Snyder Christopher W, Chandler Nicole M, Litz Cristen N, Pracht Etienne E, Danielson Paul D, Ciesla David J
From the Division of Pediatric Surgery (C.W.S., N.M.C., C.N.L., P.D.D.), Johns Hopkins All Children's Hospital, St. Petersburg, Florida; Division of Trauma and Acute Care Surgery (C.W.S., D.J.C.), University of South Florida, Tampa, Florida; and College of Public Health (E.E.P.), University of South Florida, Tampa, Florida.
J Trauma Acute Care Surg. 2017 Oct;83(4):711-715. doi: 10.1097/TA.0000000000001580.
The state of Florida's trauma system is organized into seven regions, two of which lack designated pediatric trauma centers. Injured children residing in these regions often require transfer out of their home region for definitive care. The purpose of this study was to evaluate the effectiveness and efficiency of the current regionalization approach, focusing on variations between regions.
Using the Florida Agency for Health Care Administration database, we identified all trauma patients 15 years old or younger admitted between 2009 and 2014. Patients with high-risk injury (ICD-9 Injury Severity Score < 0.85) who did not receive definitive treatment at a pediatric trauma center (PTC) were considered undertriaged. Outcomes of interest included mortality and long-term disability. Patients who were definitively treated at a facility outside their home region, but who had low risk injuries (ICD-9 Injury Severity Score > 0.9), required no procedures or ICU monitoring, and were discharged within 48 hours, were considered to have received potentially avoidable out-of-region treatment. Regions were compared, and patients treated in-region were compared to those treated out-of-region. Regression models were used to adjust for covariates.
Of 34,816 patients, 8% had high-risk injuries and the overall mortality rate was 1%. Risk-adjusted outcomes were generally similar across all regions. Regional rates of undertriage varied from 0.4% to 4.7% and were highest in regions lacking a PTC. Eleven percent of patients required definitive treatment outside their home region; these patients had higher hospital charges and stayed in the hospital 0.96 days longer (least-squares mean). Rates of potentially avoidable out-of-region treatment ranged from 7% to 12% in the two regions lacking a PTC. After adjustment for confounders, significant unexplained differences in potentially avoidable out-of-region treatment remained between these two regions (OR 2.0, 95% CI 1.6-2.6).
Florida's regionalized pediatric trauma system performs effectively, with low undertriage and acceptable outcomes. Out-of-region treatment, an inevitable byproduct of the current regionalization approach, imposes a measurable burden on the treating facility and patient/family. Unexplained variations in potentially avoidable out-of-region treatment suggest improvements can be made in system efficiency.
Economic/decision study, level III.
佛罗里达州的创伤系统分为七个区域，其中两个区域没有指定的儿科创伤中心。居住在这些区域的受伤儿童往往需要转离本地区接受确定性治疗。本研究的目的是评估当前区域化方法的有效性和效率，重点关注各区域之间的差异。
利用佛罗里达州医疗保健管理局的数据库，我们确定了2009年至2014年期间收治的所有15岁及以下的创伤患者。未在儿科创伤中心（PTC）接受确定性治疗的高危损伤患者（国际疾病分类第九版损伤严重度评分<0.85）被视为分诊不足。感兴趣的结局包括死亡率和长期残疾。在本地区以外的机构接受确定性治疗，但损伤风险较低（国际疾病分类第九版损伤严重度评分>0.9）、无需进行手术或重症监护病房监测且在48小时内出院的患者，被视为接受了可能可避免的跨地区治疗。对各区域进行比较，并将在本地区接受治疗的患者与在本地区以外接受治疗的患者进行比较。使用回归模型对协变量进行调整。
在34816例患者中，8%有高危损伤，总体死亡率为1%。所有区域的风险调整结局总体相似。分诊不足的区域发生率从0.4%到4.7%不等，在没有PTC的区域最高。11%的患者需要在本地区以外接受确定性治疗；这些患者的住院费用更高，住院时间长0.96天（最小二乘均值）。在两个没有PTC的区域，可能可避免的跨地区治疗发生率在7%至12%之间。在对混杂因素进行调整后，这两个区域在可能可避免的跨地区治疗方面仍存在显著的无法解释的差异（比值比2.0，95%置信区间1.6 - 2.6）。
佛罗里达州的区域化儿科创伤系统运行有效，分诊不足率低，结局可接受。跨地区治疗是当前区域化方法不可避免的副产品，给治疗机构以及患者/家庭带来了可衡量的负担。可能可避免的跨地区治疗中存在无法解释的差异，这表明系统效率可以提高。
经济/决策研究，三级。
