Impact of Pediatric Trauma Centers on Outcomes of Injured Children

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 DESCRIPTION (provided by applicant): Injury is the most significant public health threat to children in the United States: 14 million children less than 15 years of age are injured each year, resulting in 9 million hospital visits, 250,000 hospital admissions, and 50.5 billion dollars in toal costs annually. More children between 1 and 14 years of age die from injury-related causes than all other causes combined. Despite this, a comprehensive and evidence-based approach to pediatric trauma management is lacking. While specialized hospitals for children exist in the US, they represent only a small portion of the overall number of hospitals, and it has been estimated that only 11% of injured children are treated at pediatric hospitals and only 13% at a hospital with some trauma credentialing. The remaining injured children are treated at general acute care hospitals. The impact of this disjointed system is unknown. First, there is conflicting data over the effect of receiving care at a pediatric trauma center compared to a general acute hospital. These conflicting results stem from several features of the pediatric trauma literature. Analyzing the outcomes of pediatric trauma by the location of treatment is inherently biased by illness severity and other unmeasured factors. Pediatric centers are likely to treat the sickest patients, if they are preferentially transported to these centers "at the discretion" of emergency medical services. Available data may not be able to adequately control for these differences. Although several trauma severity scores have been published, these scores may not adequately control for casemix differences between hospitals - especially for pediatric patients. Second, there are no studies to identify the structures and processes of care that improve the outcomes of pediatric trauma. Thus, the goal of this study is to identify the structures and processes of care that optimize outcomes of pediatric trauma patients, by obtaining an unbiased estimate of the relationship between structures, processes of care, and outcomes in pediatric trauma patients from 15 states between 2012 and 2013. Many of the aforementioned methodological flaws can be addressed through a combination of (1) an instrumental variables approach for unmeasured confounders, (2) two-stage modeling for measured confounders, and (3) the first survey of the available structures and processes of care at emergency departments and trauma centers in the United States that treat children. This research falls under the Value portfolio of the Agency for Healthcare Research and Quality research program, as it projects how changes to the pediatric trauma system will affect the quality and value of this system, and the Comparative Effectiveness portfolio, to determine the most effective organization of the pediatric trauma system. Improved understanding of the impact of such service changes will result in more efficient use of health care services and optimize the value of health care dollars spent on treating pediatric injury and trauma.