Abstract
Background: Injury represents 260,000 hospitalisations and $27 billion
in healthcare costs each year in Canada. Evidence suggests that there is
significant variation in the prevalence of hospital admissions among ED
presentations between countries and providers but we lack data specific
to injury admissions. We aimed to estimate the prevalence of potentially
low-value injury admissions following injury in a Canadian provincial
trauma system, identify diagnostic groups contributing most to low-value
admissions and assess inter-hospital variation.
Methods: We conducted a retrospective multicenter cohort study based on
all injury admissions in the Québec trauma system (2013-2018). Using
literature and expert consultation, we developed criteria to identify
potentially low-value injury admissions. We used a multilevel logistic
regression model to evaluate inter-hospital variation in the prevalence
of low-value injury admissions with intraclass correlation coefficients
(ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+
years).
Results: The prevalence of low-value injury admissions was 16%
(n=19,163) among all patients, 26% (2136) in children, 11% (4695) in
young adults and 19% (12,345) in older adults. Diagnostic groups
contributing most to low-value admissions were mild traumatic brain
injury in children (48% of low-value pediatric injury admissions;
n=922), superficial injuries (14%, n=660) or minor spinal injuries
(14%, n=634) in adults aged 16-64, and superficial injuries in adults
aged 65+ (22%, n=2771). We observed strong inter-hospital variation in
the prevalence of low-value injury admissions (ICC=37%).
Conclusion: One out of six hospital admissions following injury may be
of low-value. Children with mild traumatic brain injury and adults with
superficial injuries could be good targets for future research efforts
seeking to reduce health care services overuse. Inter-hospital variation
indicates there may be an opportunity to reduce low-value injury
admissions with appropriate interventions targeting modifications in
care processes.
What is known
Low-value care leads to inefficient use of resources and less
favorable patient outcomes.
The literature suggests that unnecessary hospitalisations may be
prevalent but we lack data on this problem for injury admissions.
What this study adds
We found high variability in the prevalence of potentially low-value
injury admissions between hospitals in a trauma system, suggesting the
presence of low-value care.
Results suggest that children with mild traumatic brain injury and
adults with superficial injuries or minor spine injuries may
constitute targets for future research aiming to assess benefits &
harms and identify solutions to reduce unnecessary injury admissions.
Introduction
Injury represents 3.5 million visits to emergency rooms and 260,000
hospitalisations per year in Canada1. Furthermore,
injury care costs Canadians $27 billion per year, more than heart and
stroke disease combined1. Evidence suggests that
low-value care, defined as the provision of medical services for
which the potential for harm exceeds the potential for benefit ,
consumes around 30% of healthcare resources2, 3.
Research has shown that there is considerable variation in the
prevalence of hospital admissions among ED presentations between
countries and providers4-6, suggesting the presence of
low-value hospital admissions2. These admissions
contribute to hospital overcrowding, increased costs, medical errors,
mortality, morbidity and functional decline7-9. A
recent scoping review and expert consultation survey identified hospital
admission in specific injury populations as a potentially low-value
practice10. However, we lack knowledge on the
frequency of low-value injury admissions and on inter-provider
variations.
The objectives of this study were to estimate the prevalence of
potentially low-value injury admissions following injury, identify
diagnostic groups that most contributed to low-value admissions, and
assess inter-hospital variation.
Methods
Study Design &
Population
Our multicenter, retrospective cohort study was based on the 59
designated trauma centers of the Québec trauma care continuum, an
integrated trauma system covering a population of 8.5 million in a
geographic area of approximately 1.7 million km2 that
provides care for approximately 20,000 injured patients each
year11. The system comprises 3 level I adults trauma
centers and 2 pediatric trauma centers providing highly specialized care
in metropolitan areas (Montréal and Québec city), 5 level II centers
offering similar services in smaller urban areas (i.e. lower volume), 22
level III and 27 level IV centers generally in rural areas that
stabilize major trauma cases then transfer them to high level care. We
included all patients admitted with a primary diagnosis of injury from
April 1, 2013 to March 31, 2018 to any trauma center in the system.
Patients were followed from hospital admission to discharge.
Study
Data
We extracted data from the Québec trauma registry, based on mandatory
data collection for all hospital admissions for which injury was the
primary motivation in all provincial trauma centers. Data is collected
prospectively from patient charts in each center by trained medical
coders. The registry is centralized and managed by the Québec Ministry
of Health and Social Services. Data quality mechanisms include
standardized training for medical coders, periodic validation of the
data to correct incoherence and continuous facilitated information
exchange between data coders, trauma coordinators and clinical
experts12. Random re-abstraction of patient chart data
suggests the trauma registry has 98% accuracy on patient demographics,
vital status, injury codes, interventions and discharge destinations
(data not published).
Selection of Criteria to Identify
Low-Value Injury
Admissions
We used recommendations for the design and content validation of health
instruments to develop a tool to identify potentially low-value injury
admissions from the Québec trauma registry13. First, a
trauma registry specialist, a trauma researcher and a trauma clinical
expert used published literature14-22 and their
knowledge on trauma systems to select and define criteria consistent
with patients not requiring hospitalisation (Supplemental Digital
Content 1). For example, minor injury defined as a maximum Abbreviated
Injury Scale (AIS) score ≤ 2 and the absence of interventions requiring
hospitalisation, such as a surgery. Second, 8 experts (2 emergency
physicians, 2 critical care physicians, a trauma surgeon, a general
practitioner, a trauma care coordinator, and a trauma system manager)
were individually consulted to validate the relevance and the definition
of each criteria and were asked if any other criteria should be added.
Based on these consultations, the list of interventions that did not
require hospitalization was modified. Third, criteria were applied to
trauma registry data and an age-stratified random sample of patient
records were extracted and revised by the same experts to refine
criteria. This last step was repeated three times until no further
modifications were suggested. Criteria which were suggested but not
retained in the final version were considered in sensitivity analyses
(see section below). The final tool included 6 criteria (supplemental
digital content 1).
Statistical
Analysis
To identify diagnostic groups most contributing to low-value injury
admissions, our steering committee grouped ICD primary diagnosis codes
(supplemental digital content 2) and we stratified them by age group
(1-15, 16-64, 65-74, 75+). We then described the following aspects of
resource use among low-value admissions: i) therapeutic interventions in
the ED and following admission (grouped as medication,
reduction/immobilization, skin repair, other; supplemental digital
content 1), ii) diagnostic imaging in the ED and following admission
(none, X-ray, computed tomography by body region, magnetic resonance
imaging, angiography/arteriography), iii) length of hospital stay (days
from admission to discharge).
To evaluate inter-hospital variation in the prevalence of low-value
injury admissions, we used a multilevel logistic regression model to
generate intraclass correlation coefficients (ICC). Inter-hospital
variation was considered to be weak, moderate and strong for ICC under
5%, between 5% and 20%, and over 20%,
respectively23. We adjusted for patient case mix using
age (1-4, 5-12, 13-15, 16-54, 55-64, 65-74, 75-84, 85+), sex, anatomic
injury severity (New Injury Severity Score; 1-3, 4, 5-6, 8-11,
≥12)24, the Glasgow Coma Scale (GCS) score on arrival
in the ED (≤13, 14, 15), injury mechanism (motor vehicle collision, fall
from height, fall from own height, knife/firearm, other), number of
injuries (1, 2, 3+), primary injury diagnosis and number of
comorbidities (0, 1, 2, 3+). Analyses were conducted for the whole
sample and according to age (1-15, 16-64, 65-74, 75+). We handled
missing data on the GCS, often not evaluated in patients with minor,
extracranial injury, using multiple imputation according to recent
recommendations25.
Sensitivity
analyses
We conducted sensitivity analyses for criteria that were mentioned by
members of the steering committee during the development of criteria to
identify low-value injury admissions but did not gain consensus. Thus,
we successively removing patients in whom hospital admission may have
been justified from the numerator: i) patients with a GCS of 13 or 14 on
arrival, ii) patients who developed complications during their stay,
iii) patients discharged home with services or to long-term care/nursing
home, and iv) patients transferred-in from another hospital. For each
sensitivity analysis, we compared the prevalence of low-value admissions
and inter-hospital variation (ICC) to values from the main analysis.
All analyses were performed using Statistical Analysis Software (SAS
Institute, Cary, NC, version 9.4). The study was approved by the
research ethics committee of the CHU de Québec – Université Laval.
Results
Our study sample included 118,032 injury admissions, of which 19,163
(16%) were considered to be potentially low-value (Figure 1,
Supplemental Digital Content 1). This proportion was 26%, 11%, 14%
and 20% in children, young adults, adults 65 to 74 years of age and
adults over 74 years of age, respectively. Overall, 64% of patients
were aged 65 years or older, 39% were male, 75% were injured in a fall
and 53% had isolated injuries (Supplemental Digital Content 3).
Children had less severe injuries (59% with maximum AIS=1 compared to
40% in adults), more head injuries (60% compared to 20% in adults)
and were more often transferred-in from another hospital (16% compared
to 6% in adults).
The diagnostic groups contributing most to low-value injury admissions
were mild traumatic brain injury in children (n=922; 48% of low-value
pediatric injury admissions; Figure 2), superficial injuries (660; 14%)
or minor spine injuries (634; 14%) in adults aged 16-64, and
superficial injuries in adults aged 65+ (2771; 22%).
Out of the 19,163 patients with a potentially low-value injury
admission, 5582 (29%) had a therapeutic intervention considered not to
require hospital admission (Supplemental Digital Content 1; Figure 3) in
the emergency department and 3471 (18%) patients had such an
intervention after admission. Administration of medication was the most
common intervention in every patient group, except patients with an
extremity fracture, in whom reductions and immobilizations were more
frequent. In addition, physiotherapy and social services consultations
were used in 51% and 29% of patients, respectively. These numbers went
up to 70% and 41% in patients aged 75 +.
Overall, 18,265 (95%) patients had at least one diagnostic imaging
procedure (Table 2), of which over 90% were conducted in the ED. X-ray
was used in over 90% of patients in every age group except children.
Head CT was the predominant advanced imaging modality in every age group
(38% of patients). Median length of stay varied from 1 day in children
to 13 days in adults aged 75+ and varied across diagnostic groups (Table
1). Our population of potentially low-value injury admissions in the
Québec trauma system accrued on average 36,642 hospital days per year.
Among the 19,163 potentially low-value injury admissions, there were
over 2,500 complications including 520 cases of delirium, 598 urinary
tract infections, 50 stage II-IV decubitus ulcers and 98
hospital-acquired pneumonias.
We observed strong inter-hospital variations in the prevalence of
potentially low-value injury admissions, with an ICC of 37% (Figure 4).
When we stratified by age, inter-hospital variations remained strong for
patients aged 74 + and were moderate for every other age group
(Supplemental Digital Content 4). Even within designation levels,
variation remained high with prevalences varying between 10% and 23%
for level I and II trauma centers. However, highly specialized (level
I/II) centers had lower average prevalences than smaller referral (level
III/IV) centers.
Sensitivity
analyses
When patients with a GCS of 13 or 14 or patients who developed an
in-hospital complication were removed, prevalence and ICCs all changed
by less than 10% (Supplemental Digital Content 5). The removal of
patients transferred-in had an impact on prevalence in children (22%
compared to 26%) as did the removal of patients who were discharged
home with services or to long-term care or a nursing home (6% compared
to 16%). However, all ICC remained over the threshold for strong
inter-hospital variation.
Discussion
In this multicenter retrospective cohort study, 16% of all injury
admissions in a Canadian trauma system were potentially low-value.
Predominant diagnostic groups included mild traumatic brain injury in
children, superficial injuries or minor spine injuries in adults aged
16-64, and superficial injuries in adults aged 75+. Prevalences varied
from 0% to 34% between hospitals.
The important contribution of children with mild traumatic brain injury
to potentially low-value injury admissions is consistent with other
studies on children admitted for observation with minor head injury
despite extremely low rates of missed injuries16-18,
26-31. Contributory factors documented in the literature include the
lack of ability of children to communicate symptoms, perceived
seriousness of the consequences of missed injuries, physician discomfort
with prognostication in non-pediatric centers, pressure from parents,
concerns about non-accidental injury, and observation to avoid exposure
to ionizing radiation from CT32-36. However, 368
(40%) of children admitted for mild traumatic brain injury had a CT in
the ED. Children represented only 2% (737 days) of hospital days per
year accrued for potentially low-value injury admissions in our study
population.
Adults aged 16-64 had the lowest prevalence of low-value admissions.
They also had the most varied primary diagnoses, with none representing
more than 14% of admissions. They had the highest frequency of motor
vehicle collisions, which is widely used as a triage criteria because of
its potential for serious injuries, but often leads to
overtriage37. Intoxication could also explain
potentially low-value admissions in these patients, since substance
abuse is most prevalent in this group and intoxicated patients pose a
challenge in terms of diagnostic evaluation, notably for traumatic brain
injuries and spinal injuries38, 39. This group
represented 11.4% (4,181 days) of hospital days per year accrued for
potentially low-value injury admissions in our study population.
Patients aged 65 years and over comprised 64% of the low-value
admissions in our sample. Factors contributing to admission in this
population may be frailty, low mobility, lack of social support,
cognitive conditions or comorbidities40-42. They may
be admitted while social service evaluations are conducted and/or
alternative care is secured. Research has shown that these patients are
particularly complex to care for since many have important
comorbidities, difficulties with mobility or communication, or develop
delirium, all of which contribute to longer lengths of
stay43. They are also more susceptible to
hospital-related adverse events such as functional decline or nosocomial
infections, which often lead to additional hospital
days44, 45. Delayed discharge due to problems
accessing post-acute care is also a problem in older
adults46, 47. This age group represented 86.6%
(31,724 days) of hospital days per year accrued for potentially
low-value injury admissions in our study population.
We observed strong inter-hospital variation in the prevalence of
potentially low-value injury admissions, but more specialized trauma
centers, in general, had a lower prevalence than level III and IV
centers. A potential explanation is that physicians working in centers
with a higher volume of injury presentations have a better understanding
of whether or not patients require hospital admission. This may also be
due to bed availability, which could be less of an issue in rural
hospitals due to low patient volume48.
Most patients did not receive any therapeutic intervention while others
received interventions that can be administered in the ED (e.g. closed
reductions, immobilisations or administrations of analgesics or
antithrombotics). However, the majority of patients received a
radiographic evaluation and/or a CT scan, over 90% of which were done
before admission. This is consistent with estimates of overuse of
imaging, notably for minor head injury34, 49.
Strengths and
limitations
We had access to high-quality, current clinical data which, contrary to
hospital discharge data, has detailed information on physiological
parameters and anatomical injury severity. Furthermore, unlike many
trauma registries that condition inclusion on injury severity, the
Québec trauma registry includes all hospital admissions for injury in
any designated trauma center. However, our study did not include
patients admitted to non-designated hospitals, which are estimated to
represent 25% of all injury admissions. Thus, we may have
underestimated the prevalence of low-value injury admissions because
non-designated hospitals could be less comfortable with discharging
patients from the ED, even for minor injuries. Due to the lack of a
validated definition for low-value injury admissions, we used broad
filters based on literature and expert consultations and conducted
extensive sensitivity analyses. Therefore, despite efforts to develop a
clinically meaningful definition (including revision of a random
stratified sample of patients included and excluded after each iteration
of the algorithm), cases can only be interpreted as potentiallylow-value. We did not exclude patients based on comorbidities as we had
no information on their severity and most patients over 65 had at least
one comorbidity, which may be well controlled and unrelated to
admission. Considering the retrospective nature of our data, our study
is subject to potential measurement error and missing data (50% for the
GCS). There may be measurement error among variables used to adjust
inter-hospital comparisons (e.g. under-reporting of comorbidities). We
may also have omitted potential confounders such as patient mobility,
pain, socio-economic status and social support, because they were not
available in the registry. This could lead to an overestimation of
inter-hospital variation. In addition, the registry does not contain
information on patients who were returned home from the ED so we could
not compare patients admitted to those who were not. Finally, there is
also a possibility that hospitals with a low prevalence of low-value
injury admissions are undertriaging patients in which hospital admission
was required. However, we consider this unlikely as highly specialized,
high-volume centers in which undertriage is less likely, tended to have
a lower prevalence than lower-level centers in our sample.
Impact and future
research
This study sets the foundation for further research targeting improved
value in injury care. This research should aim to determine whether
low-value injury admissions could be reduced by interventions optimizing
care in the ED or in the community and should consider healthcare
professionals, patient and family perspectives. First, we will need to
assess whether low-value admissions are potentially avoidable using case
revision methodology. We would then need to identify modifiable
contributing factors, for example discomfort with clinical examination
and management of children with traumatic brain injury in non-pediatric
centers and difficulty obtaining physiotherapy evaluation and social
services consultations in the ED to determine if older adults can be
safely discharged with available community services. Thereafter,
interventions such as Audit & Feedback with a positive deviance
approach and consensus recommendations could be used to modify care
processes (e.g. inter-hospital transfer, virtual consultations,
screening tools, community services). Older adults are of particular
interest. On one hand, their complexity and frailty makes it harder to
adequately modify practices to reduce care. On the other hand, they are
a group in which such modifications could yield considerable gains both
in terms of resources saved and improved outcomes since they have a high
risk of functional decline and other hospital-related adverse
events44, 45.
Conclusion
In the inclusive trauma system of the province of Québec, we estimated
that one out of six hospital admissions following injury may be
low-value. This represented on average 36,642 hospital days per year in
the 59 designated trauma centers in the province of Québec alone. These
resources may be better invested in ambulatory care. Children with mild
traumatic brain injury, young adults with superficial injuries or minor
spine injuries, and older adults with superficial injuries may be good
targets for future research efforts seeking to reduce overuse. Strong
variations between providers suggests that appropriate interventions
have the potential to reduce low-value injury admissions following
injury in Canada and thus improve patient outcomes and free up
resources. We expect our results to be generalizable to other Canadian
provinces. Future research should aim to identify modifiable
determinants of low-value injury admissions and to develop potential
solutions, which consider healthcare professional, patient and family
perspectives.
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