New Consensus Identifies Questionable, Low-Value Trauma Care Practices

By Marilynn Larkin

May 04, 2022

NEW YORK (Reuters Health) - Experts have reached a consensus on low-value trauma care, targeting practices that should be questioned, rather than uniformly applied.

"Given the high-stress environment and the multitude of treatment options and specialties involved, we hypothesized that trauma care would be a fertile breeding ground for low-value care," Dr. Lynne Moore of Laval University in Quebec City told Reuters Health by email.

"In addition, we had identified unwarranted variations in resource use between trauma centers of the same designation level," she said. "Given this, and more importantly, the negative consequences of unnecessary care for patients, we decided to explore the problem of low-value care for trauma admissions."

As reported in JAMA Surgery, the two-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study included an online questionnaire and a virtual workshop. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec represented key clinical experts in trauma care and included three patient partners.

Panelists were asked to rate 50 practices on a 7-point Likert scale according to four quality indicator criteria: importance, supporting evidence, actionability, and measurability. Forty-six experts (ages 50 or older; 80%, men) completed at least one round and 36 (73%) completed both rounds.

Quality indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (e.g., of patients with suspected head, cervical spine, ankle, and pelvis injuries negative on validated clinical decision rules); (2) repeated diagnostic imaging (e.g., post-transfer computed tomography and repeat head CT in patients with no disease progression); (3) consultation (for certain mild neurosurgical and spine injuries); (4) surgery (for penetrating neck injury with soft signs on clinical exam and negative CT angiography); (5) blood product administration (e.g., above the transfusion threshold in patients who are not bleeding); (6) medication (e.g., antibiotic prophylaxis in certain situations, and late seizure prophylaxis); (7) trauma service admission (e.g., for patients with blunt abdominal trauma with normal physical exam and negative CT); (8) intensive care unit admission (e.g., of patients with mild complicated traumatic brain injury who are not receiving anticoagulation), and (9) routine blood work (e.g., in ASA grade 1 patients having minor orthopedic surgery).

"Selected indicators represented a trauma-specific list of practices, the use of which should be questioned," the authors state in the paper. "Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care."

Dr. Moore noted, "We are currently piloting implementation (of the selected indicators) in a Canadian trauma system... to inform the development of an intervention targeting the de-adoption of low-value practices. We will then conduct a cluster randomized controlled trial to evaluate the effectiveness and cost-effectiveness of the intervention."

Dr. David Spain, Chief of Acute Care Surgery at Stanford University and Trauma Medical Director, Stanford Healthcare in California, commented on the study in an email to Reuters Health. "We have or are in the process of implementing several of these (quality indicators)," he said. "But unfortunately, I'm not sure this will move the needle."

"It's easier to get someone to stop doing something if you can prove it's harmful," he said. "But low-value care is different from no-value care and must be weighed against the outcomes of missing something. Repeating a head CT might be of low value - unless you are that rare patient where it does make a difference."

Nevertheless, he added, "Healthcare resources are not unlimited and we must all be good stewards and make data-driven decisions on how best to use our resources. Ultimately, to get widespread adoption, some sort of incentive will be required - and it doesn't have to be money."

SOURCE: JAMA Surgery, online April 27, 2022.