O2157: Variability in Standardized Mortality Rates Among Pediatric Traumatic Brain Injury Patients: A Comparative Analysis of Trauma Centers

Background: Traumatic brain injury (TBI) includes a wide spectrum of brain injury that causes significant morbidity and mortality in pediatric patients. Care for pediatric TBI is highly variable. Standardized mortality ratios (SMRs) describe the mortality rate of a specific population relative to the expected mortality rate of a similar population, and they are used to account for differences in case-mix between centers when comparing mortality rates between groups. This study aimed to evaluate if variation exists in SMRs among pediatric trauma centers for TBI and identify characteristics that differ between centers with significantly higher and lower mortality rates.

Methods: Patients 1-18 years old diagnosed with TBI within the National Trauma Databank (NTDB) from 2017-2019 were included. Center-specific SMRs and their 95% confidence intervals were utilized to identify centers with mortality rates significantly better (SB) or worse (SW) than the median SMR for all centers.

Results: The study included 10,598 pediatric TBI patients at 316 centers where the range of patients per center was 10-183. SMRs were risk-adjusted for patient risk factors such as age, sex, race, Glascow Coma Score (GCS), injury severity score, non-reactive pupils, substances positive on toxicology, blood alcohol level, midline shift, and year of injury. Unadjusted mortality rates among all centers ranged from 16.5 – 29.5%. Three centers (1.5%) had SB SMR (SMR >1) and three centers (1.5%) had SW SMR (SMR < 1). Descriptive analysis between SB and SW centers demonstrated that SB centers had a lower proportion of neurosurgical intervention (2.4% vs 11.8%, p = 0.0009), and a higher proportion of provision of supplemental oxygen (93.7% vs 83.5%, p = 0.004) and venous thromboembolism (VTE) prophylaxis (53.2% vs 40.6%, p = 0.0004) compared to SW centers.

Conclusion: This study identified a proportion of centers that have significantly higher and lower mortality, relative to the overall median, for pediatric TBI patients. SB centers have lower neurosurgical intervention rates, higher supplemental oxygen utilization, and higher VTE prophylaxis utilization than SW centers. This data may help provide a benchmark for pediatric TBI outcomes and institutional quality improvement. Further research is needed to identify differences in care processes at SB centers that may also account for improved mortality rates, with the aim of improving national outcomes for pediatric TBI patients.