Medical Research: What is the background for this study? What are the main findings?
Dr. Dawes: In the fall of 2013, we formed the Los Angeles County Trauma Consortium, building upon a prior administrative relationship between LA County’s 14 trauma centers. We added health research researchers from UCLA and USC, and shifted the focus of the group from logistical issues to quality improvement. As a first project, our hospitals wanted to know if there was any variation in how traumatic brain injury patients are cared for across the county. Traumatic brain injury accounts for over 1/3 of all injury-related deaths in the U.S. and is the number one reason for ambulance transport to a trauma center in LA County.
When we looked at the data, we found widespread variation in both how these patients were cared for at different hospitals and what happened to them as a result of that care. After adjusting for important differences in patient mix, we found that mortality rates varied by hospital from roughly 25% to 55%. As we tried to explain this variation, we looked into how often hospitals complied with two evidence-based guidelines from the Brain Trauma Foundation, hoping that we could eventually develop an intervention to boost compliance with these recommended care practices. While compliance rates varied even more widely than mortality—from 10 to 65% for intracranial pressure monitoring and 7 to 76% for craniotomy—they did not appear to be associated with risk-adjusted mortality rates. Put simply, we found no connection between how often hospitals complied with the guidelines and how likely their patients were to survive.
Medical Research: What should clinicians and patients take away from your report?
Dr. Dawes: Two things. First, despite efforts from organizations like the Brain Trauma Foundation, the clinical care of patients with severe traumatic brain injury is still variable, even within a single regional trauma system. Overall less than 50% of severe traumatic brain injury patients in our county received two recommend care processes. On the one hand, this means that we have a lot of room to improve, but, on the other, learning where we need to improve an important first step. We really believe that the best way to improve quality is to come together as a trauma system, to share data and to share practices, which is what we’re doing with the Consortium.
Second, the lack of an association between compliance and mortality suggests that these particular metrics should not be used to judge a hospital’s quality. Part of this may be because the metrics themselves are rather blunt: both look only at whether or not a procedure is done, not how that procedure is done, what other treatments are used, and how additional information from these procedures is used to direct care. We believe in evidence-based medicine and in the use of guidelines to help guide care, however, our study suggests that certain metrics just don’t tell you enough about hospital quality. We need to develop and utilize better measurement strategies to help hospitals improve.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Dawes: Our major work now has been to explain the variation that we found in risk-adjusted mortality rates. If guideline compliance is not the answer—and our study suggests it is not—then what is driving these differences? To do this, we have been meeting as a Consortium to compare practices and are planning site visits where clinicians from different hospitals actually watch and comment on how other trauma teams care for their patients. We hope this will give us the information we need to try to better standardize care in ways that actually improve clinical outcomes for all traumatically-injured patients in LA County.
Citation: Dawes AJ, Sacks GD, Cryer H, et al. Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury. JAMA Surg. Published online July 22, 2015. doi:10.1001/jamasurg.2015.1678.
Aaron J. Dawes, MD (2015). Compliance With Guidelines Not Linked To Outcomes in Traumatic Brain Injury