporating outcome measures in the trauma center designation process.
        Arch Surg. 2008; 143 (discussion 120): 115-119
        • Demetriades D.
        • Martin M.
        • Salim A.
        • et al.
        Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score > 15).
        J Am Coll Surg. 2006; 202 (quiz A45): 212-215
        • Ehrlich P.F.
        • Rockwell S.
        • Kincaid S.
        • Mucha P.
        American College of Surgeons, committee on trauma verification review: does it really make a difference?.
        J Trauma. 2002; 53: 811-816
        • Simons R.
        • Kasic S.
        • Kirkpatrick A.
        • et al.
        Relative importance of designation and accreditation of trauma centers during evolution of a regional trauma system.
        J Trauma. 2002; 52 (discussion 833-834): 827-833
        • MacKenzie E.J.
        • Rivara F.P.
        • Jurkovich G.J.
        • et al.
        A national evaluation of the effect of trauma-center care on mortality.
        N Engl J Med. 2006; 354: 366-378
        • Luchette F.
        • Kelly B.
        • Davis K.
        • et al.
        Impact of the in-house trauma surgeon on initial patient care, outcome, and cost.
        J Trauma. 1997; 42 (discussion 495-497): 490-495
        • Margulies D.R.
        • Cryer H.G.
        • McArthur D.L.
        • et al.
        Patient volume per surgeon does not predict survival in adult level I trauma centers.
        J Trauma. 2001; 50 (discussion 601-603): 597-601
        • Haut E.R.
        • Chang D.C.
        • Hayanga A.J.
        • et al.
        Surgeon- and system-based influences on trauma mortality.
        Arch Surg. 2009; 144: 759-764
        • Richardson J.D.
        • Schmieg R.
        • Boaz P.
        • et al.
        Impact of trauma attending surgeon case volume on outcome: is more better?.
        J Trauma. 1998; 44 (discussion 271-272): 266-271
        • Sava J.
        • Kennedy S.
        • Jordan M.
        • Wang D.
        Does volume matter? The effect of trauma surgeons’ caseload on mortality.
        J Trauma. 2003; 54 (discussion 833-834): 829-833
        • Haut E.R.
        • Chang D.C.
        • Efron D.T.
        • Cornwell III, E.E.
        Injured patients have lower mortality when treated by ‘full-time’ trauma surgeons vs. surgeons who cover trauma ‘part-time’.
        J Trauma. 2006; 61 (discussion 278-279): 272-279
        • HCUP Central Distributor SID Description of Data Elements - All States. Healthcare Cost and Utilization Project (HCUP)
        Agency for Healthcare Research and Quality, Rockville, MD.
        2008 (Available at:) (Accessed September 2017)
        • Hawley S.T.
        • Hofer T.P.
        • Janz N.K.
        • et al.
        Correlates of between-surgeon variation in breast cancer treatments.
        Med Care. 2006; 44: 609-616
        • Snijders T.A.B.
        Multilevel Analysis. In International Encyclopedia of Statistical Science.
        Springer, London, UK2011: 879-882
        • Nakagawa S.
        • Schielzeth H.
        A general and simple method for obtaining R2 from generalized linear mixed-effects models.
        Methods Ecol Evol. 2013; 4: 133-142
        • Dallal R.M.
        • Quebbemann B.B.
        • Hunt L.H.
        • Braitman L.E.
        Analysis of weight loss after bariatric surgery using mixed-effects linear modeling.
        Obes Surg. 2009; 19: 732-737
        • Rasbash J.
        • Goldstein H.
        Efficient analysis of mixed hierarchical and cross-classified random structures using a multilevel model.
        J Educ Behav Stat. 1994; 19: 337-350
        • Goldstein H.
        • McDonald R.P.
        A general model for the analysis of multilevel data.
        Psychometrika. 1988; 53: 455-467
      1. Stata Multilevel Mixed-Effects Reference Manual.
        A Stata Press Publication, StataCorp LLC. College Station, TX2017
        • Hanchate A.D.
        • Zhang Y.
        • Felson D.T.
        • Ash A.S.
        Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets.
        Med Care. 2008; 46: 481-488
        • Breslin T.M.
        • Morris A.M.
        • Gu N.
        • et al.
        Hospital factors and racial disparities in mortality after surgery for breast and colon cancer.
        J Clin Oncol. 2009; 27: 3945-3950
        • Glance L.G.
        • Dick A.
        • Osler T.M.
        • Li Y.
        • Mukamel D.B.
        Impact of changing the statistical methodology on hospital and surgeon ranking: the case of the New York State cardiac surgery report card.
        Med Care. 2006; 44: 311-319
        • McFadden D.
        Conditional logit analysis of qualitative choice behavior.
        Front Econ. 1973; 1: 105-142
        • Cameron A.C.
        • Windmeijer A.G.F.
        An R-squared measure of goodness of fit for some common nonlinear regression models.
        J Econom. 1997; 77: 329-342
        • Greene W.R.
        • Oyetunji T.A.
        • Bowers U.
        • et al.
        Insurance status is a potent predictor of outcomes in both blunt and penetrating trauma.
        Am J Surg. 2010; 199: 554-557
        • Shafi S.
        • Stewart R.M.
        • Nathens A.B.
        • et al.
        Significant variations in mortality occur at similarly designated trauma centers.
        Arch Surg. 2009; 144: 64-68
        • Cudnik M.T.
        • Sayre M.R.
        • Hiestand B.
        • Steinberg S.M.
        Are all trauma centers created equally? A statewide analysis.
        Acad Emerg Med. 2010; 17: 701-708
        • Haas B.
        • Jurkovich G.J.
        • Wang J.
        • et al.
        Survival advantage in trauma centers: expeditious intervention or experience?.
        J Am Coll Surg. 2009; 208: 28-36
        • Sobrino J.
        • Barnes S.A.
        • Dahr N.
        • et al.
        Frequency of adoption of practice management guidelines at trauma centers.
        Proc (Bayl Univ Med Cent). 2013; 26: 256-261
        • Shafi S.
        • Collinsworth A.W.
        • Richter K.M.
        • et al.
        Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients - translating knowledge into practice.
        J Trauma Acute Care Surg. 2016; 81: 780-794
        • Shafi S.
        • Barnes S.A.
        • Rayan N.
        • et al.
        Compliance with recommended care at trauma centers: association with patient outcomes.
        J Am Coll Surg. 2014; 219: 189-198
        • Zettervall S.L.
        • Schermerhorn M.L.
        • Soden P.A.
        • et al.
        The effect of surgeon and hospital volume on mortality after open and endovascular repair of abdominal aortic aneurysms.
        J Vasc Surg. 2017; 65: 626-634
        • Duclos A.
        • Peix J.L.
        • Colin C.
        • et al.
        Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study.
        BMJ. 2012; 344: d8041
        • Schrag D.
        • Panageas K.S.
        • Riedel E.
        • et al.
        Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection.
        Ann Surg. 2002; 236: 583-592
        • Schrag D.
        • Cramer L.D.
        • Bach P.B.
        • et al.
        Influence of hospital procedure volume on outcomes following surgery for colon cancer.
        JAMA. 2000; 284: 3028-3035
        • Birkmeyer J.D.
        • Dimick J.B.
        • Staiger D.O.
        Operative mortality and procedure volume as predictors of subsequent hospital performance.
        Ann Surg. 2006; 243: 411-417
        • Ingraham A.M.
        • Haas B.
        • Cohen M.E.
        • Ko C.Y.
        • Nathens A.B.
        Comparison of hospital performance in trauma vs emergency and elective general surgery: implications for acute care surgery quality improvement.
        Arch Surg. 2012; 147: 591-598
        • Ingraham A.M.
        • Cohen M.E.
        • Raval M.V.
        • Ko C.Y.
        • Nathens A.B.
        Effect of trauma center status on 30-day outcomes after emergency general surgery.
        J Am Coll Surg. 2011; 212: 277-286
        • Hashmi Z.G.
        • Schneider E.B.
        • Castillo R.
        • et al.
        Benchmarking trauma centers on mortality alone does not reflect quality of care: implications for pay-for-performance.
        J Trauma Acute Care Surg. 2014; 76: 1184-1191
        • Haider A.H.
        • Hashmi Z.G.
        • Gupta S.
        • et al.
        Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB).
        World J Surg. 2014; 38: 1882-1891
        • DiRusso S.
        • Holly C.
        • Kamath R.
        • et al.
        Preparation and achievement of American College of Surgeons level I trauma verification raises hospital performance and improves patient outcome.
        J Trauma. 2001; 51: 294-300
        • McDermott F.T.
        • Cordner S.M.
        • Cooper D.J.
        • Winship V.C.
        • Consultative Committee on Road Traffic Fatalities in Victoria
        Management deficiencies and death preventability of road traffic fatalities before and after a new trauma care system in Victoria, Australia.
        J Trauma. 2007; 63: 331-338
        • Juillard C.J.
        • Mock C.
        • Goosen J.
        • Joshipura M.
        • Civil I.
        Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review.
        World J Surg. 2009; 33: 1075-1086
        • Mitchell F.L.
        • Thal E.R.
        • Wolferth C.C.
        Analysis of American College of Surgeons trauma consultation program.
        Arch Surg. 1995; 130 (discussion 583-584): 578-584
        • Mitchell F.L.
        • Thal E.R.
        • Wolferth C.C.
        American College of Surgeons verification/consultation program: analysis of unsuccessful verification reviews.
        J Trauma. 1994; 37 (discussion 562-564): 557-564
        • Haider A.H.
        • Chang D.C.
        • Efron D.T.
        • et al.
        Race and insurance status as risk factors for trauma mortality.
        Arch Surg. 2008; 143: 945-949