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Impact of trauma centre accreditation on mortality and complications in a Canadian trauma system: an interrupted time series analysis
  1. Brice Batomen1,
  2. Lynne Moore2,
  3. Erin Strumpf1,3,
  4. Howard Champion4,
  5. Arijit Nandi1,5
  1. 1Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
  2. 2Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada
  3. 3Department of Economics, McGill University, Montreal, Quebec, Canada
  4. 4Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
  5. 5Institute for Health and Social Policy, Montreal, Quebec, Canada
  1. Correspondence to Brice Batomen, Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC H3A 1A2, Canada; brice.batomenkuimi{at}


Background Periodic external accreditation visits aiming to determine whether trauma centres are fulfilling the criteria for optimal care are part of most trauma systems. However, despite the growing trend towards accreditation of trauma centres, its impact on patient outcomes remains unclear. In addition, a recent systematic review found inconsistent results on the association between accreditation and patient outcomes, mostly due to the lack of robust controls. We aim to address these gaps by assessing the impact of trauma centre accreditation on patient outcomes, specifically in-hospital mortality and complications, using an interrupted time series (ITS) design.

Methods We included all major trauma admissions to five level I and four level II trauma centres in Quebec, Canada between 2008 and 2017. In order to perform ITS, we first obtained monthly and quarterly estimates of the proportions of in-hospital mortality and complications, respectively, for level I and level II centres. Prognostic scores were used to standardise these proportions to account for changes in patient case mix and segmented regressions with autocorrelated errors were used to estimate changes in levels and trends in both outcomes following accreditation.

Results There were 51 035 admissions, including 20 165 for major trauma during the study period. After accounting for changes in patient case mix and secular trend in studied outcomes, we globally did not observe an association between accreditation and patient outcomes. However, associations were heterogeneous across centres. For example, in a level II centre with worsening preaccreditation outcomes, accreditation led to −9.08 (95% CI −13.29 to −4.87) and −9.60 (95% CI −15.77 to −3.43) percentage point reductions in mortality and complications, respectively.

Conclusion Accreditation seemed to be beneficial for centres that were experiencing a decrease in performance preceding accreditation.

  • accreditation
  • audit and feedback
  • health services research
  • quality improvement

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  • Contributors BB, LM, HC and AN contributed to the development of research objectives. BB conducted data analysis and drafted the manuscript. BB, AN, ES, LM and HC revised the manuscript and approved the final version.

  • Funding Funds for this project are covered by the Fonds de Recherche du Québec-Santé (FRQS) PhD Scholarship (BB) and a Canadian Institute of Health Research (CIHR) Foundation grant (FRN 353374 for LM and FRN 148467 for AN).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. Data may be obtained through a request to the Quebec’s health insurance board (Régie de l’assurance maladie du Québec, RAMQ).

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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