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Variation in Adult Traumatic Brain Injury Outcomes in the United States

Greene, Nathaniel H. MD, MHS; Kernic, Mary A. PhD, MPH; Vavilala, Monica S. MD; Rivara, Frederick P. MD, MPH

The Journal of Head Trauma Rehabilitation: January/February 2018 - Volume 33 - Issue 1 - p E1–E8
doi: 10.1097/HTR.0000000000000306
Original Articles

Objective: To ascertain the degree of variation, by state of acute care hospitalization, in outcomes associated with traumatic brain injury (TBI) in an adult population.

Setting: All acute care hospitals in 21 states in the United States in the year 2010.

Participants: Adult (> 18 years) patients (N = 95 546) admitted to a hospital with a moderate or severe TBI.

Design: Retrospective cohort study using data from State Inpatient Databases from Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Main Measures: Inpatient mortality and discharge to inpatient rehabilitation.

Results: The adjusted risk of inpatient mortality varied between states by as much as 40%, with age, severity of injury, and insurance status as significant factors in both outcomes. The adjusted risk of discharge to inpatient rehabilitation varied between by more than 100% among the states measured.

Conclusions: There was clinically significant variation between states in inpatient mortality and rehabilitation discharge after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the causes of this state-to-state variation, how these causes affect patient outcomes, and may serve as a guide to further standardization of treatment for traumatic brain injury across the United States.

Department of Anesthesiology and Pain Medicine, School of Medicine (Drs Greene and Vavilala), Department of Epidemiology, School of Public Health (Drs Kernic and Rivara), Department of Pediatrics, School of Medicine (Drs Vavilala and Rivara), and Harborview Injury Prevention and Research Center (Drs Greene, Kernic, Vavilala, and Rivara), University of Washington, Seattle. Nathaniel Greene is now affiliated with Duke University.

Corresponding Author: Nathaniel H. Greene, MD, MHS, Department of Anesthesiology, Duke University School of Medicine, Durham, NC 27710 (

This study had no external source of funding.

The authors declare no conflicts of interest.

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