Practitioners' Flawed Decision-Making Tied to Fatality Rates in Trauma

By David Douglas

November 01, 2019

NEW YORK (Reuters Health) - Despite efforts to boost quality, variation in triage patterns persists, with many severely injured patients being treated at nontrauma centers, according to a new study.

Dr. Deepika Mohan of the University of Pittsburgh, in Pennsylvania, told Reuters Health by email that "we need to pay greater attention to clinician decision-making when trying to regionalize trauma practices in the U.S., because clinicians are an important source of the variation that we see."

She added, "Up to 69% of severely injured patients who go initially to non-trauma centers are undertriaged, with important consequences for their long-term outcomes."

For their study, online October 23 in JAMA Surgery, Dr. Mohan and colleagues examined Medicare claims data spanning 2010 to 2015 on more than 124,000 severely injured patients who were evaluated by some 25,000 practitioners in the emergency department of nontrauma centers. The patients' mean age was 81 years.

Undertriage was deemed to have occurred in 68.9% of patients. The researchers defined undertriage "as the failure to transfer a patient with severe injuries to a higher level of care directly from the ED or within 1 day of admission, categorizing those who died within 24 hours of arrival or who were discharged from the ED as undertriaged."

A total of 1,337 patients died in the ED, 28,583 were discharged and 55,483 were admitted to the hospital at which they presented.

Based on intraclass correlation coefficients, 40.6% of total variation was correlated with practitioners, 37.8% with hospitals, and 6.7% with regions. Practitioners who evaluated 10 or more beneficiaries over the course of the study saw a median of four severely injured patients and undertriaged 75% of them.

The risk of death within 30 days was significantly higher for patients treated by practitioners with an undertriage rate of 25% to 50% (odds ratio, 1.08) or 50% to 75% (OR, 1.12) compared with practitioners who undertriaged 25% or fewer patients. For those whose practitioners undertriaged more than 75%, however, the increase was borderline significant (OR, 1.03; P=0.05).

All three levels of undertriage were associated with significantly higher 30-day fatality rates after excluding patients discharged from the ED.

Fewer than 10% of practitioners met the <5% undertriage threshold endorsed by the American College of Surgeons. Practitioners at hospitals with neurosurgical services were significantly more likely to undertriage (risk ratio, 1.51). This was also the case for those with spine surgeons (RR, 1.10) and general surgeons (RR, 1.13).

"We believe that interventions designed to reduce undertriage by (emergency medicine) practitioners should be evaluated in future studies," the researchers write.

Dr. Pablo Tarsicio Uribe-Leitz of Harvard Medical School, in Boston, who was not involved in the study, told Reuters Health by email, "By identifying emergency-medicine practitioners as an actionable focus group, Mohan and colleagues take an important step toward improving outcomes of severely injured older adults."

"However," added Dr. Uribe-Leitz, a research scientist and instructor in surgery, "interfacility transfers require a multidisciplinary effort (i.e. EMT, healthcare providers, staff, administrators) that need to be taken into consideration."


JAMA Surg 2019.