Patient-level resource use for injury admissions in Canada: A multicentre retrospective cohort study

  • Teegwendé V. Porgo
    Affiliations
    Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada

    Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
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  • Lynne Moore
    Correspondence
    Corresponding author at: CHU de Québec Research Center (Enfant-Jésus Hospital), Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie – Urgence - Soins intensifs (Trauma – Emergency – Critical Care Medicine), 1401, 18e rue, local Z215, Québec, QC, G1J 1Z4, Canada.
    Affiliations
    Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada

    Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada
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  • Catherine Truchon
    Affiliations
    Institut national d’excellence en santé et en services sociaux (INESSS), Québec, QC, Canada
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  • Simon Berthelot
    Affiliations
    Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada

    Department of family medicine, Université Laval, Québec, QC, Canada
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  • Henry T. Stelfox
    Affiliations
    Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
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  • Peter A. Cameron
    Affiliations
    Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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  • Belinda J. Gabbe
    Affiliations
    Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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  • Jeffrey S. Hoch
    Affiliations
    Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada

    Department of Public Health Sciences, University of California, Sacramento, CA, United States
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  • David C. Evans
    Affiliations
    Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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  • François Lauzier
    Affiliations
    Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada

    Department of Anaesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada
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  • Francis Bernard
    Affiliations
    Department of Medicine, Université de Montréal, Montréal, QC, Canada
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  • Alexis F. Turgeon
    Affiliations
    Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada

    Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec (Hôpital de l’Enfant-Jésus), Université Laval, Québec, QC, Canada

    Department of Anaesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada
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  • Julien Clément
    Affiliations
    Institut national d’excellence en santé et en services sociaux (INESSS), Québec, QC, Canada

    Department of Surgery, Université Laval, Québec, QC, Canada
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      Highlights

      • Resource use in a mature, inclusive Canadian trauma system is not solely explained by baseline risk of patients.
      • The strongest determinant of resource use was discharge destination (Cohen’s f2 = 7%) which may reflect delays in access to post-acute care.
      • While risk-adjusted resource use increased with increasing age and comorbidities for the regular ward and ICU, it decreased for the OR.
      • Risk-adjusted resource use was 18% higher in level I centres compared to level IV centres.
      • We observed significant variations in resource use across centres (ICC = 5%; 95% CI = 4–6), particularly for the OR (28% [
        • Canby 4th, J.B.
        Applying activity-based costing to healthcare settings.
        ,
        • The US Agency for International Development
        Cost and quality in healthcare: reference manual.
        ,
        • Guyatt G.H.
        • Oxman A.D.
        • Kunz R.
        • Jaeschke R.
        • Helfand M.
        • Liberati A.
        • et al.
        Incorporating considerations of resources use into grading recommendations.
        ,
        • Christensen M.C.
        • Nielsen T.G.
        • Ridley S.
        • Lecky F.E.
        • Morris S.
        Outcomes and costs of penetrating trauma injury in England and Wales.
        ,
        • Christensen M.C.
        • Ridley S.
        • Lecky F.E.
        • Munro V.
        • Morris S.
        Outcomes and costs of blunt trauma in England and Wales.
        ,
        • Curtis K.
        • Lam M.
        • Mitchell R.
        • Dickson C.
        • McDonnell K.
        Major trauma: the unseen financial burden to trauma centres, a descriptive multicentre analysis.
        ,
        • Brock G.N.
        • Barnes C.
        • Ramirez J.A.
        • Myers J.
        How to handle mortality when investigating length of hospital stay and time to clinical stability.
        ,

        Ministère de la Santé et des Services Sociaux, Direction générale des services de santé et de la médecine universitaire. Cadre normatif - Registre des traumatismes du Québec (RTQ). Version 1.0, Avril 2004.

        ,

        Ministère de la Santé et des Services sociaux du Québec. Banque de données ministérielles MED-ÉCHO. Régie de l’assurance maladie du Québec. http://www.ramq.gouv.qc.ca/en/data-statistics/Pages/data-statistics.aspx.

        ,

        Ministère de la Santé et des Services sociaux du Québec. Rapports financiers annuels des établissements 2015–2016, statsitiques et données. http://publications.msss.gouv.qc.ca/msss/document-001671/. Published 2016.

        ,

        Ministère de la Santé et des Services sociaux du Québec. Normes et pratiques de gestion, Tome II, Répertoire. http://msssa4.msss.gouv.qc.ca/fr/document/d26ngest.nsf/1f71b4b2831203278525656b0004f8bf/c1bc430d41b48eea85257f9500673c97?OpenDocument. Published 2016.

        ,
        • Canadian Agency for Drugs and Technologies in Health
        Guidelines for the economic evaluation of health technologies: Canada.
        ,

        Ministère de la Santé et des Services sociaux du Québec. Liste par centre d’activités (établissement). http://msssa4.msss.gouv.qc.ca/fr/document/d26ngest.nsf/lca?OpenView&Start=204.

        ,
        • Moore L.
        • Hanley J.A.
        • Turgeon A.F.
        • Lavoie A.
        Evaluating the performance of trauma centers: hierarchical modeling should be used.
        ,
        • Daly L.
        • Bourke G.J.
        Interpretation and uses of medical statistics.
        ,
        • Selya A.S.
        • Rose J.S.
        • Dierker L.C.
        • Hedeker D.
        • Mermelstein R.J.
        A practical guide to calculating Cohen’s f 2, a measure of local effect size, from PROC MIXED.
        ,
        • Porgo T.V.
        • Moore L.
        • Tardif P.A.
        Evidence of data quality in trauma registries: a systematic review.
        ,
        • Little R.J.A.
        • Rubin D.B.
        Statistical analysis with missing data.
        ,
        • Allison P.D.
        Missing data. Sage university papers series on quantitative application in the social sciences.
        ,
        • Sterne J.A.
        • White I.R.
        • Carlin J.B.
        • Spratt M.
        • Royston P.
        • Kenward M.G.
        • et al.
        Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls.
        ,
        • Moore L.
        • Lavoie A.
        • LeSage N.
        • Liberman M.
        • Sampalis J.S.
        • Bergeron E.
        • et al.
        Multiple imputation of the glasgow coma score.
        ]).

      Abstract

      Background

      Variations in adjusted costs have been observed among trauma centres in the United States but patient outcomes were not better in centres with higher costs. Attempts to improve injury care efficiency are hampered by insufficient patient-level information on resource use and on the drivers of resource use intensity.

      Objectives

      To estimate patient-level resource use for injury admissions, identify determinants of resource use intensity, and evaluate inter-hospital variations in resource use.

      Methods

      We conducted a retrospective cohort study including ≥16-year-olds admitted to adult trauma centres in a mature, inclusive Canadian trauma system between 2014 and 2016. We extracted data from the trauma registry and hospital financial reports. We estimated resource use with activity-based costs, identified determinants of resource use intensity using a multilevel linear model and assessed the relative importance of each determinant with Cohen’s f2. We evaluated inter-provider variations with intraclass correlation coefficients (ICC) and 95% confidence intervals.

      Results

      We included 32,411 patients. Median costs per admission were $4857 (Quartiles 1 and 3 2961–8448). The most important contributors to total resource use were the medical ward (57%), followed by the operating room (OR; 23%) and the intensive care unit (13%). The strongest determinant of resource use intensity was discharge destination (Cohen’s f2 = 7%). The most resource intense patient group was spinal cord injuries with $11,193 (7115–17,606) per admission. While resource use increased with increasing age for the medical ward, it decreased with increasing age for the OR. Resource use was 18% higher in level I centres compared to level IV centres and we observed significant variations in resource use across centres (ICC = 5% [
      • Parachute
      The cost of injury in Canada.
      ,
      • Glance L.G.
      • Dick A.W.
      • Osler T.M.
      • Meredith W.
      • Mukamel D.B.
      The association between cost and quality in trauma: is greater spending associated with higher-quality care?.
      ,
      • Clancy T.V.
      • Maxwell G.J.
      • Covington D.L.
      • Brinker C.C.
      • Blackman D.
      A statewide analysis of level I and II trauma centers for patients with major injuries.
      ]), particularly for the OR (28% [
      • Canby 4th, J.B.
      Applying activity-based costing to healthcare settings.
      ,
      • The US Agency for International Development
      Cost and quality in healthcare: reference manual.
      ,
      • Guyatt G.H.
      • Oxman A.D.
      • Kunz R.
      • Jaeschke R.
      • Helfand M.
      • Liberati A.
      • et al.
      Incorporating considerations of resources use into grading recommendations.
      ,
      • Christensen M.C.
      • Nielsen T.G.
      • Ridley S.
      • Lecky F.E.
      • Morris S.
      Outcomes and costs of penetrating trauma injury in England and Wales.
      ,
      • Christensen M.C.
      • Ridley S.
      • Lecky F.E.
      • Munro V.
      • Morris S.
      Outcomes and costs of blunt trauma in England and Wales.
      ,
      • Curtis K.
      • Lam M.
      • Mitchell R.
      • Dickson C.
      • McDonnell K.
      Major trauma: the unseen financial burden to trauma centres, a descriptive multicentre analysis.
      ,
      • Brock G.N.
      • Barnes C.
      • Ramirez J.A.
      • Myers J.
      How to handle mortality when investigating length of hospital stay and time to clinical stability.
      ,

      Ministère de la Santé et des Services Sociaux, Direction générale des services de santé et de la médecine universitaire. Cadre normatif - Registre des traumatismes du Québec (RTQ). Version 1.0, Avril 2004.

      ,

      Ministère de la Santé et des Services sociaux du Québec. Banque de données ministérielles MED-ÉCHO. Régie de l’assurance maladie du Québec. http://www.ramq.gouv.qc.ca/en/data-statistics/Pages/data-statistics.aspx.

      ,

      Ministère de la Santé et des Services sociaux du Québec. Rapports financiers annuels des établissements 2015–2016, statsitiques et données. http://publications.msss.gouv.qc.ca/msss/document-001671/. Published 2016.

      ,

      Ministère de la Santé et des Services sociaux du Québec. Normes et pratiques de gestion, Tome II, Répertoire. http://msssa4.msss.gouv.qc.ca/fr/document/d26ngest.nsf/1f71b4b2831203278525656b0004f8bf/c1bc430d41b48eea85257f9500673c97?OpenDocument. Published 2016.

      ,
      • Canadian Agency for Drugs and Technologies in Health
      Guidelines for the economic evaluation of health technologies: Canada.
      ,

      Ministère de la Santé et des Services sociaux du Québec. Liste par centre d’activités (établissement). http://msssa4.msss.gouv.qc.ca/fr/document/d26ngest.nsf/lca?OpenView&Start=204.

      ,
      • Moore L.
      • Hanley J.A.
      • Turgeon A.F.
      • Lavoie A.
      Evaluating the performance of trauma centers: hierarchical modeling should be used.
      ,
      • Daly L.
      • Bourke G.J.
      Interpretation and uses of medical statistics.
      ,
      • Selya A.S.
      • Rose J.S.
      • Dierker L.C.
      • Hedeker D.
      • Mermelstein R.J.
      A practical guide to calculating Cohen’s f 2, a measure of local effect size, from PROC MIXED.
      ,
      • Porgo T.V.
      • Moore L.
      • Tardif P.A.
      Evidence of data quality in trauma registries: a systematic review.
      ,
      • Little R.J.A.
      • Rubin D.B.
      Statistical analysis with missing data.
      ,
      • Allison P.D.
      Missing data. Sage university papers series on quantitative application in the social sciences.
      ,
      • Sterne J.A.
      • White I.R.
      • Carlin J.B.
      • Spratt M.
      • Royston P.
      • Kenward M.G.
      • et al.
      Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls.
      ,
      • Moore L.
      • Lavoie A.
      • LeSage N.
      • Liberman M.
      • Sampalis J.S.
      • Bergeron E.
      • et al.
      Multiple imputation of the glasgow coma score.
      ]).

      Conclusions

      Resource use for acute injury care in Quebec is not solely due to the clinical status of patients. We identified determinants of resource use that can be used to establish evidence-based resource allocations and improve injury care efficiency. The method we developed for estimating patient-level, in-hospital resource use for injury admissions and identifying related determinants could be reproduced using local trauma registry data and our unit costs or unit costs specific to each setting.

      Keywords

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