Beyond In-Hospital Mortality: Use of Postdischarge Quality Metrics Provides a More Complete Picture of Older Adult Trauma Care

INTRODUCTION: Answering calls to move beyond trauma’s historical focus on in-hospital mortality as the single measure of quality for older injured adults, this study sought to characterize the extent of variability in 3 new sets of 30/90/365-day putative trauma quality metrics designed to better account for the unique health needs of older patients. The extent of correlation between new quality metrics and in-hospital mortality was also compared. METHODS: Using 2013 to 2016 100% Medicare claims, we calculated hospital-specific risk-standardized—risk-adjusted hierarchical mixed-effects regression followed by Bayesian-corrections for small sample-size—quality metrics for all patients 65 years or older admitted with a primary diagnosis of trauma. Considered 30/90/365-day quality metrics included mortality (expansion of the current in-hospital standard), readmission (marker of health system performance), and patients’ average number of healthy days at home (marker of patient functional status). Correlations between new quality metrics and in-hospital mortality were calculated using volume-weighted linear/nonlinear generalized-additive models. RESULTS: A total of 785,867 patients from 3,692 hospitals were included. Although risk-standardized in-hospital mortality narrowly ranged from 0.2% to 5.1%, distributions of the new quality metrics yielded a broader range of outcomes (Figure), both for older trauma patients overall and when stratified by primary reasons for trauma admission. None of the new quality metrics consistently correlated with in-hospital mortality as postdischarge time extended beyond 30 days, nor were any strongly indirectly aligned (volume-weighted 365-day correlation coefficients [95% CI]: mortality 0.581 [0.554 to 0.608], readmission –0.221 [–0.182 to 0.260], healthy days at home –0.329 [–0.368 to 0.290]).FigureCONCLUSION: The results point toward room for improvement and suggest that among older trauma patients, use of additional postdischarge quality metrics captured important aspects of patients’ recovery not reflected by variation in in-hospital mortality alone.