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The Relationship Between Hospital Volume and Mortality in Pediatric Patients With Severe Blunt Abdominal Trauma
Zoe Flyer1, Andreina Giron1, Jeffry Nahmias2
1Department of Pediatric Surgery, Children's Hospital Orange County, Orange, California.
Introduction:
Blunt abdominal trauma (BAT) is a significant cause of mortality in pediatric patients. Hospital volume has been shown to be associated with outcomes in some studies, but its association with outcomes in severe pediatric BAT remains unclear. We hypothesized that treatment at lower-volume centers is associated with increased mortality in severe pediatric BAT.
Methods:
We performed a retrospective (2017-2022) analysis of pediatric patients (≤18 y old) with severe BAT (defined as an injury severity score ≥ 25) in the National Trauma Data Bank. Patients were divided into tertiles based on hospital volume of severe BAT (injury severity score ≥25) cases per year and compared: high-volume centers (HVCs) (≥13 cases/year), medium-volume centers (MVCs) (6-12 cases/year), and low-volume centers (LVCs) (≤5 cases/year). Multivariable logistic regression was performed to estimate the odds of mortality across volume tertiles.
Results:
Of 14,704 included patients, 4987 (33.9%) were treated at HVCs, 4830 (32.8%) at MVCs, and 4887 (33.2%) at LVCs. Patients at HVCs were younger (median 14 y vs. 15 at MVCs and 16 at LVCs, P < 0.0001) and were less often male (63.2% vs. 66.7% and 69.1%, P < 0.0001). HVCs had increased rates of intubations (30.3% vs. 28.1% and 22.2%, P < 0.0001) and intensive care unit admissions (49.3% vs. 48.7% and 37.5%, P = 0.0005). In addition, patients at HVCs were more often treated in verified American College of Surgeons level I trauma facilities (54.7% vs. 53.1% and 29.2%, P = 0.0005) and verified pediatric level I facilities (60.2% vs. 20.1% and 6.5%, P < 0.0001). In-hospital mortality increased from HVCs (14.3%) to MVCs (15.8%) to LVCs (17.0%) (P = 0.001). Multivariable analysis showed that treatment at LVCs was associated with increased odds of mortality compared with HVCs (odds ratio 1.33, 95% confidence interval 1.15-1.54, P = 0.0002).
Conclusions:
Pediatric patients with severe blunt trauma treated at LVCs had a significantly higher rate and associated risk of mortality compared to those treated at HVCs. Future research should focus on identifying and standardizing best practices associated with lower mortality mortality across trauma centers of varying patient volumes.
