Trauma system establishment and outcome improvement: a retrospective national cohort study in South Korea

Abstract

Background: Trauma is a major cause of mortality, disability, and health care costs worldwide. The establishment of a trauma system is known to solve these problems, but few studies have objectively evaluated the impact of a trauma system on outcomes. Since 2012, South Korea has established a national trauma system based on the implementation of 17 regional trauma centers nationwide and the improvement of the prehospital transfer system. This study aimed to measure the changes in performance and outcome according to the established national trauma system.

Material and methods: In this national cohort-based, retrospective follow-up observational study, the authors calculated the preventable trauma death rate (PTDR) by conducting a multipanel review of patients who died in 2015, 2017, and 2019. Furthermore, the authors constructed a risk-adjusted mortality prediction model of 4 767 876 patients between 2015 and 2019 using the extended-International Classification of Disease Injury Severity Scores to compare outcomes.

Results: The PTDR was lower in 2019 than in 2015 (15.7 vs. 30.5, P <0.001) and 2017 (15.7 vs. 19.9%, P <0.001) representing 1247 additional lives saved in 2019 compared to that in 2015. In the risk-adjusted model, total trauma mortality was highest in 2015 at 0.56%, followed by that in 2016 and 2017 (0.50%), 2018 (0.51%), and 2019 (0.48%), revealing a significant decrease in mortality over the years ( P <0.001 for trend), representing nearly 800 additional lives saved. The number of deaths for more severe patients with a probability of survival less than 0.25 significantly decreased from 81.50% in 2015 to 66.17% in 2019 ( P <0.001).

Conclusions: The authors observed a significant reduction in the PTDR and risk-adjusted trauma mortality in the 5-year follow-up since 2015 when the national trauma system was established. These findings could serve as a model for low-income and middle-income countries, where trauma systems are not yet established.

Figure 1

Process of the Multipanel Review for Preventable Trauma Death Rate. ^*One team comprised two general surgeons, one thoraco-vascular surgeon, one neurosurgeon, and one emergency medicine physician. EMIs, emergency medical institutions.

Figure 2

The flow chart for the comparative analysis of the preventable trauma death rates between 2015, 2017, and 2019 based on the multipanel review. NEDIS, National Emergency Department Information System.

Figure 3

Comparison of the preventable trauma death rates between 2015, 2017, and 2019 in South Korea. PTDR, preventable trauma death rate.

Figure 4

Multivariable analysis of the risk factors for preventable trauma deaths. DOA, death on arrival; ED, emergency department; LEMC, local emergency medical center; LEMI, local emergency medical institution; OR, odds ratio; RTC, regional trauma center; REMC, regional emergency medical center.

Figure 5

The flow chart for the comparative analysis of the trauma outcomes from 2015 to 2019 using the risk-adjusted trauma mortality prediction model based on the extended-ICISS model. ICISS, International Classification of Disease Injury Severity Score; NEDIS, National Emergency Department Information System.

Figure 6

Comparison^* of the risk-adjusted trauma mortality using the extended-ICISS model from 2015 to 2019 in South Korea; (A) risk-adjusted trauma mortality in the overall population, (B) risk-adjusted trauma mortality according to the probability of survival, and (C) number of total trauma patients and deaths over years. ^* P values were obtained from the Cochran–Armitage trend test under the hypothesis $H_0:$ no trend versus $H_1$ : decreasing trend over the years. ICISS, International Classification of Disease Injury Severity Score.

Figure 7

Trend^* of the excess survival rate (A) and excess death rate (B) of patients with trauma between 2015 and 2019 in South Korea based on the extended-ICISS model. ^*Youden’s index was used as the cut-off value.