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Injury outcomes across Canadian trauma systems: a historical cohort study

Devenir des blessures dans les systèmes de traumatologie canadiens : une étude de cohorte historique

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Abstract

Purpose

Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems.

Methods

In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province.

Results

The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high.

Conclusions

Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

Résumé

Objectif

La plupart des systèmes de traumatologie nord-américains disposent de centres de traumatologie (CT) désignés, y compris de niveau I (centres métropolitains ultraspécialisés à volume élevé), de niveau II (centres urbains spécialisés à volume moyen) et/ou de niveau III (centres semi-ruraux ou ruraux). La configuration des systèmes de traumatologie varie d’une province à l’autre et nous ne savons pas comment ces différences influent sur la répartition de la patientèle et sur les issues. Notre objectif était de comparer le mélange de cas des patient·es, le volume de cas et les issues ajustées en fonction du risque des adultes ayant subi un traumatisme majeur admis·es dans des CT désignés de niveaux I, II et III dans l’ensemble des systèmes de traumatologie canadiens.

Méthode

Dans une étude de cohorte historique nationale, nous avons extrait des données des registres provinciaux canadiens de traumatologie sur les patient·es ayant subi un traumatisme majeur traité·es entre 2013 et 2018 dans tous les CT désignés de niveau I, II ou III en Colombie-Britannique, en Alberta, au Québec et en Nouvelle-Écosse, les CT de niveau I et II au Nouveau-Brunswick, et dans quatre CT en Ontario. Nous avons utilisé des modèles linéaires généralisés à plusieurs niveaux pour comparer la mortalité, les admissions en unité de soins intensifs (USI) et les modèles de risque compétitif pour la durée du séjour à l’hôpital et à l’USI. L’Ontario n’a pas pu être inclus dans les comparaisons des devenirs parce qu’il n’y avait pas de données démographiques pour cette province.

Résultats

L’échantillon de l’étude comptait 50 959 patient·es. La répartition des patient·es dans les CT de niveaux I et II était similaire d’une province à l’autre, mais nous avons observé des différences significatives dans le mélange des cas et les volumes pour les CT de niveau III. Il y avait une faible variation de la mortalité ajustée en fonction du risque et des durées de séjour entre les provinces et les CT, mais la variation interprovinciale et intercentre des admissions à l’USI ajustées en fonction du risque était élevée.

Conclusion

Nos résultats suggèrent que les différences dans le rôle fonctionnel des CT selon leur niveau de désignation d’une province à l’autre entraînent des variations importantes dans la répartition des patient·es, le nombre de cas, l’utilisation des ressources et les issues cliniques. Ces résultats mettent en évidence les possibilités d’amélioration des soins de traumatologie au Canada et soulignent la nécessité de disposer de données normalisées sur les blessures dans la population pour appuyer les efforts nationaux d’amélioration de la qualité.

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Author contributions

All authors contributed to study design. Lynne Moore, Jaimini Thakore, David Evans, Henry T. Stelfox, Tarek Razek, John Kortbeek, Ian Watson, Christopher Evans, Mete Erdogan, Paul Engels, Barbara Haas, Rosmin Esmail, Robert Green, Jacinthe Lampron, Micheline Wiebe, Julien Clément, Recep Gezer, Jennifer McMillan, Angela Coates, and Natalie L. Yanchar were involved in data acquisition. Lynne Moore, Xavier Neveu, and Pier-Alexandre Tardif were responsible for data analysis. All authors made significant contribution to the interpretation of data and critically appraised the manuscript.

Acknowledgements

The authors would like to acknowledge trauma services and trauma registry teams from British Columbia, Alberta, Ontario, Quebec, New Brunswick, and Nova Scotia who provided data for this study, and Sonshire Figueira for contributing to the manuscript.

Disclosures

None.

Funding statement

None declared.

Prior conference presentations

This work was presented at the Trauma Association of Canada 2022 Annual Scientific Meeting and Conference (7–8 April 2022, Montreal, QC, Canada).

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Deputy Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Authors and Affiliations

  1. Santé des Populations et Pratiques Optimales en Santé (Traumatologie – Urgence – Soins intensifs), Centre de Recherche du CHU de Québec, Quebec City, QC, Canada

    Lynne Moore PhD, Xavier Neveu MSc & Pier-Alexandre Tardif MSc

  2. Department of Social and Preventive Medicine, Enfant-Jésus Hospital, Université Laval, 1401, 18e rue, local H-012a, Quebec City, QC, G1J 1Z4, Canada

    Lynne Moore PhD

  3. Department of Surgery, The University of British Columbia, Vancouver, BC, Canada

    Jaimini Thakore MBA & David Evans MD

  4. Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada

    Henry T. Stelfox MD, PhD

  5. Department of Surgery, McGill University, Montreal, QC, Canada

    Tarek Razek MD

  6. Department of Surgery, University of Calgary, Calgary, AB, Canada

    John Kortbeek MD & Natalie L. Yanchar MD, MSc

  7. New Brunswick Trauma Program, Saint John, NB, Canada

    Ian Watson MHSc

  8. Kingston Health Sciences Centre, Kingston, ON, Canada

    Christopher Evans MD, MSc

  9. Department of Emergency Medicine, Queen’s University, Kingston, ON, Canada

    Christopher Evans MD, MSc

  10. Nova Scotia Health Trauma Program, Nova Scotia Health, Halifax, NS, Canada

    Mete Erdogan PhD, MHI & Robert Green MD

  11. Department of Surgery, McMaster University, Hamilton, ON, Canada

    Paul Engels MD

  12. Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Barbara Haas MD, PhD

  13. Trauma Services, Foothills Medical Centre, Alberta Health Services, Calgary, AB, Canada

    Rosmin Esmail PhD

  14. Departments of Oncology and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada

    Rosmin Esmail PhD

  15. Department of Critical Care, Dalhousie University, Halifax, NS, Canada

    Robert Green MD

  16. Division of General Surgery, The Ottawa Hospital, Ottawa, ON, Canada

    Jacinthe Lampron MD

  17. BC Trauma Registry, Provincial Health Services Authority of British Columbia, Vancouver, BC, Canada

    Micheline Wiebe RN & Jennifer McMillan MSc

  18. Institut National d’Excellence en Santé et en Services Sociaux, Quebec City, QC, Canada

    Julien Clément MD, MSc

  19. Department of Surgery, Université Laval, Quebec City, QC, Canada

    Julien Clément MD, MSc

  20. Trauma Services BC, Provincial Health Services Authority of British Columbia, Vancouver, BC, Canada

    Recep Gezer MSc

  21. Department of Surgery, McMaster University, Hamilton, ON, Canada

    Angela Coates MEd

Authors
  1. Lynne Moore PhD
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  2. Jaimini Thakore MBA
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  3. David Evans MD
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  4. Henry T. Stelfox MD, PhD
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  6. John Kortbeek MD
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  7. Ian Watson MHSc
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  8. Christopher Evans MD, MSc
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  9. Mete Erdogan PhD, MHI
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  10. Paul Engels MD
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  11. Barbara Haas MD, PhD
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  12. Rosmin Esmail PhD
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  13. Robert Green MD
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  14. Jacinthe Lampron MD
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  15. Micheline Wiebe RN
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  16. Julien Clément MD, MSc
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  17. Recep Gezer MSc
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  18. Jennifer McMillan MSc
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  19. Xavier Neveu MSc
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  20. Pier-Alexandre Tardif MSc
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  21. Angela Coates MEd
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  22. Natalie L. Yanchar MD, MSc
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Corresponding author

Correspondence to Lynne Moore PhD.

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Moore, L., Thakore, J., Evans, D. et al. Injury outcomes across Canadian trauma systems: a historical cohort study. Can J Anesth/J Can Anesth 70, 1350–1361 (2023). https://doi.org/10.1007/s12630-023-02522-2

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