Statewide variation in the treatment of patients hospitalized with spleen injury

Hypothesis: Surgeons' treatment decisions for patients with spleen injuries in Washington state from January 1, 1990, through December 31, 1994, were different in rural compared with urban communities. Design and Settings: Retrospective cohort analyses using the Death and Illness History Database for the state of Washington, which provides a cross-linked record of an individual's sequential hospitalizations. Counties were defined as metropolitan, urban, or rural on the basis of population density. Patients: A total of 1905 patients (1927 hospitalizations) with an International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis code of 865. Main Outcome Measures: Physician management decisions (perform a celiotomy or repair the spleen) were stratified by geographic region. Results: Throughout the state, there was substantial variability in the treatment of spleen-injured patients. Factors associated with higher odds of splenectomy included older age, overall severity of injury, treatment in rural hospitals, and treatment in the earlier years of study. While the frequency of splenic salvage increased over time, hospital length of stay, rehospitalization, and 30-day mortality did not increase. Conclusions: Injury to the spleen is a common problem for which management decisions vary by geographic region, indicating that a single management protocol does not universally apply. To evaluate appropriateness of care by process measures, such as splenic injury management, will require that decision makers grant some latitude in management variability based on factors such as practice setting.