Mortality in Canadian trauma systems: A multicenter cohort study

Objective: To measure the variation in trauma center mortality across Canadian trauma systems, assess the contribution of traumatic brain injury and thoracoabdominal injury to observed variations, and evaluate whether the presence of recommended trauma system components is associated with mortality. Summary Background Data: Injuries represent one of the leading causes of mortality, disability, and health care costs worldwide. Trauma systems have improved injury outcomes, but the impact of trauma system configuration on mortality is unknown. Methods: We conducted a retrospective cohort study of adults admitted for major injury to trauma centers across Canada (2006-2012). Multilevel logistic regression was used to estimate risk-adjusted hospital mortality and assess the impact of 13 recommended trauma system components. Results: Of 78,807 patients, 8382 (10.6%) died in hospital including 6516 (78%) after severe traumatic brain injury and 749 (9%) after severe thoracoabdominal injury. Risk-adjusted mortality varied from 7.0% to 14.2% across provinces (P < 0.0001); 11.1% to 26.0% for severe traumatic brain injury (P < 0.0001), and 4.7% to 5.9% for thoracoabdominal injury (P = 0.2). Mortality decreased with increasing number of recommended trauma system elements; adjusted odds ratio = 0.93 (0.87-0.99). Conclusions: We observed significant variation in trauma center mortality across Canadian provinces, specifically for severe traumatic brain injury. Provinces with more recommended trauma system components had better patient survival. Results suggest that trauma system configuration may be an important determinant of injury mortality. A better understanding of which system processes drive optimal outcomes is required to reduce the burden of injury worldwide.