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J Trauma Acute Care Surg. 2015 Jul;79(1):138-46. doi: 10.1097/TA.0000000000000678.

Concordance of performance metrics among U.S. trauma centers caring for injured children.

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From the Division of General Surgery (C.S., P.J.K., P.W.W., A.B.N.), Department of Surgery, and Institute of Health Policy, Management, and Evaluation (C.S., P.J.K., D.C.S., A.B.N.), University of Toronto; Sunnybrook Research Institute (P.J.K., W.X., A.B.N.), and Division of General Surgery (P.J.K., A.B.N.), Department of Surgery, and Department of Critical Care Medicine (D.C.S.), Sunnybrook Health Sciences Center; Division of General and Thoracic Surgery (P.W.W.), Hospital for Sick Children; and Li Ka Shing Knowledge Institute (A.B.N.), St. Michael's Hospital, Toronto, Ontario, Canada; Division of General and Thoracic Surgery (R.S.B.), Children's National Health System, Washington, District of Columbia; and Division of General and Thoracic Surgery (M.L.N.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.



Several indicators of quality pediatric trauma care have been proposed including low in-hospital mortality, nonoperative management of blunt splenic injury, use of intracranial pressure monitors after severe traumatic brain injury, and craniotomy for children with severe subdural or epidural hematomas. It is not known if center-level performance is consistent in each of these metrics. We evaluated whether center performance in one area of quality predicted similar performance in other areas of quality.


We reviewed patients 18 years or younger who were hospitalized with an injury Abbreviated Injury Scale (AIS) score of 2 or greater from 2010 to 2011 at trauma centers (n = 150) participating in the Trauma Quality Improvement Program. Random-intercept multilevel modeling was used to generate center-specific adjusted odds ratios for each quality indicator. We evaluated correlations between center-specific adjusted odds ratios of each quality indicator and mortality using Pearson correlation coefficients. Weighted κ statistics were used to test multiple pairwise agreements between indicators and the overall agreement across all four indicators.


Among 84,880 children identified for analysis, 3,603 had blunt splenic injury, 3,503 had severe traumatic brain injury, and 1,286 had an epidural or subdural hematoma. A negative correlation between center-specific odds of mortality and craniotomy was present (Pearson correlation coefficient, -0.18; p = 0.03). There were no significant correlations between other indicators. Although κ statistics showed slight agreement for the pairwise comparison of odds of mortality and craniotomy (0.17, 0.02-0.32), there was no agreement for all other pairwise comparisons or the overall comparison of all four indicators (-0.01, -0.07 to 0.06).


Our findings demonstrate a lack of concordance in center-level performance across the four pediatric trauma quality indicators we evaluated. These findings should be considered by pediatric trauma quality improvement initiatives to allow for comprehensive measurement of hospital quality as opposed to benchmarking using a single indicator.

[Indexed for MEDLINE]

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