Less Is More: Dissecting Trauma Centers by Procedural Volume

Objective: This study aims to examine the relationship between procedural volume and annual trauma volume (ATV) of ACS Level I trauma centers (TC). Background: Although ATV is a hard criterion for TC verification, importance of procedural interventions as a potential quality indicator is understudied. Methods: Patients managed at ACS level I TCs were identified from ACS-TQIP 2017-2021. TCs were identified using facility keys and stratified into quartiles based on ATV into low, low-medium, medium-high, and high volume. TCs were also stratified into tertiles [low (LV), medium (MV), high (HV)] based on procedural volume by assessing annual number of laparotomies, thoracotomies, craniotomies/craniectomies, angioembolizations, vascular repairs, and long bone fixations performed at each center. The Cohen κ statistic was used to assess concordance between ATV and procedural volume. Results: A total of 182 Level I TCs were identified: 76 low, 47 low-medium, 35 high-medium, and 24 high volume. Long bone fixation, laparotomy, and craniotomy/craniectomy were the most performed procedures with a median of 65, 59, and 46 cases/center/year, respectively. Overall, 31% of HV laparotomy centers, 31% of HV thoracotomy centers, 22% of HV craniotomy/craniectomy centers, 22% of HV vascular repair centers, 32% of HV long bone fixation centers, and 33% of HV angioembolization centers contributed to the overall number of low-medium and low-volume TCs. The Cohen κ statistic demonstrated poor concordance between ATV and procedural volumes for all procedures (overall procedural volume - κ=0.378, laparotomy - κ=0.270, thoracotomy - κ=0.202, craniotomy/craniectomy - κ=0.394, vascular repair - κ=0.298, long bone fixation - κ=0.277, angioembolization - κ=0.286). Conclusions: ATV does not reflect the procedural interventions performed. Combination of procedural and ATV may provide a more accurate picture of the clinical experience at any given TC. Level of Evidence: Level III.