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Trauma center performance and outcome disparities in severe childhood traumatic brain injury: A Trauma Quality
1From the Division of Neurosurgery, Nemours Children's Hospital Delaware, Wilmington, Delaware; and Departments of Neurological Surgery and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
Insights
Racial disparities in pediatric traumatic brain injury mortality persist. While injury severity is the primary driver, trauma center performance also contributes to higher death rates in Black children.
Area of Science:
- Pediatric Traumatology
- Health Disparities Research
- Epidemiology
Background:
- Black children experience higher mortality rates from traumatic injuries.
- Race is a social construct, necessitating mediation analysis to understand its impact on mortality.
- Previous research highlights disparities but requires deeper investigation into mediating factors.
Purpose of the Study:
- To investigate the mediating roles of injury severity and trauma center performance in racial disparities in pediatric mortality.
- To quantify the contribution of these factors to mortality differences between Black and White children, and Hispanic and non-Hispanic White children.
- To identify actionable areas for improving outcomes in pediatric trauma care.
Main Methods:
- Observational, cross-sectional study using data from the American College of Surgeons Trauma Quality Improvement Program (2014-2022).
- Included children (≤18 years) with severe traumatic brain injury (Abbreviated Injury Scale head score ≥4).
- Causal mediation analyses assessed injury severity and trauma center performance as mediators of mortality disparities.
Main Results:
- Black children had significantly higher raw mortality rates (30.4%) compared to White children (16.1%).
- Injury severity mediated 10.8% of the increased mortality risk for Black children; trauma center performance mediated an additional 0.4%.
- Hispanic children showed a smaller disparity, with injury severity mediating 1.2% of the risk and trauma center performance having a 0.4% protective effect.
Conclusions:
- Injury severity is the predominant factor contributing to higher mortality in Black children with severe traumatic brain injury.
- Trauma center performance, while a smaller factor, significantly contributes to the observed mortality disparities.
- Addressing both injury severity and trauma center performance is crucial for reducing racial disparities in pediatric trauma outcomes.
Background:
That Black children die at higher rates from traumatic injuries has been recognized for years, but race as a social construct cannot itself be a cause of death. The effect of race must be mediated.
Methods:
This observational, cross-sectional study was based on data from the Trauma Quality Improvement Program of the American College of Surgeons for the years 2014 through 2022. Severe traumatic brain injury was defined as an Abbreviated Injury Scale head score of 4 or greater. Exclusion criteria were age older than 18 years, transfer to another acute care facility, and discharge from a facility that treated 10 or fewer cases. The outcome was mortality. A probability of mortality was assigned to each case as a metric of injury severity. A ratio of observed to expected deaths was calculated as a metric of trauma center (TC) performance. Causal mediation analyses were performed to estimate the contributions of injury severity and TC performance to mortality disparities between Black and White children and between Hispanic and non-Hispanic White children.
Results:
There were 51,025 cases in the study sample. Raw mortality rates were 30.4% and 16.1% for Black and White children, respectively ( p < 0.0001), and 16.9% and 15.9% for Hispanic and non-Hispanic White children, respectively ( p = 0.0366). Injury severity mediated a 10.8% increment in the risk of mortality for Black children, and TC performance mediated another 0.4% increment. For Hispanic children, injury severity mediated a 1.2% increment in risk of mortality, and TC performance mediated a 0.4% protective effect.
Conclusion:
Trauma center performance accounts for a small but highly significant increment to the mortality disparity between Black and White children with severe traumatic brain injury, but as in past work, injury severity makes a much greater contribution.
Level Of Evidence:
Prognostic and Epidemiologic; Level III.
