Chapitre 4 : Inter-hospital variation in Surgical Intensity for Trauma Admissions : A Multicenter Cohort Study
5.3 Retombées et impact
L’étude a été menée en collaboration avec l’Institut National d’excellence en Santé et en Services sociaux (INESSS). Cette organisation utilisera les connaissances acquises par ce projet pour identifier des opportunités d’amélioration de la qualité des soins en termes d’utilisation efficiente des ressources en soins aigus pour les admissions en traumatologie. Dans ce sens, cette étude aura un impact positif sur l’augmentation de la disponibilité des ressources, la diminution des coûts, la survenue d’effets indésirables (complications), la durée de séjour ainsi que le recours à des pratiques de moindres valeurs ajoutées. Ce projet s’intègre dans un vaste programme de recherche sur les pratiques cliniques de faible valeur en traumatologie (IRSC 2016-2023). Les résultats seront utilisés dans le développement d’une intervention d’évaluation/rétroaction visant la réduction des soins de faible valeur en traumatologie.
Conclusion
Cette étude suggère qu'il existe une variabilité significative de l'intensité des soins chirurgicaux entre les centres de traumatologie pour les patients admis à la suite d’un traumatisme physique sévère. Une variabilité modérée fut observée dans le contexte de blessures orthopédiques, alors qu’une faible variabilité fut observée pour les patients ayant des blessures thoraco-abdominales et neurologiques. Ces variations de l’intensité chirurgicale ont été observées même après ajustement pour l’état du patient à son arrivée au centre de traumatologie. Nos résultats suggèrent que les patients ayant un état de santé semblable, qui arrivent dans des hôpitaux avec un niveau de spécialisation semblable, ne reçoivent pas les mêmes soins chirurgicaux. Ce constat peut s'expliquer en termes de qualité des soins. L'absence de lignes directrices ou, tout simplement, par le non- respect de celles déjà existantes, les différences de pratiques entre les médecins, les cultures institutionnelles ainsi que la disponibilité des ressources (humaines et financières) sont des exemples d’éléments pouvant expliquer ces observations.
Bien que ces résultats doivent être interprétés avec prudence, nos observations suggèrent que les hôpitaux à forte intensité chirurgicale ont des résultats cliniques qui diffèrent d’un type de blessure à un autre. En effet, pour les patients qui ont des blessures orthopédiques, les centres qui avaient une intensité chirurgicale élevée semblaient avoir moins de complications. Dans le cas des blessures neurologiques, bien que nos résultats n’aient pas été statistiquement significatifs, les hôpitaux à forte intensité chirurgicale semblaient avoir de meilleurs résultats cliniques en termes de mortalité et de complications. Pour les blessures thoraco- abdominales, les centres avec une intensité chirurgicale élevée semblaient seulement réduire la mortalité. Il est important de rappeler que ces corrélations ne servent qu’à générer des hypothèses et non pas à les confirmer. Ils n’induisent, en aucun cas, un lien de causalité.
D’autres recherches sont nécessaires afin de mieux comprendre les facteurs qui influencent les associations que nous avons observées entre l’intensité chirurgicale et les résultats cliniques. De plus, il serait également bénéfique de s’intéresser à d’autres aspects de l’intensité des soins en traumatologie (prélèvements sanguins, pharmacologie, imagerie) ainsi qu’à leurs associations avec d’autres résultats cliniques, tels que la durée de séjour, les réadmissions et l’état fonctionnel après l’hospitalisation.
Annexe B : Sommaire des critères d’inclusion et d’exclusion
Critères d’inclusion :
• Adultes (âgés d’au moins 16 ans)
• Qui ont été admis pour traumatisme physique comme diagnostic principal (code CIM-10-CA compris entre S00 et T14) entre le 1er avril 2006 et le 31 mars 2016 dans l’un des centres de
traumatologie du Québec
• Ayant un Injury Severity Score (ISS) ≥ 12
• Qui répondent aux critères d’inclusion du RTQ (décès durant l’hospitalisation, admission aux soins intensifs, durée d’hospitalisation ≥ 3 jours ou le transfert vers un autre hôpital)
Critères d’exclusion :
• Patients ayant seulement des brulures isolées ou des fractures de fragilité • Patients décédés à l’arrivée
• Décès survenu durant les 72 premières heures suivant l’admission (pour les analyses des objectifs 1 et 2 seulement)
• Départs contre avis médical
Annexe D : Liste de comorbidités selon Elixhauser
Liste de comorbidités selon Elixhauser • Insuffisance cardiaque • Arythmies
• Valvulopathies
• Troubles de la circulation pulmonaire • Maladie vasculaire périphérique • Hypertension, non compliquée • Hypertension, compliquée • Paralysie
• Autre maladie neurologique • Maladie pulmonaire chronique • Diabète, non compliquée • Diabète, compliquée • Hypothyroïdie • Insuffisance rénale • Maladies hépatiques
• Ulcères peptidiques excluant les saignements¸ • SIDA/VIH
• Lymphome
• Cancer métastatique
• Tumeur solide sans métastases • Arthrite rhumatoïde
• Coagulopathie • Obésité • Perte de poids
• Troubles des fluides et des électrolytes • Anémie hémorragique • Arménie déficitaire • Alcoolisme • Toxicomanie • Psychoses • Dépression.
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