Much of the focus of process improvement in trauma centers has centered on public reporting and unblinding trauma outcomes. But as a field, trauma has struggled with achieving effective process improvement through public reporting, leaving many asking whether current methods of reporting are effective and how they could potentially be improved.
Dr. Mark J. Kaplan’s lecture “The Case For and Against Unblinding Trauma Center Outcomes,” now available for CME credit through AudioDigest, takes a closer look at the issue.
Public Reporting: A Complex Problem
Public reporting of trauma outcomes aligns well with a public health model, especially considering that traumatic injuries are one of our greatest health challenges.
According to Dr. Kaplan’s research, we spend $670 billion a year worldwide in combined costs and lost productivity, handling 39 million ED visits and 12.3 million hospital visits because of traumatic injury. With this burden in mind, he argues that we need methods of quality improvement and prevention. This leaves us asking how we can educate the public, since public awareness will be the cornerstone of instituting improvements.
Measures of trauma outcomes shouldn’t be the same as those used in less complex healthcare environments with fewer performance variables (cardiac surgery, for example), according to Dr. Kaplan. Trauma situations involve over 300 variable factors, including resource allocation, location and case mix index that can all influence outcomes.
And trauma care is a system that’s bigger than any individual center. It functions at the local and even regional levels to decrease morbidity and mortality, adding to variability and increasing the challenge of reporting data that can effect change. Even so, regulatory bodies still use oversimplified methods for certifying hospitals.
Informing the Public
Dr. Kaplan explains that when public transparency of trauma outcomes first became prominent, the initial thought was that consumers would increase their knowledge, make better decisions and drive improvements through increased competition, pushing out low-quality practices and performers. But trauma centers aren’t Kmart. They don’t compete with each other; they collaborate. No major trauma outcome study has proven that releasing data without the context of trauma care’s complexities improves outcomes in any significant way.
This is in part because patients don’t understand the variability of the trauma center. In a national survey cited by Dr. Kaplan, 61% of respondents indicated that they recognized injury was a leading cause of death in the U.S.; 94% expected to be taken to a trauma center but, at the same time, weren’t sure what trauma centers do or if there was even one close to their hospital.
If trauma center results are unblinded, Dr. Kaplan suggests that data be gathered for the education of the public and not for marketing efforts, as has become common. Initiatives like the “STOP THE BLEED” campaign and effective advocacy for gun control and violence reduction programs should be included in reporting. These programs have been proven to reduce mortality rates and improve outcomes and are a more effective way to use data to improve surgeons’ work.
The Downside of Public Reporting
As it stands, public reporting only supports the possibility of improvement in areas where results are measured. This potentially myopic and short-term approach means that we sacrifice broad organizational objectives. For example, we may improve mortality rates for a six-month period but miss out on long-term improvements in our work and how we’re treating patients.
Additionally, issues with the potential misrepresentation and massaging of data make outcomes appear more positive than they might be, along with the Hawthorne effect — gaming measurement periods by changing behavior while under observation, meaning results reflect that behavior and not true practices. At the same time, the Hawthorne effect isn’t completely negative if it incentivizes trauma centers to pay more attention to how they can improve outcomes.
How We Should Approach Unblinding
Unblinding reporting of trauma outcomes does have potential benefits, but it should be approached as a system-wide effort and an educational program, going beyond improved mortality rates as the only measure.
If it’s not approached properly, Dr. Kaplan explains, we could see increased confusion and decreased public confidence in trauma centers overall. Data reported should include elements like:
Pre- and post-hospital care.
Recovery and disability.
Cost of long-term care.
Results of trauma prevention programs.
Overall trauma prevention within a community.
Additionally, data should be reported by systems at the local, regional and national levels, not individual centers, which will prevent centers from using data in marketing. We should collaborate to create a mechanism to improve the quality and consistency of care; this will allow us to validate data over larger populations and sample sizes. The public should also be informed of trauma costs so they understand just how expensive it is to run a trauma center.