Volume-outcome relationship in pediatric neurotrauma care: analysis of two national databases

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Previous research has demonstrated the association between increased hospital volume and improved outcomes for a wide range of neurosurgical conditions, including adult neurotrauma. The authors aimed to determine if such a relationship was also present in the care of pediatric neurotrauma patients.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors identified 106,146 pediatric admissions for traumatic intracranial hemorrhage (tICH) in the National Inpatient Sample (NIS) for the period 2002–2014 and 34,017 admissions in the National Trauma Data Bank (NTDB) for 2012–2015. Hospitals were stratified as high volume (top 20%) or low volume (bottom 80%) according to their pediatric tICH volume. Then the association between high-volume status and favorable discharge disposition, inpatient mortality, complications, and length of stay (LOS) was assessed. Multivariate regression modeling was used to control for patient demographics, severity metrics, hospital characteristics, and performance of neurosurgical procedures.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>In each database, high-volume hospitals treated over 60% of pediatric tICH admissions. In the NIS, patients at high-volume hospitals presented with worse severity metrics and more frequently underwent neurosurgical intervention over medical management (all p &lt; 0.001). After multivariate adjustment, admission to a high-volume hospital was associated with increased odds of a favorable discharge (home or short-term facility) in both databases (both p &lt; 0.001). However, there were no significant differences in inpatient mortality (p = 0.208). Moreover, high-volume hospital patients had lower total complications in the NIS and lower respiratory complications in both databases (all p &lt; 0.001). Although patients at high-volume hospitals in the NTDB had longer hospital stays (β-coefficient = 1.17, p &lt; 0.001), they had shorter stays in the intensive care unit (β-coefficient = 0.96, p = 0.024). To determine if these findings were attributable to the trauma center level rather than case volume, an analysis was conducted with only level I pediatric trauma centers (PTCs) in the NTDB. Similarly, treatment at a high-volume level I PTC was associated with increased odds of a favorable discharge (OR 1.28, p = 0.009), lower odds of pneumonia (OR 0.60, p = 0.007), and a shorter total LOS (β-coefficient = 0.92, p = 0.024).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Pediatric tICH patients admitted to high-volume hospitals exhibited better outcomes, particularly in terms of discharge disposition and complications, in two independent national databases. This trend persisted when examining level I PTCs exclusively, suggesting that volume alone may have an impact on pediatric neurotrauma outcomes. These findings highlight the potential merits of centralizing neurosurgery and pursuing regionalization policies, such as interfacility transport networks and destination protocols, to optimize the care of children affected by traumatic brain injury.</jats:p></jats:sec>

Association of Patient Frailty With Vestibular Schwannoma Resection Outcomes and Machine Learning Development of a Vestibular Schwannoma Risk Stratification Score

“…β-coefficient = 1.10 signifies +10% increase in cost relative to the reference category of low frailty). 23…”

“…lww.com/NEU/D107; and Supplemental Digital Content 3, http://links.lww.com/NEU/D108. [20][21][22][23]…”

Patient frailty association with cerebral arteriovenous malformation microsurgical outcomes and development of custom risk stratification score: an analysis of 16,721 nationwide admissions

“…18,19 In-hospital mortality was not chosen as the primary endpoint for this study due to being present in a small frequency of the study population (2.2%, n = 365), creating the risk of model overfitting. 20…”

“…Discharge status was categorized as routine if patients were discharged to home or a short-term facility, consistent with prior NIS neurosurgical studies. 18,20 Complications were identified using ICD-9 and ICD-10 codes extracted from validated Clinical Classifications Software groupings, as reported in prior NIS neurosurgical studies. 19,21 Inpatient complications were classified as medical or surgical.…”

The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases

“…Association between frailty and tICH outcomes, after patient stratification by presenting GCS, performance of neurosurgery, and withdrawal of care. A-C, Patients stratified by GCS (mild[13][14][15], moderate[9][10][11][12], or severe[3][4][5][6][7][8]). D and E, Patients stratified by performance of neurosurgical intervention.…”