Trauma centers around the country long have used hospital death rates (the number of injured patients who die before leaving the hospital) as a measure of their success. But a group of researchers at Oregon Health Sciences University has found that injured patients have a much higher death rate after leaving the hospital than the general population. An article being published in the June 3 edition of the Journal of the American Medical Association suggests those deaths need to be included in any meaningful analysis of a trauma center's quality. The study looked at data on more than 90 thousand injured patients admitted to all acute-care hospitals in Washington state between 1991 and 1993.
"When we looked at deaths within 30 days of discharge from the hospital, death rates went up quite dramatically," said Richard Mullins, M.D., director of OHSU's trauma service and lead author of the article. In fact, injury-related deaths within those 30 days increased the overall death rate by 67 percent. And non-injury-related deaths increased the overall rate by 500 percent.
Deaths after hospital discharge rose most dramatically for elderly patients. For example, injured male patients between the ages of 70 and 74 were more than three times as likely to die within a year after hospital discharge than patients of the same age in the general population. "Elderly patients often come into a trauma center not only with their injuries, but with pre-existing medical conditions," said Mullins. "Those pre-existing conditions, along with other complications, help account for the high rate of death after hospital discharge. That suggests we need to broaden our definition of caring for those patients to include services such as consultation with a geriatric specialist, better follow up of medical conditions after discharge, or emphasis on prevention of further injury."
The article suggests managed care is also playing a role in making in-hospital death statistics less meaningful. Because managed care has led to shorter hospital stays, the authors argue current death statistics are deceptively low for injured patients who are quickly discharged to a skilled-nursing facility.
"What all of this means is we can do a better job of combining statistics on hospital deaths with what happens with patients after they leave the hospital," said Mullins. "This is a clear example of how improving our statistical models could help make a direct improvement in outcomes for many patients."
Jerris Hedges, M.D., chair of Emergency Medicine at OHSU and N. Clay Mann, Ph.D., assistant professor of Emergency Medicine at OHSU also contributed to the JAMA article. Other contributors include: William Worrall, M.A., Mark Helfand, M.D., Andrew D. Zechnich, M.D., M.P.H. and Gregory J. Jurkovich, M.D.
Journal
JAMA