Teegwendé V Porgo1, Lynne Moore2, Catherine Truchon3, Simon Berthelot4, Henry T Stelfox5, Peter A Cameron6, Belinda J Gabbe6, Jeffrey S Hoch7, David C Evans8, François Lauzier9, Francis Bernard10, Alexis F Turgeon11, Julien Clément12. 1. 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. 2. 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. Electronic address: lynne.moore@fmed.ulaval.ca. 3. Institut national d'excellence en santé et en services sociaux (INESSS), Québec, QC, Canada. 4. 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. 5. Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada. 6. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. 7. 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. 8. Department of Surgery, University of British Columbia, Vancouver, BC, Canada. 9. 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. 10. Department of Medicine, Université de Montréal, Montréal, QC, Canada. 11. 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. 12. Institut national d'excellence en santé et en services sociaux (INESSS), Québec, QC, Canada; Department of Surgery, Université Laval, Québec, QC, Canada.
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% [4-6]), particularly for the OR (28% [20-40]). 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.
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 insufficientpatient-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% [4-6]), particularly for the OR (28% [20-40]). 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.