Outcomes of major trauma patients by hospital level of care in New Zealand.

Abstract

Major trauma centres generally deliver better outcomes than non-specialist centres, but whether this association holds true in New Zealand, a country with challenging geography and a dispersed population, is uncertain. The aim of this study was to determine whether definitive care at a tertiary trauma hospital compared with a regional (non-tertiary) hospital was associated with improved survival in patients with major trauma in New Zealand. We also aimed to identify factors that predict transfer from a regional hospital to a tertiary centre. A registry-based cohort study of adults with major trauma was conducted using data from the New Zealand Trauma Registry. All patients who were in a tertiary hospital at any time during their hospitalisation were considered to have received definitive care in a tertiary centre. The primary outcome was in-hospital mortality during the index hospitalisation episode (including where a hospitalisation episode included care in multiple hospitals). Secondary outcomes were 30 and 90-day mortality, requirement for secondary transfer, and discharge destination. Multivariable logistic regression analysis was used to assess the association between definitive care hospital level and in-hospital mortality, and to identify factors associated with secondary transfer. 10,001 major trauma patients were identified, with inpatient case fatality rate of 11.1% (regional hospitals 12.7%, tertiary hospitals 10.5%; P = 0.001). After risk adjustment, definitive care at a tertiary trauma hospital was associated with substantially lower odds of in-hospital death compared with regional hospitals (adjusted odds ratio 0.68 [95% CI, 0.57-0.82]; P < 0.001). Factors associated with secondary inter-hospital transfer included intubation, injury due to falls, Māori ethnicity, higher injury severity, and younger age. Definitive care provided at a tertiary trauma hospital was associated with decreased odds of mortality in major trauma patients in New Zealand, indicating the importance of improving equity of access to specialised trauma care for patients suffering from serious injuries.