Facility Characteristics and Inhospital Pediatric Mortality after Severe Traumatic Brain Injury

Abstract

More than 500,000 children sustain a traumatic brain injury (TBI) each year. Previous studies have described significant variation in inhospital mortality after pediatric TBI. The aim of this study was to identify facility-level characteristics independently associated with 30-day inhospital mortality after pediatric severe TBI. We hypothesized that, even after accounting for patient-level characteristics associated with mortality, the characteristics of facilities where patients received care would be associated with inhospital mortality. Using data from the National Trauma Data Bank from 2009-2012, we identified a cohort of 6707 pediatric patients hospitalized with severe TBI in 391 facilities and investigated their risk of 30-day inhospital mortality. Pre-specified facility-level characteristics (trauma certification level, teaching status, census region, facility size, nonprofit status, and responsibility for pediatric trauma care) were added to a Poisson regression model that accounted for patient-level characteristics associated with mortality. In multivariable analyses, patients treated in facilities located in the Midwest (risk ratio [RR] = 1.42; 95% confidence interval [CI] 1.12-1.81) and South (RR = 1.39; 95% CI: 1.12-1.72) regions had higher likelihoods of 30-day inhospital mortality compared with patients treated in the Northeast. Other facility-level characteristics were not found to be significant. To our knowledge, this is one of the largest investigations to identify regional variation in inhospital mortality after pediatric severe TBI in a national sample after accounting for individual and other facility-level characteristics. Further investigations to help explain this variation are needed to inform evidence-based decision-making for pediatric severe TBI care across different settings.

Demographic and clinical risk factors associated with hospital mortality after isolated severe traumatic brain injury: a cohort study

“…Brown and colleagues [ 21 ] demonstrated that among 118,611 Medicare beneficiaries hospitalized for acute myocardial infarction, larger hospitals had a significantly reduced 30-day hospital readmission rate, compared to smaller hospitals. In the pediatric TBI population, it has been shown that hospitals with improved guideline adherence have reduced mortality and improved functional outcomes [ 11 ]; in addition, regional variation in mortality after pediatric TBI has been demonstrated as well [ 22 ]. In our study, we pre-specified facility-level factors in an attempt to adjust for differences in processes of care across facilities, but our hospital characteristics may have only served as a crude proxy and likely did not capture with enough granularity factors such as adherence to guidelines and evidence-based care pathways.…”

Healthcare Utilization and Missed Workdays for Parents of Children With Traumatic Brain Injury

“…For example, several recent publications have documented differences in a variety of pediatric TBI outcomes such as discharge to rehabilitation and inpatient mortality by region or state in the United States. 19,20 An additional study described factors that are important for successful recovery for pediatric TBI patients (including identifying at-risk children at the time of injury and receiving follow-up medical, transitional, and educational services). 21 These studies suggest that the availability and adequacy of acute and follow-up care may be quite different in different areas of the country, which could lead to differences in the outcomes of our study.…”

Structure, Process, and Culture Differences of Pediatric Trauma Centers Participating in an International Comparative Effectiveness Study of Children with Severe Traumatic Brain Injury

“…An approach to study quality of care in hospital units is via a global assessment of culture with a focus on the human resources, organizational structure, patient care management, culture of safety and consistency of approach towards specific issues (e.g. infection control, medication safety, or pain management) [7, 11, 16–18]. Therefore, we conducted a global assessment of structure, process, and culture, with specific domains potentially relevant for pediatric TBI.…”