From the Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada (A.K.M., H.S., C.W.S., R.J., J.R.W., C.D.W.); Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada (A.K.M., H.S., C.W.S., R.J., J.R.W., C.D.W.); Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (A.K.M., H.S., R.J., A.V.K., J.R.W., C.D.W., A.B.N.); American College of Surgeons, Chicago, Illinois, United States (B.P., C.J.H., A.B.N.); Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada (A.V.K.); Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada (A.B.N.).
J Trauma Acute Care Surg. 2024 May 1;96(5):777-784. doi: 10.1097/TA.0000000000004126. Epub 2023 Aug 21.
There is conflicting evidence regarding the relationship between trauma center type and mortality for children with traumatic brain injuries. Identification of mortality differences following brain injury across differing trauma center types may result in actionable quality improvement initiatives to standardize care for these children.
We used Trauma Quality Improvement Program data from 2017 to 2020 to identify children with severe traumatic brain injury (TBI) managed at levels I and II state or American College of Surgeon-verified trauma centers. We used a random intercept multilevel logistic regression model to assess the relationship between exposure (trauma center type either adult, pediatric, or mixed) and outcome (in-hospital mortality). Several secondary analyses were performed to assess the influence of trauma center volume, age strata, and TBI heterogeneity.
There were 10,105 patients identified across 512 trauma centers. Crude mortality was 25.2%, 36.2%, and 28.9% for pediatric, adult, and mixed trauma centers, respectively. After adjustment for confounders, odds of mortality were higher for children managed at adult trauma centers (odds ratio, 1.67; 95% confidence interval, 1.30-2.13) compared with pediatric trauma centers. There were several patient demographic and injury factors associated with greater odds of death; these included male sex, self-pay insurance status, interfacility transfer, non-fall related inury, age-adjusted hypotension, lack of pupil reactivity and midline shift >5 mm. Adjustment for trauma volume and subgroup analysis using a homogenous TBI subgroup did not change the demonstrated associations.
Our results suggest that mortality was higher at adult trauma centers compared with mixed and pediatric trauma centers for children with traumatic brain injuries. Importantly, there exists the potential for unmeasured confounding. We aim for these findings to direct continuing quality improvement initiatives to improve outcomes for brain injured children.
Prognostic and Epidemiological; Level III.
创伤中心类型与创伤性脑损伤儿童死亡率之间的关系存在相互矛盾的证据。确定不同创伤中心类型的脑损伤后死亡率差异，可能会产生可行的质量改进措施，以规范这些儿童的护理。
我们使用 2017 年至 2020 年创伤质量改进计划的数据，确定在一级和二级州或美国外科医师学院认证的创伤中心接受治疗的严重创伤性脑损伤（TBI）儿童。我们使用随机截距多水平逻辑回归模型评估暴露（创伤中心类型为成人、儿科或混合）与结局（院内死亡率）之间的关系。进行了几项二次分析，以评估创伤中心数量、年龄分层和 TBI 异质性的影响。
在 512 个创伤中心中确定了 10105 名患者。儿科、成人和混合创伤中心的死亡率分别为 25.2%、36.2%和 28.9%。在调整混杂因素后，与儿科创伤中心相比，接受成人创伤中心治疗的儿童死亡的可能性更高（比值比，1.67；95%置信区间，1.30-2.13）。有几个与死亡风险增加相关的患者人口统计学和损伤因素；这些因素包括男性、自付保险状态、院内转移、非跌倒相关损伤、年龄调整性低血压、瞳孔反应性缺乏和中线移位>5mm。调整创伤量和使用同质 TBI 亚组进行亚组分析并没有改变所显示的关联。
我们的结果表明，与混合和儿科创伤中心相比，成人创伤中心的死亡率更高对于创伤性脑损伤儿童。重要的是，可能存在未测量的混杂因素。我们希望这些发现能够指导持续的质量改进措施，以改善脑损伤儿童的结局。
预后和流行病学；III 级。
