Practice Makes Perfect: Impact of Volume on Outcomes

BACKGROUND: The American College of Surgeons (ACS) verifies trauma centers (TCs) based on annual trauma volume (ATV) without incorporating procedural volume (PV). We compared outcomes at Level I TCs between ATV and PV. STUDY DESIGN: We performed a 5-year (2017 to 2021) retrospective analysis of the ACS-TQIP, including trauma patients treated at ACS Level I TCs. Centers were grouped into tertiles of low volume (LV), medium volume (MV), and high volume (HV) by ATV and PV. PV was defined as annual emergent laparotomies, thoracotomies, craniectomies and craniotomies, angioembolizations, and vascular repairs. Outcomes were in-hospital mortality and major complications. Multivariable regression assessed independent associations between volume metrics and outcomes. RESULTS: 2,218,425 patients at 182 Level I TCs (LV 91, MV 54, HV 37), with 34.6% (n = 766,555) undergoing procedural intervention, were identified. The mean (SD) age was 48 (23) years and 63% were men. When stratified by PV, HV TCs had significantly lower rates of mortality (LV 5.4%, MV 4.4%, HV 3.7%, p < 0.001) and major complications (LV 8.1%, MV 3.8%, HV 3.1%, p < 0.001). However, when stratified by ATV, HV TCs had higher mortality rates (LV 3.9%, MV 4.2%, HV 4.5%, p < 0.001), whereas MV TCs had the highest major complication rates (LV 4.7%, MV 5.3%, HV 4.8%, p < 0.001). After adjusting for potential confounders, higher PV was independently associated with lower odds of mortality and major complications. CONCLUSIONS: PV, rather than ATV, is a superior predictor of improved outcomes. Integrating PV into the TC verification criteria may enhance the regionalization of trauma care based on injury-specific patient needs.