Variation in pediatric traumatic brain injury outcomes in the United States

Abstract

Objective: To ascertain the degree of variation, by state of hospitalization, in outcomes associated with traumatic brain injury (TBI) in a pediatric population.

Design: A retrospective cohort study of pediatric patients admitted to a hospital with a TBI.

Setting: Hospitals from states in the United States that voluntarily participate in the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Participants: Pediatric (age ≤ 19 y) patients hospitalized for TBI (N=71,476) in the United States during 2001, 2004, 2007, and 2010.

Interventions: None.

Main outcome measures: Primary outcome was proportion of patients discharged to rehabilitation after an acute care hospitalization among alive discharges. The secondary outcome was inpatient mortality.

Results: The relative risk of discharge to inpatient rehabilitation varied by as much as 3-fold among the states, and the relative risk of inpatient mortality varied by as much as nearly 2-fold. In the United States, approximately 1981 patients could be discharged to inpatient rehabilitation care if the observed variation in outcomes was eliminated.

Conclusions: There was significant variation between states in both rehabilitation discharge and inpatient mortality after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.

Keywords: Healthcare disparities; Patient outcome assessment; Rehabilitation; Traumatic brain injury.

Fig 1

Adjusted relative risk of rehabilitation discharge by state. Multivariate Poisson regression estimates with robust 95% confidence interval estimates. *P<.05. Abbreviations: AR, Arkansas; AZ, Arizona; CO, Colorado; FL, Florida; IA, Iowa; KY, Kentucky; MA, Massachusetts; MD, Maryland; MS, Mississippi; NC, North Carolina; NJ, New Jersey; NV, Nevada; NY, New York; OR, Oregon; RR, relative risk; UT, Utah; WA, Washington; WI, Wisconsin; WV, West Virginia.

Fig 2

Adjusted relative risk of inpatient mortality by state. Multivariate Poisson regression estimates with robust 95% confidence interval estimates. *P<.05. Abbreviations: AR, Arkansas; AZ, Arizona; CA, California; CO, Colorado; FL, Florida; IA, Iowa; KY, Kentucky; MA, Massachusetts; MD, Maryland; ME, Maine; MS, Mississippi; NC, North Carolina; NJ, New Jersey; NV, Nevada; NY, New York; OR, Oregon; RI, Rhode Island; RR, relative risk; UT, Utah; VT, Vermont; WA, Washington; WI, Wisconsin; WV, West Virginia.

Fig 3

Adjusted relative risk estimates for rehabilitation multivariable regression model when assessing for the presence of effect modification between insurance status and state. Government insurance is referent value; black line, private insurance; gray line, uninsured. Abbreviations: AR, Arkansas; AZ, Arizona; CO, Colorado; FL, Florida; IA, Iowa; KY, Kentucky; MA, Massachusetts; MD, Maryland; MS, Mississippi; NC, North Carolina; NJ, New Jersey; NV, Nevada; NY, New York; OR, Oregon; RR, relative risk; UT, Utah; WA, Washington; WI, Wisconsin; WV, West Virginia.

Fig 4

Adjusted relative risk estimates for mortality multivariable regression model when assessing for the presence of effect modification between insurance status and state. Government insurance is referent value; black line, private insurance; gray line, uninsured. Abbreviations: AR, Arkansas; AZ, Arizona; CA, California; CO, Colorado; FL, Florida; IA, Iowa; KY, Kentucky; MA, Massachusetts; MD, Maryland; ME, Maine; MS, Mississippi; NC, North Carolina; NJ, New Jersey; NV, Nevada; NY, New York; OR, Oregon; RI, Rhode Island; RR, relative risk; UT, Utah; VT, Vermont; WA, Washington; WI, Wisconsin; WV, West Virginia.