Pediatric traumatic brain injury is inconsistently regionalized in the United States

Abstract

Objectives: Traumatic brain injury is a leading cause of death in children. On the basis of evidence of better outcomes, the American College of Surgery Committee on Trauma recommends that children with severe traumatic brain injury receive care at high-level trauma centers. We assessed rates of adherence to these recommendations and factors associated with adherence.

Methods: We studied population and hospital discharge data from 2001 from all of the health care referral regions (n = 68) in 6 US states (Florida, Massachusetts, New Jersey, New York, Texas, and Virginia). We identified children with severe traumatic brain injury by using International Classification of Diseases, Ninth Revision, Clinical Modification, codes and American College of Surgery Committee on Trauma criteria. We defined "high-level centers" as either level I or pediatric trauma centers. We considered an area to be well regionalized if >or=90% of severe traumatic brain injury hospitalizations were in high-level centers. We also explored how use of level II trauma centers affected rates of care at high-level centers.

Results: Of 2117 admissions for severe pediatric traumatic brain injury, 67.3% were in high-level centers, and 87.3% were in either high-level or level II centers. Among states, 56.4% to 93.6% of severe traumatic brain injury admissions were in high-level centers. Only 2 states, Massachusetts and Virginia, were well regionalized. Across health care referral regions, 0% to 100% of severe traumatic brain injury admissions were in high-level centers, and only 19.1% of health care referral regions were well regionalized. Only a weak relationship existed between the distance to the nearest high-level center and regionalization. The age of statewide trauma systems had no relationship to the extent of regionalization.

Conclusions: Despite evidence for improved outcomes of severely injured children admitted to high-level trauma centers, we found that almost one third of the children with severe traumatic brain injury failed to receive care in such centers. Only 2 of 6 states and less than one fifth of 68 health care referral regions were well regionalized. This study highlights problems with current pediatric trauma care that can serve as a basis for additional research and health care policy.

FIGURE 1

Proportions of children with severe TBI receiving care at high-level centers according to state and HRR. The percentage of severe pediatric TBI admissions to high-level centers varied widely among the HRRs, ranging from 0% in 3 HRRs to 100% in another 3 HRRs.

FIGURE 2

Case distribution and percentage of patients admitted to a high-level center as a function of distance to the nearest high-level center for HRRs with ≥1 high-level center. A, Well-regionalized HRRs. B, Poorly regionalized HRRs. In well-regionalized HRRs, ≥90% of patients with severe TBI were admitted to high-level centers regardless of the distance to the centers (A). In moderately and poorly regionalized HRRs, the percentage was never >80%, even for children residing <10 miles from high-level centers (B).