Injury 53 (2022) 2915–2922

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Change in outcomes for trauma patients over time: Two decades of a

state trauma system
Elinore J. Kaufman a,∗, Patrick M. Reilly a, Justin S. Hatchimonji b, Ruiying Aria Xiong c,
Wei Yang c, C. William Schwab a, Jay A. Yelon a,d, Daniel N. Holena a,#
a
Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine
b
Department of Surgery, University of Pennsylvania Perelman School of Medicine
c
Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania
d
Naval Strategic Health Alliance for Readiness and Performance, Navy Medicine Operational Training Command

a r t i c l e i n f o a b s t r a c t

Article history: Background: Trauma center mortality rates are benchmarked to expected rates of death based on patient
Accepted 9 June 2022 and injury characteristics. The expected mortality rate is recalculated from pooled outcomes across a
trauma system each year, obscuring system-level change across years. We hypothesized that risk-adjusted
Keywords: mortality would decrease over time within a state-wide trauma system.
Trauma systems Methods: We identified adult trauma patients presenting to Level I and II Pennsylvania trauma centers,
Shock 1999–2018, using the Pennsylvania Trauma Outcomes Study. Multivariable logistic regression generated
risk-adjusted models for mortality in all patients, and in key subgroups: penetrating torso injury, blunt
multisystem trauma, and patients presenting in shock.
Results: Of 162,646 included patients, 123,518 (76.1%) were white and 108,936 (67.0%) were male. The
median age was 49 (interquartile range [IQR] 29–70), median injury severity score was 16 (IQR 10–24),
and 87.5% of injuries were blunt. Overall, 9.9% of patients died, and compared to 1999, no year had sig-
nificantly higher adjusted odds of mortality. Overall mortality was significantly lower in 20 07–20 09 and
2011–2018. Of patients with blunt, multisystem injuries, 17.7% died, and adjusted mortality improved over
time. Mortality rates were 24.9% for penetrating torso injury, and 56.9% for shock, with no significant
change. Mortality improved for patients with ISS < 25, but not for the most severely injured.
Conclusions: Over 20 years, Pennsylvania trauma centers demonstrated improved risk-adjusted mortality
rates overall, but improvement remains lacking in high-risk groups despite numerous innovations and
practice changes in this time period. Identifying change over time can help guide focus to these critical
gaps.
© 2022 Elsevier Ltd. All rights reserved.

Introduction of improving center performance over time. Center reports typi-

cally compare each center’s performance to that of their peers, us-
Trauma systems have long been leaders in quality and per- ing an risk-adjusted outcome metric such as observed-to-expected
formance improvement. Quality improvement programs, such as (O:E) mortality ratios [1]. These collaborative systems allow cen-
the American College of Surgeons’ Trauma Quality Improvement ters to evaluate their own performance against that of their peers,
Program (TQIP) provide risk-adjusted benchmarking with the aim and can spark performance improvement and the sharing of best
practices [1]. However, they do not allow the system or an in-
dividual center to assess its performance over time in absolute
∗
Corresponding author. terms. As the expected mortality rate is calculated from the risk-
E-mail addresses: elinore.kaufman@pennmedicine.upenn.edu (E.J. Kaufman), adjusted outcomes of patients within the system, if system-wide
patrick.reilly2@pennmedicine.upenn.edu (P.M. Reilly), performance changes from year to year, this change will not ap-
jhat@pennmedicine.upenn.edu (J.S. Hatchimonji), aria.xiong@pennmedicine.upenn.edu pear in quality reports [1]. This is particularly true as patient fac-
(R.A. Xiong), weiyang@pennmedicine.upenn.edu (W. Yang),
tors included in risk adjustment have changed over time, and in-
charles.schwab@pennmedicine.upenn.edu (C.W. Schwab),
daniel.holena@pennmedicine.upenn.edu, dholena@mcw.edu (D.N. Holena). jured patients are older and have more comorbid conditions than
#
Current affiliation: Department of Surgery, Medical College of Wisconsin previously [2].

https://doi.org/10.1016/j.injury.2022.06.011
0020-1383/© 2022 Elsevier Ltd. All rights reserved.

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E.J. Kaufman, P.M. Reilly, J.S. Hatchimonji et al.
Implementation and coordination of trauma systems decreases
mortality after severe injury [3–5], but less is known about change
over time within an established trauma system. In the first decade
of the 21st century, the proportion of deaths due to trauma in-
creased at the population level, with the largest increase in older
adults [6]. During this time period, risk-adjusted trauma mortal-
ity was stable nationally [2], but declined by 29% in Pennsylvania
trauma centers [7]. However, these benefits were not equally dis-
tributed. Moderate to severely injured patients showed the great-
est improvement. There was no change in outcomes for patients
presenting with hypotension or for the mildly or very severely
injured. Despite these encouraging results, progress for the most
severely injured and ill remains elusive, particularly for patients
who present with hemodynamic compromise.
In this study, we assessed performance over time in a statewide
trauma system. Our goal was to determine how outcomes would
have differed if an identical patient with identical injuries pre-
sented 5 or 10 years earlier or later. We aimed to extend the find-
ings of the prior Pennsylvania study over a longer time period, and
to focus on key, high-risk groups of injured patients. We hypothe-
sized that risk-adjusted mortality would decrease over time.
Patients and methods
Data source and population
We performed a retrospective cohort study of injured patients
presenting to all level I and II trauma centers in Pennsylvania from
1999 to 2018. The Pennsylvania Trauma Systems Foundation (PTSF)
accredits all trauma centers in Pennsylvania [8]. PTSF also main-
tains a statewide trauma registry, the Pennsylvania Trauma Out-
comes Study (PTOS) [9]. PTOS includes demographic, physiologic,
injury and outcomes data for patients presenting to accredited
trauma centers in the state of Pennsylvania. This registry includes
all patients admitted for injury, as well as all trauma deaths, and
all admitted transfers in or out. We excluded patients <16 years
old, those with a mechanism of burn, and those transferred out
(as final outcomes could not be determined). We included only
patients treated at centers that participated throughout the study
period. Injury diagnoses were classified according to International
Classification of Disease, version 9 (ICD-9) codes for data through
September 2015 and with ICD-10 codes thereafter. Data for this
work were provided by the Pennsylvania Trauma Systems Foun-
dation (Mechanicsburg, PA), which specifically disclaims respon-
sibility for any analyses, interpretations, or conclusions presented
herein. The Institutional Review Board of the University of Penn-
sylvania approved this study.
Variables
The outcome of interest was in-hospital mortality. The exposure
of interest was year of injury. Patient demographics, comorbidities,
injury mechanism, diagnoses, and severity, and presenting physiol-
ogy were collected and compared. The Center for Disease Control-
recommended framework for external-cause-of-injury-codes was
used to determine the major mechanism and intention of injury
[10].
The database includes registrar-recorded AIS and ISS scores.
However, the AIS version was updated in 2011 from AIS 1998 to
AIS 2005 [11]. This yielded AIS values that were not directly com-
parable across years. That is, a given injury in 2010 would have
received a different (and often lower) AIS score if it had occurred
in 2012. There is no crosswalk between AIS versions. Therefore,
to achieve consistency across all years we calculated AIS and ISS
scores from ICD-9 and 10 codes using a validated algorithm, ICD-
PIC [12,13].
2916
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Injury 53 (2022) 2915–2922
Analysis
Demographics, injury characteristics and severity variables were
described using chi-squared test for categorical variables. Trends
over time in patient characteristics were assessed using the non-
parametric trend test [14]. We constructed multivariable logistic
regression models designed to approximate the TQIP approach [1].
In the model, we adjusted for Glasgow coma scale (GCS) motor
component, systolic blood pressure, and heart rate (all measured
on presentation), patient age, mechanism of injury, maximum ab-
breviated injury score (AIS) for head and for lower extremity, over-
all maximum AIS, and patient comorbidities: cancer, liver disease,
heart disease, hypertension, dialysis, functional dependence, bleed-
ing disorder, peripheral vascular disease, and dementia as defined
by PTOS [15]. Data were evaluated for missingness. As < 5% of pa-
tients had missing values for the variables included in the regres-
sion model, we excluded patients with missing exposure variables
and conducted a complete case analysis. We conducted a sensi-
tivity analysis using multiple imputation for missing values of ex-
posure variables. This analysis yielded nearly identical results. For
simplicity, we present here only the complete case analysis. To as-
sess for change over time, we included a categorical variable for
year in the model.
Beyond overall performance, we identified three key subgroups
for performance analysis: 1. Blunt multisystem injury, defined as
blunt mechanism of injury with AIS ≥ 3 in at least 2 body regions;
2. Penetrating truncal injury, defined as penetrating mechanism of
injury with AIS ≥ 3 in the chest, abdomen, or pelvis; 3. Shock, de-
fined as patients presenting with presenting systolic blood pres-
sure < 90 mmHg. We also stratified our analysis by injury sever-
ity and assessed adjusted odds of mortality in mild-moderately in-
jured patients (ISS < 16), severely[16–24], and very severely in-
jured (ISS ≥ 25). Analysis was performed using Stata (Version 16,
StataCorp) and R (Version 4.2, R Foundation).
Results
We included 162,646 patients at 23 Level I and II trauma cen-
ters. The median age was 49 (interquartile range 29–70), 68.4%
were male, and 87.4% were injured by blunt mechanism. Median
ISS was 16 (interquartile range 10–24). Patient characteristics are
shown in Table 1.
Key patient characteristics changed significantly over the 20-
year study period, as shown in Fig. 1. Median age increased from
40 in 1999 to 62 in 2018 (p for trend < 0.001), with the propor-
tion age 65 or older increasing from 24.9 to 45.8. The proportion
of women increased from 31.4% to 38.2%, p<0.001. The proportion
injured by fall increased from 21.5% to 53.5% (p < 0.001), while
the proportion injured by firearm decreased from 11.3 to 6.7% (p
< 0.001) and the proportion injured in a motor vehicle crash de-
creased from 37.7% to 15.5% (p < 0.001). Median injury severity
was 16 throughout the study period.
Overall, 116,406 (71.6%) of patients had at least one comorbid-
ity recorded, and this proportion increased from 53.2% in 1999 to
85.3% in 2018 (p for trend < 0.001). The proportion of patients
with heart disease increased from 9.4 to 16.3% (p < 0.001), while
hypertension increased from 18.6% to 45.0%. The proportions of pa-
tients with liver disease, cancer, and those on dialysis increased
significantly but remained < 2%.
Overall mortality
A total of 16,118 patients died, for an unadjusted mortality rate
of 9.9%. In multivariable analysis, adjusted odds of mortality de-
creased during the study period, with an odds ratio for 2018 of
E.J. Kaufman, P.M. Reilly, J.S. Hatchimonji et al. Injury 53 (2022) 2915–2922

Table 1
Characteristics of patients treated at Pennsylvania trauma centers, 1999–2018.

All patients Blunt multisystem Penetrating truncal injury Patients in shock

N = 162,646 N = 20,303 N = 17,058 N = 11,186

Age# 49 (29–70) 43 (26–61) 27 (21–38) 37 (24–57)
Male 108,936 (67.0) 13,879 (68.4) 15,338 (89.9) 8584 (76.7)
GCS Motor score
1–2 21,175 (13.0) 5694 (28.0) 4666 (27.4) 6650 (59.4)
3–4 3690 (2.3) 794 (3.9) 363 (2.1) 330 (3.0)
5–6 137,781 (84.7) 13,815 (68.0) 12,029 (70.5) 4206 (37.6)
Systolic blood pressure# 137 (118- 154) 127 (105–146) 120 (89–141) 63 (0–80)
Heart rate# 88 (75–102) 95 (80–112) 92 (72–110) 76 (0–107)
Injury severity score
< 16 80,006 (49.2) 66 (0.3) 8369 (49.1) 3367 (30.1)
16–24 59,413 (36.5) 7342 (36.2) 4103 (24.1) 3160 (28.2)
≥25 23,227 (14.3) 12,895 (63.5) 4586 (26.9) 4659 (41.7)
Mechanism of injury
Fall 49,581 (30.5) 3325 (16.4) 42 (0.2) 1069 (9.6)
Pedestrian/Pedal cyclist 9099 (5.6) 1982 (9.8) 10 (0.1) 860 (7.7)
Motor vehicle crash 43,569 (26.8) 10,237 (50.4) 7 (0.0) 2975 (26.6)
Motorcycle crash 10,222 (6.3) 2448 (12.1) 1 (0.0) 762 (6.8)
Firearm injury 14,935 (9.2) 17 (0.1) 11,574 (67.9) 3863 (34.5)
Struck 7593 (4.7) 447 (2.2) 55 (0.3) 183 (1.6)
Cut or stabbed 5521 (3.4) 28 (0.1) 4922 (28.9) 667 (6.0)
Other 22,126 (13.6) 1819 (9.0) 447 (2.6) 807 (7.2)
Comorbidities
Heart disease 20,888 (12.8) 1782 (8.8) 247 (1.4) 761 (6.8)
Liver disease 1666 (1.0) 191 (0.9) 43 (0.3) 124 (1.1)
Cancer 2209 (1.4) 167 (0.8) 46 (0.3) 95 (0.8)
Hypertension 52,095 (32.0) 4666 (23.0) 1205 (7.1) 1540 (13.8)
Dialysis 1076 (0.7) 87 (0.4) 14 (0.1) 47 (0.4)
Dementia 6820 (4.2) 418 (2.1) 19 (0.1) 117 (1.0)
Functional dependence∗ 4237 (2.6) 242 (1.2) 26 (0.2) 59 (0.5)
Peripheral vascular disease∗ 687 (0.4) 61 (0.3) 19 (0.1) 19 (0.2)
∗
Variables available 2012–2018.
#
Median (interquartile range). All others N (%).

Fig. 1. Change in Pennsylvania trauma patient characteristics over time, 1999–2018.

2917

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E.J. Kaufman, P.M. Reilly, J.S. Hatchimonji et al. Injury 53 (2022) 2915–2922

Fig. 2. Adjusted odds ratio of mortality for Pennsylvania trauma patients, 1999–2018
A: Overall mortality and blunt multisystem injury
B: Penetrating torso injury and patients presenting in shock.

2918

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E.J. Kaufman, P.M. Reilly, J.S. Hatchimonji et al.
Fig. 3. Adjusted odds ratio of mortality for Pennsylvania trauma patients by injury severity, 1999–2018.
0.75 (95% CI 0.66, 0.86). As shown in Fig. 2A, in multivariable anal-
ysis, odds of mortality were significantly lower than baseline in
20 07–20 09 and 2011–2018 compared to 1999. Additional factors
that were significantly associated with mortality in multivariable
analysis included patient age (OR 1.04, 95% CI 1.04–1.05), low GCS
motor score, abnormal vital signs, and higher ISS. Patients trans-
ferred in had lower odds of death (OR 0.62, 95% CI 0.58–0.65),
as did those with a mechanism of firearm injury or pedestrian
struck. Comorbidities associated with higher odds of mortality in-
cluded heart disease (OR 1.68, 95% CI 1.58–1.79), cancer (OR 2.16,
95% CI 1.89–2.46), and liver disease (OR 3.85, 95% CI 3.31–4.47).
Full regression results are included in the online supplementary
material.
Blunt multisystem injury
We identified 20,303 patients with blunt multisystem injury
(12.5% of trauma patients). The median age was 43 (IQR 26–61)
and 68.4% were male. The most common mechanism of injury was
motor vehicle crash (50.4) followed by fall (16.4%) and pedestrian
struck (9.8%). Median ISS was 27 (interquartile range 22–34). Unad-
justed mortality was 17.7%. In multivariable analysis, adjusted odds
of mortality decreased during the study period, with an odds ra-
tio for 2018 of 0.68 (95% CI 0.50–0.91). Odds of mortality were
significantly below baseline in 2003 and in 2006–2018, as shown
in Fig. 2A. Factors independently associated with mortality in this
group were similar to those in the overall population, though the
only mechanism independently associated with higher mortality
was pedestrian struck (OR 1.69, 95% CI 1.43, 2.02).
Penetrating truncal injury
We identified 17,058 patients (10.5%) with penetrating injury to
the neck, chest, or abdomen. The median age was 27 (interquar-
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Injury 53 (2022) 2915–2922
tile range 21–38) and 89.9% were male. Firearm injuries accounted
for 67.9% and cut or stab injuries for 28.9%. Median ISS was 16
(interquartile range 9–25). Unadjusted mortality was 24.9%, and
there was no significant change in adjusted mortality over time
as shown in Fig. 2B. Factors that were independently associated
with odds of mortality in multivariable analysis were similar to the
overall group. Compared to firearm injury, cut/stab injuries were
associated with lower odds of mortality (OR 0.18, 95% CI 0.15–
0.23).
Shock
Overall, 11,186 patients (6.9%) presented in shock. The median
age was 37 (IQR 24–57) and 76.7% were male. The most common
mechanism of injury was firearm (34.5%) followed by motor vehi-
cle crash (26.3) and median ISS was 21 (interquartile range 13–29).
Of the 6362 (56.9) patients in shock who died, 3664 (57.1%) died
within an hour of presentation, and another 1246 died between 1
and 6 h. There was no consistent change in risk-adjusted mortality
rates over time, but rates were higher in 2005 and 2016 as shown
in Fig. 2B.
Analysis stratified by injury severity
Of the 80,006 (49.2%) of patients with mild to moderate in-
juries (ISS < 16), unadjusted mortality was 4.7%. For the 59,413
(36.5%) with severe injuries (ISS 16–24), 10.0% died. Among the
23,227 (14.3%) with very severe injuries (ISS ≥ 25), 27.7% died.
In multivariable analysis, mortality declined significantly for mild-
moderate and severe injuries. For the very severe injuries, adjusted
odds of mortality were lower during the middle of the study pe-
riod, but returned to baseline between 2014 and 2016, as shown in
Fig. 3.
E.J. Kaufman, P.M. Reilly, J.S. Hatchimonji et al.
Discussion
Over 20 years, risk-adjusted mortality decreased by 25% for
the injured patients treated at Pennsylvania trauma centers. When
expected rates of mortality are recalculated annually, the bench-
mark changes over time. By calculating a single expected rate of
mortality for the 20-year period, we were able to compare out-
comes over time to assess absolute, as well as relative, improve-
ments. These results provide important context for performance
improvement efforts not revealed by annual performance reports
based on observed-to-expected ratios. Mortality improved signif-
icantly for key groups including patients with blunt multisystem
injury and those with mild to severe injuries. While this progress
is encouraging, it is limited, and vexing challenges remain in the
care for the most severely injured patients, and the overlapping
groups of patients with penetrating injury and those presenting
in shock. Moreover, the bulk of the improvement we see appears
to have occurred in the first 10 years of our study, as previously
documented by Glance et al. [7]. without additional improvement
in more recent years. Numerous practice changes and innovations
have focused on these high-risk patients, but with no discernible
change in risk-adjusted outcomes across Pennsylvania. While all
patients stand to benefit from ongoing innovation and quality im-
provement, those who have been refractory to our efforts thus far
deserve our focused attention moving forward.
The retrospective nature of this study prevents us from iden-
tifying any particular clinical innovation or performance improve-
ment effort responsible for the improvements we saw, but several
major changes in trauma care during this period are likely to have
benefited patients with blunt, multi-system injury and the overall
trauma population. Cross sectional imaging has become widely and
readily available, as have interventional radiologic techniques for
controlling hemorrhage and infection. The concept of damage con-
trol has become central to the management of seriously injured
patients during this time period and can decrease mortality sub-
stantially in high-risk patients [16]. Damage control resuscitation
and balanced blood product resuscitation have also been widely
adopted over the last two decades, and have been shown to reduce
mortality [17]. Moreover, these 20 years have seen increasing focus
on performance improvement within trauma systems, as evidenced
by widespread adoption of the Trauma Quality Improvement Pro-
gram, initiated in 2008 [18]. While these initiatives in themselves
are not enough to improve quality of care [19], they have brought
a focus on preventing and managing complications, which can be
key to reducing later mortality after injury [20]. For example, since
2016, the Pennsylvania Trauma System Foundation quality collab-
orative has used TQIP data to identify statewide priorities for im-
provement and to share best practices and strategies for change
[21].
Patients in shock represent the highest risk group of injured
patients. Death rates remain high, and the bulk of deaths occur
soon after injury. Our findings are consistent with prior evidence—
for example, in the Resuscitation Outcomes Consortium multicen-
ter randomized trial, Tisherman et al. found that median time to
death for patients in shock was 2 h [22]. This short time frame
may limit our opportunity for intervention, but we must do better.
We also saw no improvement in survival for patients with pen-
etrating injury, with deaths again occurring primarily early and
among patients who also presented in shock. These results par-
allel findings that patients with penetrating trauma and hypoten-
sion have very short times to death [23]. Our findings reinforce
those reported by Glance et al. for the same trauma system in a
time period overlapping the first portion of the current study [7].
A recent study of patients undergoing massive transfusion showed
similar lack of improvement [24]. Since the advent of hemostatic
resuscitation, efforts to offer better care to these patients have fo-
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Injury 53 (2022) 2915–2922
cused resuscitation and on reducing time to definitive surgical con-
trol. Rapid identification of patients at risk is necessary along with
rapid intervention, but at least two key innovations in Pennsylva-
nia have not shown clear benefit. First, in Philadelphia, an increas-
ing majority of patients with penetrating injury are transported
by police with no prehospital intervention and exceedingly short
prehospital times. Although many have hypothesized that rapid
transit to definitive care is life-saving for these patients, studies
have shown equivalent outcomes to ambulance transport, without
demonstrating a clear advantage [25,26]. A recent analysis demon-
strated that patients transported by police were less likely to be
dead upon arrival[26] and Maher et al. found that patients trans-
ported by police had more severe injuries but similar survival to
those transported by EMS [27]. While this may indicate an inter-
venable subgroup, it is also possible that rapid transport of pa-
tients with unsurvivable injuries falsely elevates in-hospital mor-
tality rates in a way not fully accounted for by our risk adjustment
models. Second, the University of Pittsburgh has pioneered the use
of plasma for prehospital resuscitation. These results are relatively
recent, and may not be reflected in survival rates reported in this
study [28]. Likewise, optimizing use of pre- and in-hospital tranex-
amic acid administration holds some promise for patients in hem-
orrhagic shock [29]. Efforts to shorten transport times through al-
location of transport resources; strategic location of trauma centers
[30]; and reducing time spent on field interventions may still prove
useful. Rigorous implementation of transfusion protocols is cru-
cial, including thromboelastography[31], balanced transfusion ra-
tios[32,33], whole blood[34], and medical adjuncts such as tranex-
amic acid[35], calcium [36], and arginine vasopressin[37]. Emerg-
ing hemorrhage control technologies for field and hospital use may
also help move us toward zero preventable deaths [38].
Our study has inherent limitations, including the potential for
variation in data entry and coding inherent in a retrospective, reg-
istry study. We saw substantial changes in the population and in-
juries treated at Pennsylvania trauma centers over 20 years. Con-
sistent with national evidence, the proportion of patients who
were 65 or older nearly doubled in this time frame [39]. It is
also possible that the nature of the injured population of the state
changed less or differently than our results would make it ap-
pear. If subgroups were more or less likely to be admitted to the
hospital or to present to or be transferred into a trauma cen-
ter, their representation in this data would be altered. Without
true population-level surveillance that includes non-trauma cen-
ters and non-admitted patients, our ability to assess injury out-
comes accurately remains limited [40]. We were not able to assess
preventability of death. If we could reliably exclude the subset of
deaths that were non-preventable, an analysis focusing on the re-
mainder might be more accurate. To compensate for the change
in AIS system, we used diagnosis codes to estimate AIS and ISS
scores, which may have introduced bias. Our study spanned the
transition from ICD-9 to 10, and changes in diagnosis coding for
injuries and comorbidities may have influenced our results. Injury
severity score remains an imperfect metric for assessing risk, par-
ticularly for those with penetrating injury [41]. We did not assess
for within-center correlation in this analysis. Finally, both the cur-
rent study and the American College of Surgeons’ Trauma Quality
Improvement Project focus on outcomes at the level of the trauma
center, but factors that contribute to outcomes after injury span
a continuum which includes the prehospital setting and presenta-
tions to non-trauma centers followed by transfer to trauma centers.
It is therefore likely that some of the factors which influence pa-
tient outcomes are beyond the control of trauma centers and may
have changed in ways that we cannot account for in the current
study. We chose to focus on in-hospital mortality as this outcome
is unambiguous and universally assessed. It is not, however, the
only or necessarily the most important outcome. Complications,
E.J. Kaufman, P.M. Reilly, J.S. Hatchimonji et al.
length of stay, long-term functional status, and costs all must play
a role in assessing the quality of trauma care but have not been
recorded in a consistent fashion at all centers over this 20-year
time frame. Tracking these outcomes would allow us to assess care
more accurately, particularly in groups of patients with low rates
of inpatient mortality. Ground level falls, for example, make up a
rising segment of trauma care, and may have long-term implica-
tions for health and well-being that are not captured in mortality
statistics [42,43].
Conclusion
Over 20 years, risk-adjusted mortality decreased by 253% for
the injured patients treated at Pennsylvania trauma centers, but
gains did not extend to patients with penetrating injury or those
presenting in shock. While trauma center performance reporting
typically compares centers to one another in a cross-sectional
fashion, this practice may obscure system-level change over time.
Center- and system-level performance improvement should con-
sider absolute as well as relative progress in patient outcomes.
Longitudinal, system-level outcomes are crucial to identifying key
areas for performance improvement, particularly for challenging
injury patterns and patient groups.
Funding/Financial support
No specific funding was obtained for this research. Dr. Kaufman
is supported by AHRQ (grant 5K12 HS026372).
Declaration of Competing Interest
The authors have no conflicts of interest to report.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.injury.2022.06.011.
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