Piatt Joseph
J Neurosurg Pediatr. 2018 Jul;22(1):9-17. doi: 10.3171/2018.1.PEDS17625. Epub 2018 Apr 20.
OBJECTIVE An implicit expectation of the pioneers of trauma system design was that high clinical volume at select centers could lead to superior outcomes. There has been little study of the regionalization of pediatric craniospinal trauma care, and whether it continues to trend in the direction of regionalization is unknown. The motivating hypothesis for this study was that trauma system design in the United States is proceeding on a rational basis, producing hospital caseloads that are increasing over time and, because of geographic siting appropriate to the needs of catchment areas, in an increasingly uniform manner. METHODS Data were obtained from the Kids' Inpatient Database (KID) for 1997, 2000, 2003, 2006, 2009, and 2012. Cases of traumatic spinal injury (TSI) and severe traumatic brain injury (sTBI) were identified by ICD-9 diagnostic and procedural codes. Records of patients 18 years of age and older were excluded. Hospital caseloads and descriptive statistics were calculated for each year of the study, and trends were examined. The distributions of hospital caseloads were compared year with year and with simulations of idealized systems. RESULTS Caseloads of TSI trended upward and caseloads of sTBI were stable, despite a declining nationwide incidence of these conditions during the study period, so the pool of hospitals providing services for pediatric craniospinal trauma contracted to a degree. The distributions of hospital caseloads did not change, and in every year of the study large numbers of hospitals reported small numbers of discharges. In the last year of the study, a quarter of all children with TSI were discharged from hospitals that treated approximately 1 case or fewer every other month and a quarter of all children with sTBI were discharged from hospitals that treated 1 case or fewer every 3 months. CONCLUSIONS There has been no previous study of nationwide trends in pediatric craniospinal trauma caseloads. Analysis of hospital caseloads from 1997 through 2012 supports inference of a persisting geographical mismatch between population needs and the availability of services. These observations falsify the study hypothesis. A notable fraction of pediatric craniospinal trauma care continues to be rendered at low-caseload institutions. Novel quality assurance methods tailored to the needs of low-caseload institutions deserve development and study.
目的 创伤系统设计先驱者的一个潜在期望是，特定中心的高临床量能带来更好的治疗效果。关于小儿颅脊髓创伤护理的区域化研究很少，且其是否仍朝着区域化方向发展尚不清楚。本研究的驱动假设是，美国的创伤系统设计是基于合理的基础进行的，医院的病例量随时间增加，并且由于地理位置适合集水区的需求，病例量的增加方式越来越统一。方法 从1997年、2000年、2003年、2006年、2009年和2012年的儿童住院数据库（KID）中获取数据。通过ICD - 9诊断和程序编码识别创伤性脊髓损伤（TSI）和重度创伤性脑损伤（sTBI）病例。排除18岁及以上患者的记录。计算研究各年的医院病例量和描述性统计数据，并检查趋势。将医院病例量的分布逐年进行比较，并与理想化系统的模拟结果进行比较。结果 尽管在研究期间全国范围内这些疾病的发病率下降，但TSI的病例量呈上升趋势，sTBI的病例量稳定，因此为小儿颅脊髓创伤提供服务的医院数量在一定程度上有所减少。医院病例量的分布没有变化，并且在研究的每一年中，大量医院报告的出院病例数很少。在研究的最后一年，四分之一的TSI患儿从每隔一个月治疗约1例或更少病例的医院出院，四分之一的sTBI患儿从每三个月治疗1例或更少病例的医院出院。结论 此前没有关于小儿颅脊髓创伤病例量全国趋势的研究。对1997年至2012年医院病例量的分析支持了这样的推断，即人口需求与服务可及性之间存在持续的地理不匹配。这些观察结果证伪了研究假设。相当一部分小儿颅脊髓创伤护理仍在低病例量机构进行。适合低病例量机构需求的新型质量保证方法值得开发和研究。
