Citation

Tsai SHL, Goyal A, Alvi MA, Kerezoudis P, Yolcu YU, Wahood W, Habermann EB, Burns TC, Bydon M. J. Neurosurg. 2020; ePub(ePub): ePub.

Affiliation

Departments of4Neurologic Surgery and.

Copyright

(Copyright © 2020, American Association of Neurological Surgeons)

DOI

10.3171/2020.1.JNS192115

PMID

32168482

Abstract

OBJECTIVE: The nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States.

METHODS: The authors queried the National Trauma Data Bank for the years 2007-2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1-Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size.

RESULTS: A total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I-IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40-4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3-7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6-4.8 days, p < 0.001).

CONCLUSIONS: Higher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.

Language: en

Keywords

ACS = American College of Surgeons; AIS = Abbreviated Injury Scale; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ICU = intensive care unit; ICU days; ISS = Injury Severity Score; LOS = length of stay; MD = mean difference; NTDB = National Trauma Data Bank; National Trauma Data Bank; TBI = traumatic brain injury; head trauma; hospital volume; length of stay; mortality; outcome analysis; surgery; traumatic brain injury; volume-outcome relationship