Background: According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains.
Methods: Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients.
Results: Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS).
Conclusion: Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes.
Level of evidence: Prognostic study, level III.
Moore L, Stelfox HT, Turgeon AF, Nathens AB, Lavoie A, Bourgeois G, Lapointe J. Moore L, et al. J Trauma Acute Care Surg. 2014 May;76(5):1310-6. doi: 10.1097/TA.0000000000000202. J Trauma Acute Care Surg. 2014. PMID: 24747466
Moore L, Stelfox HT, Turgeon AF, Nathens AB, Lavoie A, Emond M, Bourgeois G, Neveu X. Moore L, et al. Ann Surg. 2014 Dec;260(6):1121-7. doi: 10.1097/SLA.0000000000000648. Ann Surg. 2014. PMID: 24743606
Kuimi BL, Moore L, Cissé B, Gagné M, Lavoie A, Bourgeois G, Lapointe J. Kuimi BL, et al. Injury. 2015 Jul;46(7):1257-61. doi: 10.1016/j.injury.2015.02.024. Epub 2015 Mar 9. Injury. 2015. PMID: 25801066
Moore L, Stelfox HT, Boutin A, Turgeon AF. Moore L, et al. J Trauma Acute Care Surg. 2013 May;74(5):1331-43. doi: 10.1097/TA.0b013e31828c4787. J Trauma Acute Care Surg. 2013. PMID: 23609287 Review.
Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. Stelfox HT, et al. Arch Surg. 2010 Mar;145(3):286-95. doi: 10.1001/archsurg.2009.289. Arch Surg. 2010. PMID: 20231631 Review.
Bremen HV, Kroes T, Seppala LJ, Gans EA, Hegeman JH, van der Velde N, Willems HC. Bremen HV, et al. J Clin Med. 2024 Aug 6;13(16):4589. doi: 10.3390/jcm13164589. J Clin Med. 2024. PMID: 39200731 Free PMC article.
Jang S, Drescher MJ, Armstrong TA, Neil ER, Eberman LE. Jang S, et al. Int J Environ Res Public Health. 2024 Apr 30;21(5):577. doi: 10.3390/ijerph21050577. Int J Environ Res Public Health. 2024. PMID: 38791791 Free PMC article.
Kum Ghabowen I, Epane JP, Shen JJ, Goodman X, Ramamonjiarivelo Z, Zengul FD. Kum Ghabowen I, et al. Healthcare (Basel). 2024 Mar 29;12(7):750. doi: 10.3390/healthcare12070750. Healthcare (Basel). 2024. PMID: 38610171 Free PMC article. Review.
AbouNader K, Abou Mourad G, Chalouhi G, Rady A, Von Schreeb J, Halmin M. AbouNader K, et al. Int J Qual Health Care. 2024 Apr 30;36(2):mzae028. doi: 10.1093/intqhc/mzae028. Int J Qual Health Care. 2024. PMID: 38581654 Free PMC article.
Sreedharan J, Subbarayalu AV, Kamalasanan A, Albalawi I, Krishna GG, Alahmari AD, Alsalamah JA, Alkhathami MG, Alenezi M, Alqahtani AS, Alahmari M, Phillips MR, MacDonald J. Sreedharan J, et al. Clinicoecon Outcomes Res. 2024 Mar 26;16:173-185. doi: 10.2147/CEOR.S446614. eCollection 2024. Clinicoecon Outcomes Res. 2024. PMID: 38562567 Free PMC article. Review.