Supplementary Materials A. Assigning Patients to Study Groups

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Supplementary Materials A. Assigning Patients to Study Groups 1

Step 1. For each site, calculate service- and year-specific proportion of physicians with PARS Scores >50.

2

Trauma surgeons at each site reviewed the list of all credentialed clinicians from services that provided 3

trauma care to identify which of their site’s physicians “ever” or “never” participated in the care of 4

trauma patients. The PARS scores for all “ever” physicians were reviewed to calculate a service- and 5

year-specific proportion of physicians with PARS scores >50 for that site. Consider the following 6

example services for site 3 in study year=2017:

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Specialty A, Site 3, Year=2017 (1 of 8 physicians, 12.5%, with PARS score >50) 8

*

9

Specialty B, Site 3, Year=2017 (4 of 12 physicians, 33%, with PARS score >50) 10

11

Specialty C, Site 3, Year=2017 (1 of 20 physicians, 5%, with PARS score >50) 12

13

*Red color denotes a physician with a PARS score >50.

14

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Step 2. Calculate specialty- and year-specific risk ranking across sites.

15

For each specialty, compare service- and year-specific proportions of physicians with PARS scores >50 16

from step 1 across all study sites. Identify the top 3 highest-ranking proportion for each specialty and year 17

combination. Using Specialty B from Site 3 and Year=2017 in the previous step as an example:

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National Ranking for Specialty B, Year=2017 19

Site Proportion of Physicians in Specialty B with PARS

Scores >50 at site

National Specialty Ranking

Risk Group

3 33% 1 High

9 25% 2 High

4 20% 3 High

7 12% 4 Low

2 10% 5 Low

6 10% 6 Low

8 8% 7 Low

1 5% 8 Low

5 5% 9 Low

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Step 3. Assign Cohort Patients to Study Group based on services that participate in their care.

21

Each patient was assigned to a study group based on the number of services participating in their care that 22

were identified as high risk based on the service’s national specialty- and year-specific risk ranking in 23

Step 2. In the patient examples below, red specialties ranked in top 3 for national specialty- and year- 24

specific comparisons and were considered high risk; green specialties were considered low risk:

25

Patient 123, Site 3, Year 2017, 2 high-risk services based on national specialty- and year-specific ranking 26

Specialty A Specialty B Specialty H Specialty H

Patient 456, Site 5, Year 2015, 1 high-risk services based on national specialty- and year-specific ranking 27

Specialty A Specialty C Specialty E

Top 3 of each national specialty- and year-specific proportion identified as high-risk service.

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As a quality check for step 3, we assessed the average proportion of physicians with PARS scores >50 for highest and lowest tertiles, by specialty 30

and year and found sufficient differences between the highest and lowest tertiles in the proportion to suggest meaningful spread in this measure.

31

We also found that the proportion of physicians identified varied by specialty, as we have demonstrated in previous studies (Dombrino RJ et al. J 32

Neurosurg 2020; Hultman et al. Ann Plast Surg 2015; Stimson CJ et al. J Urology 2010; Mukherjee KJ. Trauma 2010; Murff HJ et al. Quality Saf 33

Health Care 2006).

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Step 4. Internal Validation of Specialty Ranking 36

We internally validated the aggregate measure of professionalism by asking trauma surgeons at four sites to identify, without knowledge of PARS 37

data, services which were challenging to work with because of communication concerns, disrespectful behavior, or difficulties with access and 38

response; all are domains identified in the PARS scores which impact team interactions. We then compared the services identified by the trauma 39

surgeons to services in the highest tertiles for their specialty during the last study year, the year closest to the identification of the services by the 40

trauma surgeons. We found that 10 of 12 services (83.3%) identified by trauma surgeons as being difficult were also identified as being in the top 41

tertile across all study sites during the last year and 12 of 12 (100%) were in the top tertile for at least one study year. None of the four (0%) 42

services identified as being favorable to work with by trauma surgeons were in the top tertile during the last study year.

43

2012 2013 2014 2015 2016 2017

Highest Tertile

Lowest Tertile

Lowest Tertile Emergency

Medicine 16.7% 2.9% 15.4% 4.1% 17.8% 5.7% 24.4% 2.5% 23.1% 4.0% 19.6% 0.0%

General Surgery 12.0% 1.4% 17.6% 2.1% 10.0% 2.0% 16.1% 0.0% 18.5% 0.0% 7.3% 0.0%

Neurosurgery 41.7% 11.1% 27.3% 9.6% 17.4% 17.1% 40.0% 10.9% 33.3% 3.7% 36.4% 0.0%

Orthopedics 33.3% 4.3% 16.7% 2.4% 19.4% 4.0% 13.9% 6.2% 18.2% 4.6% 28.0% 5.8%

Plastic Surgery 25.0% 0.0% 30.8% 0.0% 27.3% 0.0% 18.2% 0.0% 11.1% 0.0% 16.7% 0.0%

Trauma 25.0% 0.0% 20.0% 8.3% 20.0% 0.0% 20.0% 0.0% 20.0% 0.0% 16.7% 0.0%

Urology 26.7% 7.6% 20.0% 6.9% 21.4% 1.1% 20.0% 0.0% 26.7% 0.0% 20.0% 1.8%

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eFigure 1. Calibration Curve for Primary Model

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Supplementary Materials eTable 1. Comorbidities by PARS Service Exposure Group 44

Number of High-Risk Services Participating in Care

Comorbidity N 0 (N = 16,107) 1 (N = 28,085) 2+ (N = 26,854)

Overall

(N = 71,046) P-value Attention Deficit Hyperactivity 71046 163 (1.0) 216 (0.8) 194 (0.7) 573 (0.8) P=0.003 Advanced Directive in Place 71046 245 (1.5) 634 (2.3) 616 (2.3) 1,495 (2.1) P<0.001

Alcoholism 71046 1,264 (7.8) 2,207 (7.9) 2,281 (8.5) 5,752 (8.1) P=0.01

Angina 71046 1 (0.0) 3 (0.0) 1 (0.0) 5 (0.0) P=0.617

Anticoagulant therapy 71046 729 (4.5) 519 (1.8) 765 (2.8) 2013 (2.8) P<0.001

Bleeding Disorder 71046 207 (1.3) 844 (3.0) 742 (2.8) 1793 (2.5) P<0.001

Cancer 71046 127 (0.8) 76 (0.3) 107 (0.4) 310 (0.4) P<0.001

Chemotherapy 71046 34 (0.2) 87 (0.3) 79 (0.3) 200 (0.3) P=0.15

Congestive Heart Failure 71046 496 (3.1) 661 (2.4) 739 (2.8) 1896 (2.7) P<0.001

Cirrhosis 71046 159 (1.0) 259 (0.9) 268 (1.0) 686 (1.0) P=0.629

Congenital Malformation 71046 58 (0.4) 68 (0.2) 63 (0.2) 189 (0.3) P=0.031

Chronic Obstructive Pulmonary Disease 71046 1,058 (6.6) 1,622 (5.8) 1,527 (5.7) 4,207 (5.9) P<0.001

Chronic Renal Failure 71046 124 (0.8) 228 (0.8) 271 (1.0) 623 (0.9) P=0.012

Cerebrovascular Accident 71046 294 (1.8) 476 (1.7) 515 (1.9) 1285 (1.8) P=0.144

Dementia 71046 389 (2.4) 646 (2.3) 673 (2.5) 1708 (2.4) P=0.287

Diabetes 71046 2,076 (12.9) 3,053 (10.9) 3,339 (12.4) 8,468 (11.9) P<0.001

Functionally Dependent Health Status 71046 673 (4.2) 667 (2.4) 702 (2.6) 2,042 (2.9) P<0.001 Hypertension 71046 4,975 (30.9) 7,508 (26.7) 7,727 (28.8) 20,210 (28.4) P<0.001 Mental Health Disorder 71046 1,906 (11.8) 2,923 (10.4) 2,484 (9.3) 7,313 (10.3) P<0.001

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Number of High-Risk Services Participating in Care

Comorbidity N 0 (N = 16,107) 1 (N = 28,085) 2+ (N = 26,854)

Overall

(N = 71,046) P-value Myocardial Infarction 71046 1,040 (6.5) 1,326 (4.7) 1,546 (5.8) 3,912 (5.5) P<0.001

Obesity 71046 749 (4.7) 1,487 (5.3) 1,211 (4.5) 3,447 (4.9) P<0.001

Other 71046 1,178 (7.3) 2,287 (8.1) 2,195 (8.2) 5,660 (8.0) P=0.002

Peripheral Arterial Disease 71046 117 (0.7) 114 (0.4) 121 (0.5) 352 (0.5) P<0.001

Smoker 71046 4,727 (29.3) 7,774 (27.7) 8,001 (29.8) 20,502 (28.9) P<0.001

Steroids 71046 188 (1.2) 194 (0.7) 187 (0.7) 569 (0.8) P<0.001

Substance Abuse 71046 1,456 (9.0) 2,662 (9.5) 2,237 (8.3) 6,355 (8.9) P<0.001 45

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Supplementary Materials eTable 2. Primary Model – Outcome is Any Complication or Death, Site 46

is Treated as a Random Effect 47

Variable Coefficient SE Pval

(Intercept) -4.9295 0.1181 0.0000

DEMO_AGE 0.0155 0.0009 0.0000

DEMO_GENDERMale 0.1623 0.0287 0.0000

DEMO_RACEAmerican Indian or Alaska Native 0.143 0.1707 0.4024

DEMO_RACEAsian 0.1649 0.0887 0.0632

DEMO_RACEBlack or African American -0.0072 0.0387 0.8521 DEMO_RACENative Hawaiian or Pacific Islander 0.1614 0.3195 0.6134

DEMO_RACEUnknown/Not Reported 0.0201 0.0542 0.7099

COM_ADHD1 -0.0562 0.1541 0.7151

COM_ADVANCEDDIR1 0.4976 0.0706 0.0000

COM_ALCO1 0.3749 0.0446 0.0000

COM_ANTICOAG1 0.0734 0.0673 0.2755

COM_BLEEDING1 0.3819 0.0678 0.0000

COM_CANCER1 0.3238 0.1497 0.0306

COM_CHEMO1 0.6583 0.1832 0.0003

COM_CHF1 0.3722 0.0666 0.0000

COM_CIRRHOSIS1 0.7143 0.0998 0.0000

COM_CONGENITAL1 0.5788 0.221 0.0088

COM_COPD1 0.3637 0.049 0.0000

COM_CRF1 0.4907 0.1114 0.0000

COM_CVA1 0.1579 0.0833 0.0581

COM_DEMENTIA1 0.1629 0.0721 0.0237

COM_DIABETES1 0.0866 0.0394 0.0278

COM_FUNCTIONAL1 -0.1796 0.0734 0.0144

COM_HTN1 -0.0617 0.033 0.0612

COM_MENTAL1 0.0508 0.0421 0.2277

COM_MI1 0.1843 0.0512 0.0003

COM_OBESITY1 0.4262 0.0529 0.0000

COM_OTHER1 0.0173 0.0471 0.7131

COM_PAD1 0.2057 0.1452 0.1565

COM_SMOKER1 -0.261 0.0318 0.0000

COM_STEROIDS1 0.1426 0.127 0.2615

COM_SUBSTANCE1 -0.101 0.0496 0.0418

TRAUMA.TYPE.FORMATOther 1.2156 0.0802 0.0000

TRAUMA.TYPE.FORMATPenetrating 0.9087 0.0414 0.0000

TRAUMA.TYPE.FORMATUnknown 1.387 0.5409 0.0103

TRAU_ISS 0.1136 0.0013 0.0000

TOP3_NATL_CAT1 0.2709 0.0365 0.0000

TOP3_NATL_CAT2+ 0.2204 0.0379 0.0000

48 49

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Supplementary Materials eTable 3. Outcome is Death Only, Site is Treated as a Random Effect 50

(Intercept) -7.4581 0.1731 0.0000

DEMO_AGE 0.0329 0.0014 0.0000

DEMO_GENDERMale 0.2429 0.0457 0.0000

DEMO_RACEAsian 0.1914 0.1447 0.1858

DEMO_RACEBlack or African American -0.0771 0.0652 0.2372 DEMO_RACENative Hawaiian or Pacific Islander -0.3378 0.7537 0.6541

COM_ADHD1 -0.6979 0.3783 0.0650

COM_ADVANCEDDIR1 0.9825 0.084 0.0000

COM_ALCO1 0.0673 0.0807 0.4044

COM_ANTICOAG1 0.2909 0.0928 0.0017

COM_BLEEDING1 0.5749 0.0885 0.0000

COM_CANCER1 0.7326 0.1956 0.0002

COM_CHEMO1 1.0133 0.221 0.0000

COM_CHF1 0.4475 0.0909 0.0000

COM_CIRRHOSIS1 1.331 0.1327 0.0000

COM_CONGENITAL1 0.013 0.406 0.9744

COM_COPD1 0.3968 0.0747 0.0000

COM_CRF1 0.7362 0.1468 0.0000

COM_CVA1 0.1345 0.1226 0.2728

COM_DEMENTIA1 0.1879 0.0965 0.0516

COM_DIABETES1 0.0301 0.06 0.6166

COM_FUNCTIONAL1 -0.2046 0.1092 0.0610

COM_HTN1 -0.29 0.051 0.0000

COM_MENTAL1 -0.1646 0.0752 0.0287

COM_MI1 0.2156 0.0721 0.0028

COM_OBESITY1 -0.0238 0.0889 0.7886

COM_OTHER1 -0.208 0.0778 0.0075

COM_PAD1 0.3406 0.2037 0.0944

COM_SMOKER1 -0.835 0.0599 0.0000

COM_STEROIDS1 0.1376 0.1946 0.4795

COM_SUBSTANCE1 -0.5662 0.1022 0.0000

TRAU_ISS 0.1258 0.0018 0.0000

TOP3_NATL_CAT1 0.2519 0.0582 0.0000

TOP3_NATL_CAT2+ 0.0375 0.061 0.5388

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Supplementary Materials eTable 4. Outcome is Surgical Complication Only 53

(Intercept) -5.5446 0.2319 0.0000

DEMO_AGE -0.0066 0.0023 0.0048

DEMO_GENDERMale 0.3848 0.0835 0.0000

DEMO_RACEAsian 0.3412 0.2484 0.1696

COM_ADHD1 0.0396 0.2848 0.8894

COM_ADVANCEDDIR1 -0.5301 0.3637 0.1449

COM_ALCO1 0.4104 0.1028 0.0001

COM_ANTICOAG1 -0.5632 0.2907 0.0526

COM_BLEEDING1 0.237 0.2498 0.3426

COM_CANCER1 -1.5965 1.0014 0.1109

COM_CHEMO1 0.6622 0.5901 0.2618

COM_CHF1 0.1153 0.2497 0.6443

COM_CIRRHOSIS1 0.1864 0.2919 0.5232

COM_CONGENITAL1 0.1072 0.5889 0.8556

COM_COPD1 -0.1341 0.1503 0.3724

COM_CRF1 0.0703 0.4577 0.8780

COM_CVA1 0.0273 0.3162 0.9311

COM_DEMENTIA1 -0.9971 0.5079 0.0496

COM_DIABETES1 0.0821 0.1207 0.4961

COM_FUNCTIONAL1 -0.6378 0.3293 0.0528

COM_HTN1 -0.114 0.0963 0.2367

COM_MENTAL1 0.1683 0.0989 0.0889

COM_MI1 0.1074 0.1685 0.5238

COM_OBESITY1 0.6329 0.1184 0.0000

COM_OTHER1 -0.027 0.1374 0.8440

COM_PAD1 0.786 0.3739 0.0355

COM_SMOKER1 0.1949 0.072 0.0068

COM_STEROIDS1 0.543 0.3287 0.0985

COM_SUBSTANCE1 0.0219 0.1055 0.8355

TRAUMA.TYPE.FORMATUnknown -8.9162 12.1508 0.4631

TRAU_ISS 0.0402 0.0023 0.0000

TOP3_NATL_CAT1 0.191 0.0882 0.0303

TOP3_NATL_CAT2+ 0.1942 0.0917 0.0342

54 55

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Supplementary Materials eTable 5. Outcome is Medical Complication Only 56

(Intercept) -4.7589 0.1441 0.0000

DEMO_AGE 0.0087 0.001 0.0000

DEMO_GENDERMale 0.0892 0.0338 0.0083

DEMO_RACEAsian 0.1379 0.1012 0.1732

DEMO_RACEBlack or African American 0.0515 0.0457 0.2592 DEMO_RACENative Hawaiian or Pacific Islander 0.0899 0.3608 0.8031

DEMO_RACEUnknown/Not Reported -0.0051 0.0656 0.9384

COM_ADHD1 -0.1221 0.1827 0.5037

COM_ADVANCEDDIR1 -0.0741 0.0929 0.4249

COM_ALCO1 0.4434 0.0502 0.0000

COM_ANTICOAG1 -0.0223 0.0801 0.7804

COM_BLEEDING1 0.2048 0.0833 0.0140

COM_CANCER1 0.1662 0.1795 0.3545

COM_CHEMO1 0.037 0.2479 0.8814

COM_CHF1 0.196 0.0799 0.0141

COM_CIRRHOSIS1 0.5184 0.1114 0.0000

COM_CONGENITAL1 0.7447 0.2315 0.0013

COM_COPD1 0.3395 0.0565 0.0000

COM_CRF1 0.2488 0.1361 0.0676

COM_CVA1 0.1532 0.098 0.1182

COM_DEMENTIA1 0.2109 0.0878 0.0163

COM_DIABETES1 0.156 0.0458 0.0007

COM_FUNCTIONAL1 -0.2501 0.0898 0.0054

COM_HTN1 0.1329 0.039 0.0007

COM_MENTAL1 0.1311 0.048 0.0063

COM_MI1 0.2723 0.0591 0.0000

COM_OBESITY1 0.5661 0.0578 0.0000

COM_OTHER1 0.1626 0.0532 0.0023

COM_PAD1 0.1922 0.1639 0.2410

COM_SMOKER1 -0.0295 0.0372 0.4281

COM_STEROIDS1 0.1387 0.1453 0.3396

COM_SUBSTANCE1 0.0593 0.056 0.2894

TRAU_ISS 0.0789 0.0013 0.0000

TOP3_NATL_CAT1 0.3141 0.0448 0.0000

TOP3_NATL_CAT2+ 0.4225 0.0456 0.0000

57

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Supplementary Materials eTable 6. Outcome is Other Complication Only 59

(Intercept) -5.6435 0.1944 0.0000

DEMO_AGE 0.014 0.0015 0.0000

DEMO_GENDERMale 0.3305 0.0522 0.0000

DEMO_RACEAsian 0.0336 0.1588 0.8324

DEMO_RACEBlack or African American 0.0846 0.066 0.1999

DEMO_RACENative Hawaiian or Pacific Islander 0.7282 0.4266 0.0879

COM_ADHD1 0.2992 0.2402 0.2129

COM_ADVANCEDDIR1 -0.179 0.1294 0.1664

COM_ALCO1 0.2715 0.0742 0.0003

COM_ANTICOAG1 -0.0031 0.1177 0.9793

COM_BLEEDING1 0.3919 0.1015 0.0001

COM_CANCER1 -0.1604 0.2701 0.5527

COM_CHEMO1 0.4844 0.3106 0.1188

COM_CHF1 0.5095 0.1029 0.0000

COM_CIRRHOSIS1 0.5397 0.1551 0.0005

COM_CONGENITAL1 0.618 0.3399 0.0690

COM_COPD1 0.297 0.0805 0.0002

COM_CRF1 0.4033 0.1684 0.0166

COM_CVA1 -0.1222 0.14 0.3827

COM_DEMENTIA1 0.0206 0.1256 0.8701

COM_DIABETES1 0.1429 0.0655 0.0291

COM_FUNCTIONAL1 0.1014 0.1197 0.3970

COM_HTN1 0.0251 0.0568 0.6586

COM_MENTAL1 0.0403 0.0723 0.5768

COM_MI1 0.1552 0.0864 0.0724

COM_OBESITY1 0.4116 0.0894 0.0000

COM_OTHER1 -0.1188 0.0887 0.1807

COM_PAD1 0.6241 0.2005 0.0019

COM_SMOKER1 -0.0808 0.0556 0.1460

COM_STEROIDS1 0.0934 0.226 0.6795

COM_SUBSTANCE1 -0.2492 0.0853 0.0035

TRAUMA.TYPE.FORMATOther -0.6434 0.2199 0.0034

TRAU_ISS 0.0658 0.0016 0.0000

TOP3_NATL_CAT1 0.0042 0.0683 0.9511

TOP3_NATL_CAT2+ 0.1572 0.0693 0.0234

60 61

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Supplementary Materials eTable 7. Blunt Injury Type Patients Only 62

(Intercept) -4.945 0.1252 0.0000

DEMO_AGE 0.0157 0.0009 0.0000

DEMO_GENDERMale 0.1714 0.0302 0.0000

DEMO_RACEAsian 0.2041 0.0911 0.0250

COM_ADHD1 -0.1116 0.1806 0.5365

COM_ADVANCEDDIR1 0.4634 0.0726 0.0000

COM_ALCO1 0.388 0.0482 0.0000

COM_ANTICOAG1 0.0761 0.0685 0.2667

COM_BLEEDING1 0.364 0.0694 0.0000

COM_CANCER1 0.3085 0.155 0.0465

COM_CHEMO1 0.7044 0.1869 0.0002

COM_CHF1 0.3794 0.0682 0.0000

COM_CIRRHOSIS1 0.6678 0.1029 0.0000

COM_CONGENITAL1 0.6785 0.2294 0.0031

COM_COPD1 0.3995 0.0521 0.0000

COM_CRF1 0.4716 0.1131 0.0000

COM_CVA1 0.1559 0.0849 0.0662

COM_DEMENTIA1 0.1641 0.0731 0.0248

COM_DIABETES1 0.095 0.041 0.0206

COM_FUNCTIONAL1 -0.1913 0.075 0.0108

COM_HTN1 -0.0442 0.0348 0.2037

COM_MENTAL1 -0.0259 0.0476 0.5859

COM_MI1 0.1861 0.0528 0.0004

COM_OBESITY1 0.4678 0.0564 0.0000

COM_OTHER1 0.0632 0.0503 0.2086

COM_PAD1 0.2127 0.1478 0.1501

COM_SMOKER1 -0.2292 0.0354 0.0000

COM_STEROIDS1 0.1897 0.1285 0.1400

COM_SUBSTANCE1 0.0011 0.0566 0.9839

TRAU_ISS 0.1113 0.0014 0.0000

TOP3_NATL_CAT1 0.2855 0.0406 0.0000

TOP3_NATL_CAT2+ 0.2767 0.0418 0.0000

63 64 65

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Supplementary Materials eTable 8. Penetrating Injury Type Patients Only 69

(Intercept) -3.5295 0.218 0.0000

DEMO_AGE 0.0092 0.0029 0.0015

DEMO_GENDERMale -0.039 0.1061 0.7131

DEMO_RACEAsian -0.7143 0.4505 0.1128

COM_ADHD1 0.1236 0.3311 0.7090

COM_ADVANCEDDIR1 1.414 0.382 0.0002

COM_ALCO1 0.1205 0.1421 0.3968

COM_ANTICOAG1 -0.1882 0.4924 0.7023

COM_BLEEDING1 0.7473 0.4025 0.0634

COM_CANCER1 0.8517 0.7472 0.2544

COM_CHEMO1 -0.7471 1.1926 0.5310

COM_CHF1 0.511 0.4322 0.2371

COM_CIRRHOSIS1 1.4123 0.5095 0.0056

COM_CONGENITAL1 0.1005 0.8285 0.9034

COM_COPD1 -0.0006 0.183 0.9973

COM_CRF1 0.7042 0.7292 0.3342

COM_CVA1 -0.6648 0.6222 0.2854

COM_DEMENTIA1 0.5401 0.6099 0.3759

COM_DIABETES1 -0.0254 0.1811 0.8887

COM_FUNCTIONAL1 -0.3637 0.6293 0.5633

COM_HTN1 -0.2654 0.1303 0.0416

COM_MENTAL1 0.2343 0.1064 0.0276

COM_MI1 0.36 0.2607 0.1673

COM_OBESITY1 0.2672 0.1803 0.1383

COM_OTHER1 -0.0801 0.1809 0.6579

COM_PAD1 -0.0838 1.7397 0.9616

COM_SMOKER1 -0.488 0.0813 0.0000

COM_STEROIDS1 -12.9715 346.2722 0.9701

COM_SUBSTANCE1 -0.4158 0.1114 0.0002

TRAU_ISS 0.1244 0.0037 0.0000

TOP3_NATL_CAT1 0.2227 0.0937 0.0174

TOP3_NATL_CAT2+ 0.0317 0.1058 0.7643

70 71 72 73 74 75

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Supplementary Materials eTable 9. Other Injury Type Patients Only 76

(Intercept) -5.5963 0.5535 0.0000

DEMO_AGE 0.027 0.0057 0.0000

DEMO_GENDERMale 0.3806 0.1981 0.0546

DEMO_RACEAsian -0.0178 0.991 0.9856

DEMO_RACEBlack or African American 0.1622 0.2419 0.5024

COM_ADHD1 -0.0449 0.8455 0.9577

COM_ADVANCEDDIR1 0.9236 0.7575 0.2228

COM_ALCO1 0.3344 0.2631 0.2038

COM_ANTICOAG1 -1.0405 0.8257 0.2076

COM_BLEEDING1 0.5439 0.6067 0.3700

COM_CANCER1 -0.1139 1.115 0.9186

COM_CHEMO1 -0.1206 1.4302 0.9328

COM_CHF1 -0.4615 0.4699 0.3260

COM_CIRRHOSIS1 0.8681 1.0305 0.3996

COM_CONGENITAL1 -13.486 832.7272 0.9871

COM_COPD1 0.4297 0.2768 0.1206

COM_CRF1 0.6729 1.8933 0.7223

COM_CVA1 0.3633 0.6647 0.5847

COM_DEMENTIA1 0.7989 0.7321 0.2752

COM_DIABETES1 0.1268 0.2493 0.6108

COM_FUNCTIONAL1 -0.1011 0.4761 0.8319

COM_HTN1 0.0458 0.2124 0.8295

COM_MENTAL1 0.368 0.237 0.1205

COM_MI1 0.5345 0.458 0.2432

COM_OBESITY1 0.0413 0.3152 0.8958

COM_OTHER1 -0.5066 0.2553 0.0472

COM_PAD1 -0.5246 0.9347 0.5746

COM_SMOKER1 0.152 0.1867 0.4156

COM_STEROIDS1 -0.9008 1.1725 0.4424

COM_SUBSTANCE1 -0.0253 0.3083 0.9347

TRAU_ISS 0.1697 0.0107 0.0000

TOP3_NATL_CAT1 0.7003 0.2289 0.0022

TOP3_NATL_CAT2+ 0.5149 0.2318 0.0263

77 78 79 80

(15)

Supplementary Materials eTable 10. ISS Score 0-9 Patients Only 86

(Intercept) -5.4816 0.1996 0.0000

DEMO_AGE 0.0142 0.0018 0.0000

DEMO_GENDERMale 0.1260 0.0582 0.0305

DEMO_RACEAsian 0.2278 0.1979 0.2498

COM_ADHD1 -0.1080 0.3186 0.7346

COM_ADVANCEDDIR1 0.6841 0.1371 0.0000

COM_ALCO1 0.5089 0.0912 0.0000

COM_ANTICOAG1 0.0387 0.1263 0.7594

COM_BLEEDING1 0.4449 0.1294 0.0006

COM_CANCER1 0.1624 0.3061 0.5956

COM_CHEMO1 0.2870 0.4038 0.4772

COM_CHF1 0.2706 0.1219 0.0265

COM_CIRRHOSIS1 0.5023 0.2099 0.0167

COM_CONGENITAL1 0.1347 0.4430 0.7611

COM_COPD1 0.3785 0.0884 0.0000

COM_CRF1 0.5096 0.1952 0.0090

COM_CVA1 0.3332 0.1432 0.0200

COM_DEMENTIA1 0.2600 0.1369 0.0575

COM_DIABETES1 0.1022 0.0751 0.1735

COM_FUNCTIONAL1 0.1657 0.1157 0.1521

COM_HTN1 0.0591 0.0651 0.3639

COM_MENTAL1 0.1221 0.0792 0.1230

COM_MI1 0.1403 0.1050 0.1816

COM_OBESITY1 0.3833 0.1043 0.0002

COM_OTHER1 0.1775 0.0881 0.0440

COM_PAD1 0.1016 0.2548 0.6900

COM_SMOKER1 0.0099 0.0645 0.8785

COM_STEROIDS1 0.4066 0.1935 0.0356

COM_SUBSTANCE1 0.0369 0.1058 0.7271

TRAU_ISS 0.1541 0.0102 0.0000

TOP3_NATL_CAT1 0.4024 0.0715 0.0000

TOP3_NATL_CAT2+ 0.3870 0.0761 0.0000

87 88

(16)

Supplementary Materials eTable 11. ISS Score 10-16 Patients Only 89

(Intercept) -5.0842 0.2382 0.0000

DEMO_AGE 0.0146 0.0020 0.0000

DEMO_GENDERMale 0.1638 0.0645 0.0111

DEMO_RACEAsian 0.4570 0.1816 0.0119

DEMO_RACEBlack or African American 0.1711 0.0847 0.0434 DEMO_RACENative Hawaiian or Pacific Islander 1.8064 0.4232 0.0000

COM_ADHD1 -0.1036 0.3731 0.7813

COM_ADVANCEDDIR1 0.4480 0.1517 0.0032

COM_ALCO1 0.5349 0.0937 0.0000

COM_ANTICOAG1 0.1524 0.1369 0.2654

COM_BLEEDING1 0.3924 0.1438 0.0064

COM_CANCER1 -0.1621 0.3175 0.6097

COM_CHEMO1 1.6517 0.3268 0.0000

COM_CHF1 0.4853 0.1279 0.0001

COM_CIRRHOSIS1 0.8016 0.1899 0.0000

COM_CONGENITAL1 1.1155 0.3965 0.0049

COM_COPD1 0.3907 0.0969 0.0001

COM_CRF1 0.5252 0.2174 0.0157

COM_CVA1 0.3140 0.1582 0.0471

COM_DEMENTIA1 0.3506 0.1333 0.0085

COM_DIABETES1 0.0575 0.0824 0.4855

COM_FUNCTIONAL1 -0.1885 0.1411 0.1814

COM_HTN1 -0.0049 0.0707 0.9443

COM_MENTAL1 0.1441 0.0889 0.1052

COM_MI1 0.3086 0.1034 0.0029

COM_OBESITY1 0.4595 0.1151 0.0001

COM_OTHER1 -0.0242 0.1050 0.8180

COM_PAD1 0.2690 0.2936 0.3595

COM_SMOKER1 -0.1088 0.0708 0.1245

COM_STEROIDS1 0.0533 0.2619 0.8388

COM_SUBSTANCE1 -0.1790 0.1125 0.1117

TRAU_ISS 0.1234 0.0138 0.0000

TOP3_NATL_CAT1 0.0667 0.0797 0.4031

TOP3_NATL_CAT2+ 0.1468 0.0826 0.0756

90

(17)

Supplementary Materials eTable 12. ISS Score 17+ Patients Only 92

(Intercept) -4.5045 0.1419 0.0000

DEMO_AGE 0.0162 0.0011 0.0000

DEMO_GENDERMale 0.1726 0.0385 0.0000

DEMO_RACEAmerican Indian or Alaska Native -0.2108 0.2307 0.3608

DEMO_RACEAsian 0.0083 0.1183 0.9442

COM_ADHD1 -0.0229 0.2001 0.9089

COM_ADVANCEDDIR1 0.4597 0.0961 0.0000

COM_ALCO1 0.2483 0.0600 0.0000

COM_ANTICOAG1 0.0689 0.0965 0.4751

COM_BLEEDING1 0.3418 0.0954 0.0003

COM_CANCER1 0.6771 0.2226 0.0023

COM_CHEMO1 0.2401 0.2610 0.3576

COM_CHF1 0.3305 0.1010 0.0011

COM_CIRRHOSIS1 0.7123 0.1409 0.0000

COM_CONGENITAL1 0.5346 0.3355 0.1111

COM_COPD1 0.3059 0.0733 0.0000

COM_CRF1 0.4609 0.1715 0.0072

COM_CVA1 -0.0758 0.1289 0.5562

COM_DEMENTIA1 0.0038 0.1070 0.9718

COM_DIABETES1 0.0821 0.0558 0.1416

COM_FUNCTIONAL1 -0.5787 0.1214 0.0000

COM_HTN1 -0.1459 0.0456 0.0014

COM_MENTAL1 -0.0384 0.0596 0.5193

COM_MI1 0.1461 0.0702 0.0372

COM_OBESITY1 0.4117 0.0722 0.0000

COM_OTHER1 0.0044 0.0661 0.9468

COM_PAD1 0.2814 0.2199 0.2007

COM_SMOKER1 -0.4355 0.0423 0.0000

COM_STEROIDS1 -0.0818 0.2039 0.6882

COM_SUBSTANCE1 -0.1339 0.0645 0.0378

TRAU_ISS 0.1020 0.0022 0.0000

TOP3_NATL_CAT1 0.3252 0.0508 0.0000

TOP3_NATL_CAT2+ 0.2056 0.0521 0.0001

93 94

(18)

Supplementary Materials eTable 13. Complete Case Patients Only 95

(Intercept) -4.9392 0.1179 0.0000

DEMO_AGE 0.0157 0.0009 0.0000

DEMO_GENDERMale 0.1575 0.0297 0.0000

DEMO_RACEAsian 0.1599 0.0895 0.0741

COM_ADHD1 -0.0951 0.1606 0.5535

COM_ADVANCEDDIR1 0.5038 0.0717 0.0000

COM_ALCO1 0.3670 0.0463 0.0000

COM_ANTICOAG1 0.0452 0.0689 0.5117

COM_BLEEDING1 0.3619 0.0697 0.0000

COM_CANCER1 0.3344 0.1521 0.0279

COM_CHEMO1 0.6131 0.1890 0.0012

COM_CHF1 0.3502 0.0682 0.0000

COM_CIRRHOSIS1 0.6900 0.1024 0.0000

COM_CONGENITAL1 0.5552 0.2257 0.0139

COM_COPD1 0.3537 0.0500 0.0000

COM_CRF1 0.5055 0.1137 0.0000

COM_CVA1 0.1736 0.0851 0.0413

COM_DEMENTIA1 0.1445 0.0738 0.0503

COM_DIABETES1 0.0966 0.0407 0.0176

COM_FUNCTIONAL1 -0.2147 0.0754 0.0044

COM_HTN1 -0.0654 0.0340 0.0542

COM_MENTAL1 0.0707 0.0434 0.1038

COM_MI1 0.1813 0.0521 0.0005

COM_OBESITY1 0.4406 0.0543 0.0000

COM_OTHER1 0.0123 0.0486 0.7997

COM_PAD1 0.2057 0.1480 0.1645

COM_SMOKER1 -0.2601 0.0329 0.0000

COM_STEROIDS1 0.1377 0.1296 0.2880

COM_SUBSTANCE1 -0.1223 0.0516 0.0178

TRAU_ISS 0.1133 0.0013 0.0000

TOP3_NATL_CAT1 0.2812 0.0379 0.0000

TOP3_NATL_CAT2+ 0.2274 0.0394 0.0000

96 97 98

(19)

Supplementary Materials eTable 14. Primary Predictor Treated as Binary (0 or 1+ High-Risk Services) 100

(Intercept) -4.925 0.119 0.000

DEMO_AGE 0.016 0.001 0.000

DEMO_GENDERMale 0.162 0.029 0.000

DEMO_RACEAsian 0.164 0.089 0.064

DEMO_RACEBlack or African American -0.008 0.039 0.846

DEMO_RACENative Hawaiian or Pacific Islander 0.164 0.319 0.606

COM_ADHD1 -0.057 0.154 0.712

COM_ADVANCEDDIR1 0.499 0.071 0.000

COM_ALCO1 0.375 0.045 0.000

COM_ANTICOAG1 0.069 0.067 0.309

COM_BLEEDING1 0.387 0.068 0.000

COM_CANCER1 0.322 0.150 0.031

COM_CHEMO1 0.659 0.183 0.000

COM_CHF1 0.373 0.067 0.000

COM_CIRRHOSIS1 0.715 0.100 0.000

COM_CONGENITAL1 0.576 0.221 0.009

COM_COPD1 0.365 0.049 0.000

COM_CRF1 0.492 0.111 0.000

COM_CVA1 0.157 0.083 0.059

COM_DEMENTIA1 0.163 0.072 0.023

COM_DIABETES1 0.086 0.039 0.029

COM_FUNCTIONAL1 -0.181 0.073 0.014

COM_HTN1 -0.062 0.033 0.060

COM_MENTAL1 0.051 0.042 0.227

COM_MI1 0.185 0.051 0.000

COM_OBESITY1 0.428 0.053 0.000

COM_OTHER1 0.015 0.047 0.749

COM_PAD1 0.205 0.145 0.157

COM_SMOKER1 -0.261 0.032 0.000

COM_STEROIDS1 0.141 0.127 0.268

COM_SUBSTANCE1 -0.101 0.050 0.042

TRAU_ISS 0.113 0.001 0.000

SERVICE.BINARY 0.248 0.034 0.000

101 102 103

(20)

Supplementary Materials eTable 15. Model Adjusted for Number of Services Participating in Patient’s 104

Care 105

(Intercept) -5.4544 0.1401 0.0000

DEMO_AGE 0.0157 0.0009 0.0000

DEMO_GENDERMale 0.1581 0.0287 0.0000

DEMO_RACEAsian 0.1720 0.0891 0.0535

COM_ADHD1 -0.0636 0.1538 0.6791

COM_ADVANCEDDIR1 0.5006 0.0706 0.0000

COM_ALCO1 0.3783 0.0447 0.0000

COM_ANTICOAG1 0.0830 0.0673 0.2174

COM_BLEEDING1 0.3811 0.0678 0.0000

COM_CANCER1 0.3555 0.1499 0.0177

COM_CHEMO1 0.6553 0.1828 0.0003

COM_CHF1 0.3725 0.0666 0.0000

COM_CIRRHOSIS1 0.7228 0.1000 0.0000

COM_CONGENITAL1 0.5646 0.2216 0.0109

COM_COPD1 0.3653 0.0491 0.0000

COM_CRF1 0.4949 0.1115 0.0000

COM_CVA1 0.1579 0.0834 0.0583

COM_DEMENTIA1 0.1677 0.0720 0.0199

COM_DIABETES1 0.0841 0.0394 0.0331

COM_FUNCTIONAL1 -0.1872 0.0735 0.0108

COM_HTN1 -0.0618 0.0330 0.0613

COM_MENTAL1 0.0506 0.0422 0.2299

COM_MI1 0.1920 0.0513 0.0002

COM_OBESITY1 0.4190 0.0530 0.0000

COM_OTHER1 0.0422 0.0473 0.3716

COM_PAD1 0.1917 0.1454 0.1873

COM_SMOKER1 -0.2678 0.0318 0.0000

COM_STEROIDS1 0.1411 0.1271 0.2671

COM_SUBSTANCE1 -0.1048 0.0496 0.0348

TRAU_ISS 0.1093 0.0013 0.0000

TOP3_NATL_CAT1 0.2118 0.0369 0.0000

TOP3_NATL_CAT2+ 0.0884 0.0398 0.0263

PARS_NSERVICES 0.2034 0.0180 0.0000

(21)

Supplementary Materials eTable 16. Model Limited to Patients with Neurosurgery or Orthopaedics Services Participating in Care

(Intercept) -4.8912 0.1222 0.0000

DEMO_AGE 0.0146 0.001 0.0000

DEMO_GENDERMale 0.1585 0.033 0.0000

DEMO_RACEAsian 0.1632 0.0972 0.0931

COM_ADHD1 -0.0405 0.1734 0.8153

COM_ADVANCEDDIR1 0.4624 0.0805 0.0000

COM_ALCO1 0.362 0.053 0.0000

COM_ANTICOAG1 0.1124 0.0757 0.1379

COM_BLEEDING1 0.3583 0.0783 0.0000

COM_CANCER1 0.4087 0.1641 0.0128

COM_CHEMO1 0.5758 0.2075 0.0055

COM_CHF1 0.3661 0.0767 0.0000

COM_CIRRHOSIS1 0.5961 0.1225 0.0000

COM_CONGENITAL1 0.6017 0.242 0.0129

COM_COPD1 0.3017 0.0583 0.0000

COM_CRF1 0.5426 0.1347 0.0001

COM_CVA1 0.1381 0.095 0.1460

COM_DEMENTIA1 0.1651 0.0819 0.0438

COM_DIABETES1 0.0552 0.0456 0.2260

COM_FUNCTIONAL1 -0.1961 0.0821 0.0170

COM_HTN1 0.0115 0.0381 0.7635

COM_MENTAL1 0.0817 0.0481 0.0896

COM_MI1 0.135 0.0604 0.0255

COM_OBESITY1 0.4218 0.0588 0.0000

COM_OTHER1 0.0381 0.0545 0.4840

COM_PAD1 0.1715 0.163 0.2929

COM_SMOKER1 -0.2112 0.0374 0.0000

COM_STEROIDS1 0.0979 0.1417 0.4897

COM_SUBSTANCE1 -0.0908 0.0585 0.1207

TRAU_ISS 0.1139 0.0015 0.0000

TOP3_NATL_CAT1 0.284 0.0417 0.0000

TOP3_NATL_CAT2+ 0.2187 0.0428 0.0000