High volume geriatric trauma facilities provide better geriatric trauma outcomes

Image: PD 

1. Geriatric patients received trauma care with better outcomes related to in-hospital mortality, major complications, and mortality after major complications, at trauma centers with higher volumes of geriatric trauma cases. 

2. Paradoxically, trauma centers with higher volumes of non-geriatric trauma cases were associated with greater odds of major complications in geriatric trauma care. 

Evidence Rating Level: 2 (Good) 

Study Rundown: Over the past 50 years, as America’s population has steadily aged, the number of elderly patients requiring trauma care has increased significantly. Previous studies have shown a strong connection between higher volumes of trauma cases and improved patient outcomes in the general population. However, no previous studies have characterized this association for specific higher-risk groups such as geriatric patients. The authors of this study postulated that effective geriatric trauma care requires unique skill sets and systems and sought to determine how outcomes in geriatric trauma care differ across institutions with different volumes of geriatric and non-geriatric trauma cases. Outcome measures were improved at trauma centers with higher geriatric trauma volume, whereas greater non-geriatric trauma volume led to higher odds of a major complication.

Overall, these results demonstrate that trauma care for one group of patients may influence the care of different groups of patients, and suggest that differentiated pathways of care for specific high-risk patients may improve outcomes across the board. Though this study found statistically significant associations between volume and outcomes, it was limited in several ways. The study could not adjust for variations in hospital admissions and patient comorbidities, nor could it ascertain post-discharge mortality. Additionally, differences in the nature of traumatic injuries and access to care in different parts of the country may limit the generalizability of these results.

Click to read the study in JAMA Surgery

Relevant Reading: The Volume-Outcomes Relationship for United States Level I Trauma Centers

In-Depth [retrospective cohort study]: This study examined clinical information about 39,431 patients over the age of 65, which was collected from the Pennsylvania Trauma Outcome Study (PTOS) database—a patient registry drawing from 20 level 1 and 2 trauma centers in Pennsylvania. The 20 trauma centers included in the analysis had an average annual number of geriatric trauma cases ranging between 62 and 554 and non-geriatric trauma cases ranging between 161 and 1140. Overall there was a proportional relationship between number of geriatric and non-geriatric trauma cases in each trauma center with a correlation coefficient of 0.75.

The primary outcome was in-hospital mortality, but rates of major complications—classified from a list of 20 standard complications in PTOS—and failure to rescue were also calculated.  Greater institutional volume of geriatric trauma cases was significantly associated with a decrease in the odds of mortality (OR, 0.75 per 100-patient increase; p = 0.005), a decrease in the odds of major complications, and a decrease in the failure to rescue. However, a greater institutional volume of non-geriatric trauma cases was associated with an insignificant increase in the odds of mortality (OR, 1.08 per 100-patient increase; p = 0.11), a significant increase in the odds of major complications, and an insignificant increase in the failure to rescue.

By: Michael Milligan and James Jiang

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