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Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system
Michael L Kelly1, Mary Jo Roach, Aman Banerjee
1From the Department of Neurosurgery (M.L.K.), Neurological Institute, Cleveland Clinic; Center for Healthcare Research and Policy (M.J.R., J.A.C.), Northern Ohio Trauma System (A.B., J.A.C.), Department of Surgery, and Department of Neurosurgery (M.S.), MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.
Background:
We previously demonstrated that regionalization of trauma (RT) significantly reduced in-hospital mortality from 19% to 14% in patients with severe traumatic brain injury (sTBI). However, functional and long-term outcomes had not been assessed. We hypothesized that RT would be associated with improved functional and long-term outcomes in sTBI patients.
Methods:
All TBI patients older than 14 years with a head Abbreviated Injury Scale (AIS) score of 3 or greater were identified from the RT database and matched to the state death index and the regional TBI rehabilitation (TBIr) database. Data from 2008 through 2012 were analyzed before and after RT in 2010. For patients discharged to the TBIr unit, overall Functional Independence Measure (FIM) scores and FIM score gains were compared before and after RT.
Results:
A total of 3,496 patients with sTBI were identified in the RT database, 1,359 in the pre-RT and 2,137 in the post-RT period. The mortality rate after discharge decreased significantly after RT from 21% to 16% (p < 0.0001) at 30 days and from 24% to 20% (p = 0.004) at 6 months. Multivariable logistic regression demonstrated RT to be an independent predictor against mortality at 30 days (odds ratio, 0.74; 95% confidence interval, 0.60-0.91; C statistic, 0.84) and 6 months (odds ratio, 0.82; 95% confidence interval, 0.67-0.99; C statistic, 0.82). Discharges to the TBIr unit increased from 117 (9%) in the pre-RT to 297 (14%) in the post-RT period (p < 0.0001), while discharges to home and non-TBIr units remained similar. Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score for all discharged patients remained similar. FIM admission scores were similar in the pre-RT (median, 54; interquartile range [IQR], 30-65) and post-RT period (median, 48; IQR, 31-61) (p = 0.2) and remained similar at discharge in the pre-RT (median, 92; IQR, 75-102) and post-RT period (median, 89; IQR, 73-100) (p = 0.1). TBIr patients showed similar FIM score gains in the pre-RT (median, 37; IQR, 26-46) and post-RT period (median, 36; IQR, 24-49) (p = 0.6).
Conclusion:
RT was associated with reduced long-term mortality, increased TBIr admissions, and similar FIM score improvements for patients with sTBI.
Level Of Evidence:
Therapeutic/care management study, level IV.
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