Impact of Pediatric Trauma Centers on Outcomes of Injured Children

 描述(申请人提供)：伤害是对美国儿童最严重的公共健康威胁：每年有1400万15岁以下儿童受伤， 导致每年900万人次的医院就诊，25万人次的住院，以及505亿美元的总成本。1至14岁的儿童死于与伤害有关的原因比所有其他原因的总和还要多。尽管如此，儿科创伤处理缺乏全面和循证的方法。虽然美国有儿童专科医院，但它们只占医院总数的一小部分，据估计，只有11%的受伤儿童在儿科医院接受治疗，只有13%在有一些创伤认证的医院接受治疗。其余受伤儿童在普通急性护理医院接受治疗。这个脱节的系统的影响是未知的。首先，与普通急诊医院相比，在儿科创伤中心接受护理的效果存在相互矛盾的数据。这些相互矛盾的结果源于儿科创伤文献的几个特点。根据治疗地点分析儿童创伤的结果，固有地受到疾病严重程度和其他不可测量因素的影响。儿科中心可能会治疗病情最严重的患者，如果他们被优先运送到这些中心，由紧急医疗服务机构酌情决定。现有的数据可能无法充分控制这些差异。尽管已经公布了几个创伤严重程度评分，但这些评分可能不足以控制不同医院之间的病例差异--特别是对儿科患者。其次，没有研究确定改善儿科创伤预后的护理结构和过程。因此，这项研究的目标是通过对来自15个州的2012至2013年间儿科创伤患者的结构、护理过程和结果之间的关系进行公正的估计，确定能够优化儿科创伤患者结局的护理结构和流程。上述许多方法学缺陷可以通过(1)针对未测量混杂因素的工具变量方法，(2)针对已测量混杂因素的两阶段建模，以及(3)对美国治疗儿童的急诊科和创伤中心现有护理结构和流程的第一次调查来解决。这项研究属于医疗保健研究和质量研究计划的价值组合，因为它预测儿科创伤系统的变化将如何影响该系统的质量和价值，以及比较有效性组合，以确定儿科创伤系统的最有效组织。更好地了解这种服务变化的影响将导致更有效地使用卫生保健服务，并优化用于治疗儿科伤害和创伤的卫生保健资金的价值。

 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.