Effects of trauma quality improvement program implementation on mortality: A multi-center controlled interrupted time-series study

BackgroundTrauma is the leading cause of quality-related mortality in low- and middle-income countries, with an estimated two million preventable deaths each year. Although trauma quality improvement programmes have been utilised in high-income countries for more than three decades, there is no high-level evidence of their effect on patient outcomes. We aimed to assess whether implementing a continuous trauma quality improvement programme using audit filters improves mortality among adult trauma patients in urban India. MethodsWe conducted a prospective controlled interrupted time-series study across four tertiary hospitals in urban India between 2017 and 2022. Two hospitals implemented a trauma quality improvement programme after a one-year observation phase (intervention arm); two continued standard care (control arm). Time-series analysis was done using monthly aggregated data with generalised additive models. A difference-in-differences approach was used for secondary analysis. The primary outcome was all-cause in-hospital mortality; the secondary outcome was 30-day mortality. FindingsIn total, 10 143 adult trauma patients were included (median age 35 years; 83% men). In-hospital mortality decreased by 11.2% (95% CI -16.0 to -5.5) in the intervention arm, with no evidence of change in the control arm (-0.5%; 95% CI -4.0 to 5.4). Secondary difference-in-differences analysis showed consistent reductions in in-hospital mortality (-12%; 95% CI -16 to -9) and 30-day mortality (-15%; 95% CI -19 to -11). No seasonal or autocorrelation effects were observed. External factors, including the opening of a dedicated trauma centre at one site and the COVID-19 pandemic, may have influenced the results. InterpretationTrauma quality improvement programmes may improve mortality, particularly in settings with a high number of preventable deaths, and can contribute to reducing the global burden of quality-related mortality. Further research is needed to confirm these results, clarify the mechanisms through which such programmes mediate their effect, and determine how they can be sustained over time. FundingThis work was funded by the Swedish Research Council (2016-02041). Trial registrationTrauma Audit Filter Trial, ClinicalTrials.gov ID NCT03235388, https://clinicaltrials.gov/study/NCT03235388 Research in context Evidence before this studyWe searched MEDLINE, Embase, Web of Science, Cochrane CENTRAL, CINAHL, and PubMed, plus ClinicalTrials.gov (English only records), using combinations of ("trauma" OR "injury") AND ("audit filter" OR "quality indicator"). We found no randomised or quasi-experimental studies assessing the effect of trauma quality improvement programmes on mortality. Two prospective before-after studies were identified: one from Thailand (2001) reporting a reduction in preventable deaths and improved care processes, and one from Germany (2002) showing process improvements with a non-significant reduction in mortality. These studies were included in the review that informed the 2009 WHO Guidelines for Trauma Quality Improvement Programmes. Added value of this studyThis is the first quasi-experimental study to assess whether implementing a trauma quality improvement programme using audit filters reduces mortality. The programme was implemented in two tertiary hospitals in urban India, with two hospitals serving as controls. Implementation was associated with significant reductions in in-hospital and 30-day mortality. This study provides the first high-level evidence that a data driven continuous trauma quality improvement program, as outlined in the WHO guidelines, may improve mortality in adult trauma patients. Implications of all the available evidenceTrauma quality improvement programmes may reduce mortality, particularly in settings with high numbers of preventable deaths. The available evidence supports the implementation and scale-up of structured, continuous trauma quality improvement programmes to reduce quality related trauma mortality in LMICs. Further research is needed to confirm these findings in other settings, and to identify the mechanisms through which such programmes achieve and sustain their effects.