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Original Investigation |

Association Between Trauma Center Type and Mortality Among Injured Adolescent Patients

Rachel B. Webman, MD1; Elizabeth A. Carter, PhD, MPH1; Sushil Mittal, PhD2; Jichaun Wang, PhD3; Chethan Sathya, MD4; Avery B. Nathens, MD, PhD4; Michael L. Nance, MD5; David Madigan, PhD6; Randall S. Burd, MD, PhD1
[+] Author Affiliations
1Division of Trauma and Burn Surgery, Children’s National Medical Center, Washington, DC
2Scibler Corporation, Santa Clara, California
3Center for Clinical and Community Research, Children’s National Medical Center, Washington, DC
4Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
5Department of Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
6Department of Statistics, Columbia University, New York, New York
JAMA Pediatr. 2016;170(8):780-786. doi:10.1001/jamapediatrics.2016.0805.
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Importance  Although data obtained from regional trauma systems demonstrate improved outcomes for children treated at pediatric trauma centers (PTCs) compared with those treated at adult trauma centers (ATCs), differences in mortality have not been consistently observed for adolescents. Because trauma is the leading cause of death and acquired disability among adolescents, it is important to better define differences in outcomes among injured adolescents by using national data.

Objectives  To use a national data set to compare mortality of injured adolescents treated at ATCs, PTCs, or mixed trauma centers (MTCs) that treat both pediatric and adult trauma patients and to determine the final discharge disposition of survivors at different center types.

Design, Setting, and Participants  Data from level I and II trauma centers participating in the 2010 National Trauma Data Bank (January 1 to December 31, 2010) were used to create multilevel models accounting for center-specific effects to evaluate the association of center characteristics (PTC, ATC, or MTC) on mortality among patients aged 15 to 19 years who were treated for a blunt or penetrating injury. The models controlled for sex; mechanism of injury (blunt vs penetrating); injuries sustained, based on the Abbreviated Injury Scale scores (post-dot values <3 or ≥3 by body region); initial systolic blood pressure; and Glasgow Coma Scale scores. Missing data were managed using multiple imputation, accounting for multilevel data structure. Data analysis was conducted from January 15, 2013, to March 15, 2016.

Exposures  Type of trauma center.

Main Outcomes and Measures  Mortality at each center type.

Results  Among 29 613 injured adolescents (mean [SD] age, 17.3 [1.4] years; 72.7% male), most were treated at ATCs (20 402 [68.9%]), with the remainder at MTCs (7572 [25.6%]) or PTCs (1639 [5.5%]). Adolescents treated at PTCs were more likely to be injured by a blunt than penetrating injury mechanism (91.4%) compared with those treated at ATCs (80.4%) or MTCs (84.6%). Mortality was higher among adolescents treated at ATCs and MTCs than those treated at PTCs (3.2% and 3.5% vs 0.4%; P < .001). The adjusted odds of mortality were higher at ATCs (odds ratio, 4.19; 95% CI, 1.30-13.51) and MTCs (odds ratio, 6.68; 95% CI, 2.03-21.99) compared with PTCs but was not different between level I and II centers (odds ratio, 0.76; 95% CI, 0.59-0.99).

Conclusion and Relevance  Mortality among injured adolescents was lower among those treated at PTCs, compared with those treated at ATCs and MTCs. Defining resource and patient features that account for these observed differences is needed to optimize adolescent outcomes after injury.

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