Traditional burn mortality models are derived using all age groups. We hypothesized that age variably impacts mortality after burn and that age-specific models for children, adults, and seniors will more accurately predict mortality than an all-ages model. We audited data from the American Burn Association (ABA) National Burn Repository (NBR) from 2000-2009 and used mixed effect logistic regression models to assess the influence of age, total body surface area (TBSA) burn, and inhalation injury on mortality. Mortality models were constructed for all ages and age-specific models: children (<18 years), adults (18-60 years), and seniors (>60 years). Model performance was assessed by area under the receiver operating curve (AUC). Main effect and two-way interactions were used to construct age-group specific mortality models. Each age-specific model was compared to the All Ages model. Of 286,293 records 100,051 had complete data. Overall mortality was 4% but varied by age (17% seniors, <1% children). Age, TBSA, and inhalation injury were significant mortality predictors for all models (p<0.05). Differences in predicted mortality between the All Ages model and the age-specific models occurred in children and seniors. In the age-specific pediatric model, predicted mortality decreased with age; inhalation injury had greater effect on mortality than in the All Ages model. In the senior model mortality increased with age. Seniors had greater increase in mortality per 1% increment in burn size and 1 year increase in age than other ages. The predicted mortality in seniors using the senior-specific model was higher than in the All Ages model. “One size fits all” models for predicting burn outcomes do not accurately reflect the outcomes for seniors and children. Age-specific models for children and seniors may be advisable.

IMPORTANCE Current outcome predictors for illness and injury are measured at a single time point—admission. However, patient prognosis often changes during hospitalization, limiting the usefulness of those predictions. Accurate depiction of the dynamic interaction between competing events during hospitalization may enable real-time outcome assessment. OBJECTIVE To determine how the effects of burn outcome predictors (ie, age, total body surface area burn, and inhalation injury) and the outcomes of interest (ie, mortality and length of stay) vary as a function of time throughout hospitalization. DESIGN, SETTING, AND PARTICIPANTS In this retrospective study, we used the American Burn Association’s National Burn Repository, containing outcomes and patient and injury characteristics, to identify 95 579 patients admitted with an acute burn injury to 80 tertiary American Burn Association burn centers from 2000 through 2009. We applied competing risk statistical methods to analyze patient outcomes. MAIN OUTCOMES AND MEASURES We estimated the cause-specific hazard rates for death and discharge to assess how the instantaneous risk of these events changed across time. We further evaluated the varying effects of patient age, total body surface area burn, and inhalation injury on the probability of discharge and death across time. RESULTS Maximum length of stay among patients who died was 270 days and 731 days among those discharged. Total body surface area, age, and inhalation injury had significant effects on the subdistribution hazard for discharge (P < .001); these effects varied across time (P < .002). Burn size (coefficient –0.046) determined early outcomes, while age (coefficient –0.034) determined outcomes later in the hospitalization. Inhalation injury (coefficient –0.622) played a variable role in survival and hospital length of stay. CONCLUSIONS AND RELEVANCE Real-time measurement of dynamic interrelationships among burn outcome predictors using competing risk analysis demonstrated that the key factors influencing outcomes differed throughout hospitalization. Further application of this analytic technique to other injury or illness types may improve assessment of outcomes.

Objective Health-related registries arose due from clinician desire to improve patient quality of care for a specific disorder. As such, disease registries differ from administrative registries in concept, organization, purpose, data recording, and results. Due to their voluntary nature, health-related disease registries are not regularly audited, have a narrow focus, and are designed for clinicians, not administrators. As part of a Department of Defense initiative we conducted an intensive qualitative review of the American Burn Association’s National Burn Repository (NBR). Our objectives are to inform future users of the NBR of issues that could affect statistical analyses and inferences and assist efforts to improve data collection. Methods We obtained a deidentified copy of the 2009 release of the NBR containing 286,293 records. We reviewed this data set for 1) records lacking vital patient information (age, burn size, survival, gender), 2) inconsistencies between data in different fields of the database, and 3) duplicate values. Results Restricting our review to records with an admission year of 2000 or later, vital patient information was missing or invalid for about 60,000 records. Data inconsistencies were found in hospital admission status (initial admission or readmission) for about 12,000 records, survival for about 950 records, and burn injury for about 5,500 records. Depending on the criteria used to identify duplicate records, we found at least 4,000 duplicate records but as many as 14,000 in the database. Finally, significant data quality issues were found for facilities not using the TRACS software. Conclusions All health-related disease registries, unlike administrative databases, are voluntary. Anonymity of data is vital, and data auditing and reporting are challenging. The data contained in the NBR is disease-specific, and, as such, has the potential to provide valuable epidemiologic, treatment, and outcome data as reported by clinicians, not registrars. The NBR provides substantive data on burn injury; however, data review needs to precede data analysis. Revisions to NBR data collection have improved the quality of data submitted, yet data quality issues remain in the current database. Investigators are cautioned to thoroughly assess all fields prior to conducting analyses using the NBR.

Traditional LOS estimates of 1day/%TBSA burn rule is biased, underestimating LOS, particularly for patients >40 years with inhalation injury. The following formulas applied at admission can accurately estimate hospital LOS, improve prediction over 1day/%TBSA, and provide results comparable to complicated models.

The relationship between center volume and patient outcomes has been analyzed for multiple conditions, including burns, with variable results. To date, studies on burn volume and outcomes have primarily addressed adults. Burned children require age specific equipment and competencies in addition to burn wound care. Hence, volume may make a difference for this special population. We used the National Burn Repository (NBR) release from 2000–2009 to evaluate the influence of pediatric burn volume on outcomes using mixed effect logistic regression modeling. Of the 210,683 records in the NBR over that time span, 33,115 records for children ≤18 years of age met criteria for analysis. Of the 33,115 records, 26,280 had burn sizes smaller than 10%; only 32 of these children died. Volume of children treated varied greatly among facilities. Age, total body surface area (TBSA) burn, inhalation injury, and burn center volume influenced mortality (p<0.05) An increase in the median yearly admissions of 100 decreased the odds of mortality by approximately 40%. High volume centers (admitting >200 pediatric patients/year) had the lowest mortality when adjusting for age and injury characteristics (p<0.05). The lower mortality of children a high volume centers could reflect greater experience, resource, and specialized expertise in treating pediatric patients.