Comparison of Outcomes in Level I vs Level II Trauma Centers in Patients Undergoing Craniotomy or Craniectomy for Severe Traumatic Brain Injury

Abstract

BACKGROUNDTraumatic brain injury (TBI) carries a devastatingly high rate of morbidity and mortality.OBJECTIVETo assess whether patients undergoing craniotomy/craniectomy for severe TBI fare better at level I than level II trauma centers in a mature trauma system.METHODSThe data were extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients > 18 yr with severe TBI (Glasgow Coma Scale [GCS] score less than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania from January 1, 2002 through September 30, 2017.RESULTSOf 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline characteristics were similar between the 2 groups except for significantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I centers vs 40.4% in level II centers (P = .08). Mean Functional Independence Measure (FIM) scores at discharge were significantly higher in level I (10.9 ± 5.5) than level II centers (9.8 ± 5.3; P < .005). In multivariate analysis, treatment at level II trauma centers was significantly associated with in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.03-1.37; P = .01) and worse FIM scores (odds ratio, 1.4; 95% confidence interval, 1.1-1.7; P = .001). Mean hospital and ICU length of stay were significantly longer in level I centers (P < .005).CONCLUSIONThis study showed superior functional outcomes and lower mortality rates in patients undergoing a neurosurgical procedure for severe TBI in level I trauma centers.

The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer

“…13,14 Previous data, however, would suggest that admission to a Level II center is associated with mortality and adverse outcomes 4,6,12 compared to a Level I center particularly in the TBI patient. 10,11 Similar data exist for TBI patients who undergo interfacility transfer to a Level II center. 16 The current recommendation for transfer of TBI patients to a Level I or II center is incongruent with these data.…”

“…Similarly, Level I center admissions have shown increased survival for complex injuries such as traumatic brain injury (TBI). 10,11 Through Resource Manual revisions there has been an evolution of progressively specific requirements of each tier of trauma center with Level I and II centers becoming more robust and similar. 1 As such, many of these previous data become outdated as they were reported before the latest version of the Resources Manual (Orange Book) was implemented in 2014 4,10 or utilized other obsolete data sets.…”

“…Despite this, other data support equivalence 8 or even better, 9 outcomes at Level II centers. Similarly, Level I center admissions have shown increased survival for complex injuries such as traumatic brain injury (TBI) 10,11 . Through Resource Manual revisions there has been an evolution of progressively specific requirements of each tier of trauma center with Level I and II centers becoming more robust and similar 1 .…”

The Effect of Trauma Center Verification on Outcomes of Traumatic Brain Injury Patients Undergoing Interfacility Transfer

“…However, we submit that other study designs (e.g., difference in difference) would be more appropriate to examine the association between changes in health policy and clinical outcomes. 6 For that reason, as well as the fact that more recent data suggest that differences persist between outcomes at ACS Level I and Level II trauma centers, 1 attribution of this study's findings to changes in policy are unwarranted.…”

“…For example, a limited amount of evidence suggests that patients with traumatic brain injuries (TBIs) have improved survival when treated at ACS Level I trauma centers compared with ACS Level II trauma centers. 1,2 While those studies favor the transfer of TBI patients to ACS Level I trauma centers, the amount and quality of evidence supporting that decision is quite limited. One of the studies cited above uses data that predate current ACS trauma center verification criteria, while the other uses data that are limited to a single state.…”