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The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011

Wang, Nancy E. MD; Saynina, Olga MA; Vogel, Lara D. MBA; Newgard, Craig D. MD, MPH; Bhattacharya, Jayanta MD, PhD; Phibbs, Ciaran S. PhD

Journal of Trauma and Acute Care Surgery: October 2013 - Volume 75 - Issue 4 - p 704–716
doi: 10.1097/TA.0b013e31829a0a65
Original Articles

BACKGROUND Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care.

METHODS This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999–2011). DRG International Classification of Diseases—9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0–18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child’s residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables.

RESULTS Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, −0.80 to −0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs.

CONCLUSION Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care.

LEVEL OF EVIDENCE Therapeutic/care management, level III.

From the Center for Primary Care and Outcomes Research (O.S., J.B.), Center for Policy, Outcomes and Prevention, Stanford University School of Medicine (N.E.W., L.D.V.), Stanford, California; Health Economics Resource Center (C.S.P.), Palo Alto VA Health Care System, Palo Alto, California; and Center for Policy and Research in Emergency Medicine (C.D.N.), Oregon Health & Science University, Portland, Oregon.

Submitted: December 23, 2012, Revised: April 9, 2013, Accepted: April 15, 2013.

The article’s abstract was accepted but was not presented at Academy Health Conference 2011.

Address for reprints: Nancy E. Wang, MD, 300 Pasteur Drive - Alway M121, Stanford University School of Medicine, Stanford, CA 94305; email:

© 2013 Lippincott Williams & Wilkins, Inc.