Variability in Pediatric Utilization of Trauma Facilities in California: 1999 to 2005

doi:10.1016/j.annemergmed.2008.05.011

Annals of Emergency Medicine

Volume 52, Issue 6, December 2008, Pages 607-615

Presented as a poster at the American College of Emergency Physicians annual meeting, October 2007, Seattle, WA.

https://doi.org/10.1016/j.annemergmed.2008.05.011 Get rights and content

Study objective

We identify geographic, system, and socioeconomic differences between injured children cared for within and outside of state-designated trauma centers.

Methods

This was a nonconcurrent observational study of a population-based sample from the California Office of Statewide Health Planning and Development Public Patient Discharge Database 1999 to 2005. Patients were 1 to 14 years of age, with International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes indicative of trauma. Injury Severity Scores were calculated from ICD-9 codes and categorized into severity categories. Outcomes were hospitalization in a trauma or nontrauma center.

Results

Children with severe injury who resided 0 to 10, 11 to 25, 26 to 50, and more than 50 miles from a trauma center were hospitalized in these centers at rates of 80.0%, 71.2%, 51.4%, and 28.5%, respectively. Children with severe injury who were living in a county with a trauma center were hospitalized in these centers at rates of 78.8%, whereas children living in a county without a trauma center were hospitalized in trauma centers at rates of 39.0%. Children with severe injury and public, private non–health maintenance organization (HMO), and HMO insurance were hospitalized in trauma centers at rates of 77.7%, 68.0%, and 55.4%, respectively. Age, injury severity, insurance type, residence in a county with a trauma center, and proximity to a trauma center were identified as predictors of trauma center utilization by logistic regression.

Conclusion

We demonstrate considerable variation in the utilization pattern of trauma specialty care for children with moderate and severe injuries. Children with HMO and private insurance are cared for less often in trauma centers than those with public insurance, even after adjustment for other variables. Increased distance to a trauma center, as well as lack of trauma center within a county, also decreases trauma center utilization. These results suggest that assessing trauma center utilization patterns in total populations of children may identify opportunities for improved referral policies and practices as part of a larger effort to ensure high-quality trauma care for all children in need.

Introduction

Trauma systems were developed to provide a system of coordinated trauma care including: timely and appropriate transportation from the site of injury, comprehensive and coordinated medical care, and rehabilitation services. Trauma centers, or hospitals with an explicit commitment to treating injured patients, are an integral part of these trauma systems. Trauma center outcomes for serious injury are superior to non–trauma center outcomes.1, 2, 3, 4, 5 There is a debate about whether children have improved survival in pediatric trauma centers versus adult trauma centers; however, only a small number of pediatric trauma centers exist nationwide, with only 12 pediatric trauma centers in California. Although it may be unrealistic to hold specialized pediatric trauma care in a pediatric center as a standard of care, trauma center care, whether it be pediatric, adult with a commitment to pediatrics, or adult only, is superior to care outside a trauma center.6, 7 Previous work has demonstrated that 20% to 46% of injured children with serious injury or death do not receive care within a designated trauma center.8, 9, 10

State and county emergency medical services (EMS) are systems charged with providing a timely local response to medical emergencies and subsequent transport to appropriate definitive care. Trauma systems are dependent on EMS to provide timely out-of-hospital care, as well as appropriate triage and transfer to hospital care. California EMS consists of local EMS agencies (county or multicounty based) under the governance of the state EMS authority. Suboptimal integration of multiple local EMS agencies, coupled with inherent difficulties in EMS operations, such as geographic inaccessibility and limited resources in less-populated rural areas, could account for decreased trauma center access. It has also been postulated that socioeconomic factors such as insurance status may play a role in trauma center access.¹¹

We identify geographic, system, and socioeconomic differences between injured children cared for within and outside of designated trauma center hospitals.

Section snippets

Materials and Methods

We conducted a population-based inquiry to understand clinical and demographic characteristics of children hospitalized within and outside of California trauma center hospitals.

Characteristics of Study Subjects

A total of 65,434 children met our study criteria, representing 8.3% of the 787,910 children aged 1 to 14 years and hospitalized during the study period. Children aged 1 to 4 years composed 30% of the study population. Children aged 5 to 9 and 10 to 14 years each accounted for approximately 35% of the remaining population. Twenty-one percent (14,001) of children had an Injury Severity Score of 5 to 15, whereas 9.6% (6,267) had an Injury Severity Score greater than 15. Four hundred forty-seven

Limitations

These analyses were performed on the public Office of Statewide Health Planning and Development hospital discharge data set. To prevent individual patient identification, characteristics that could facilitate patient identification, such as age, ethnicity, and race, are masked. Approximately half of all cases were masked for the race and ethnicity variables, thereby precluding analysis in this study. In addition, approximately 11% of the entire data set had the age variable masked; presumably,

Discussion

Our findings suggest substantial variation in the utilization of trauma centers for moderately and severely injured children in California. Increased distances to a trauma center, as well as lack of a trauma center within a county, decrease trauma center utilization. Socioeconomic status, as measured by insurance status and median household income of the zip code of residence, significantly affects trauma center utilization. Contrary to our expectations, public insurance and low household

References (34)

M. Segui-Gomez et al.
Pediatric trauma care: an overview of pediatric trauma systems and their practices in 18 US states
J Pediatr Surg
(2003)
E.J. MacKenzie
Injury severity scales: overview and directions for future research
Am J Emerg Med
(1984)
E.J. MacKenzie et al.
A national evaluation of the effect of trauma-center care on mortality
N Engl J Med.
(2006)
N.C. Mann et al.
Systematic review of published evidence regarding trauma system effectiveness
J Trauma
(1999)
R.J. Mullins et al.
Population-based research assessing the effectiveness of trauma systems
J Trauma
(1999)
A.B. Nathens et al.
The effect of organized systems of trauma care on motor vehicle crash mortality
JAMA
(2000)
A.B. Nathens et al.
Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation
J Trauma
(2000)
F. Hulka et al.
Influence of a statewide trauma system on pediatric hospitalization and outcome
J Trauma
(1997)
T.M. Osler et al.
Do pediatric trauma centers have better survival rates than adult trauma centers?An examination of the National Pediatric Trauma Registry
J Trauma
(2001)
M.J. Vassar et al.
Prediction of outcome in intensive care unit trauma patients: a multicenter study of Acute Physiology and Chronic Health Evaluation (APACHE), Trauma and Injury Severity Score (TRISS), and a 24-hour intensive care unit (ICU) point system
J Trauma
(1999)

N.E. Wang et al.

Trauma center utilization for children in California 1998-2004: trends and areas for further analysis

Acad Emerg Med

(2007)

A.B. Nathens et al.

Payer status: the unspoken triage criterion

J Trauma

(2001)

Public patient discharge data set

ICDMAP-90 Software and Users Guide

(1997)

J.P. Marcin et al.

A population-based analysis of socioeconomic status and insurance status and their relationship with pediatric trauma hospitalization and mortality rates

Am J Public Health

(2003)

E.J. MacKenzie et al.

Evaluating performance of statewide regionalized systems of trauma care

J Trauma

(1990)

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Delivering Value Through Evidence-Based Practice
2017, Clinical Pediatric Emergency Medicine
Citation Excerpt :
In prehospital care, Shah and colleagues described the prehospital transport of 250 actively seizing children to 10 urban EDs in which a wide variation in delivery of medication routes for midazolam were noted with approximately half resulting in dosing errors.7 Similar variation also has been noted in utilization patterns for trauma specialty care for children with moderate and severe injuries.8 Although variation in care delivery for children treated in EDs has been well described,4 the association between this variation with cost and quality is becoming increasingly highlighted.
Unwanted variation in care is a challenge to high-quality care delivery in any healthcare system. Across the Emergency Medical Services for Children (EMSC) continuum, there is wide variation in care delivery for which best practices have demonstrated opportunities to minimize that variation through clinical standards (evidence-based pathways, protocols, and guidelines for care). A model of development of clinical standards is delineated and tools used in that process are described. Implementation strategies for improving utilization are also described with clinical decision support tools being a promising strategy for accelerating uptake of guidelines. Critical to implementing guidelines through improvement science strategies is the ability to make iterative improvements directed by data and analytics. The progression of sophistication in a system's informatics and analytics capabilities is driven by a maturity of data reporting to analytics that drives decision support for implementing clinical standards. Integration of financial data into the clinical standards processes and analytics platforms is necessary to determine value of the work. Within the EMSC continuum, a number of initiatives will drive national clinical standards activities and are fueled by current pockets of successful development and implementation activities within organizations and systems.
Patient- and Community-Level Sociodemographic Characteristics Associated with Emergency Department Visits for Childhood Injury
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We found higher proportions of injured children had private insurance compared with noninjured children and that among injury-related visits, non-Hispanic Black children with private, public, and no insurance were less likely to be admitted than non-Hispanic White children with private insurance after adjusting for available measures of injury severity, anticipated ED resource utilization, child demographic characteristics, and community-level measures of poverty and disadvantage. Other studies examining healthcare utilization following an injury and insurance status have demonstrated mixed results.39-41 Prospectively collected information from clinicians and parents at the time of admission decision-making would be helpful in determining underlying reasons for the observed relationships.
To examine pediatric emergency department (ED) visits over 5 years, trends in injury severity, and associations between injury-related ED visit outcome and patient and community-level sociodemographic characteristics.
Retrospective analysis of administrative data provided to the Pediatric Emergency Care Applied Research Network Core Data Project, 2004-2008. Home addresses were geocoded to determine census block group and associated sociodemographic characteristics. Maximum Abbreviated Injury Scale severity and Severity Classification System scores were calculated. Generalized estimating equations were used to test for associations between sociodemographic characteristics and admission or transfer among injury-related ED visits.
Overall ED visits and injury-related visits increased from 2004 to 2008 at study sites. Of 2 833 676 successfully geocoded visits, 700 821 (24.7%) were injury-related. The proportion of higher severity injury-related visits remained consistent. Nearly 10% of injury-related visits resulted in admission or transfer each year. After adjusting for age, sex, payer, and injury severity, odds of admission or transfer were lower among minority children and children from areas with moderate and high prevalence of poverty.
Pediatric injury-related ED visits to included sites increased over the study period while injury severity, anticipated resource utilization, and visit outcomes remained stable, with low rates of admission or transfer. Sociodemographic differences in injury-related visits and ED disposition were apparent. ED-based injury surveillance is essential to understand disparities, inform targets for prevention programs, and reduce the overall burden of childhood injuries.
Academic-community partnerships improve outcomes in pediatric trauma care
2015, Journal of Pediatric Surgery
To address the specialized needs of injured children, pediatric trauma centers (PTCs) were established at many large, academic hospitals. This study explores clinical outcomes observed for injured children treated at an academic-sponsored community facility.
In partnership with an academic medical center in a major metropolitan area, a not-for-profit community hospital became a designated Level II PTC in October 2010. Data for injured children < 15 years old treated prior to PTC designation from January 2000 to September 2010 were prospectively collected using the Trauma and Emergency Medicine Information System and compared to data collected after PTC designation from January 2011 to December 2013.
Overall, 681 injured children were treated at the community hospital from January 2011 to December 2013. Children treated after PTC designation were less likely to undergo computed tomography (CT) (50.9% vs. 81.3%, p < 0.01), even when controlling for age, gender, injury type, injury severity, and year (OR 0.18, 95%CI 0.08–0.37). Specifically, fewer head (45.7% vs. 68.7%, p < 0.01) and abdominal CTs (13.2% vs. 26.5%, p < 0.01) were performed. Hospital length of stay was significantly shorter (2.8 ± 3.7 days vs. 3.7 ± 5.9 days, p < 0.01). Mortality was low overall, but also decreased after PTC designation (0.4% vs. 2.0%, p = 0.02).
These results indicate that academic-community partnerships in pediatric trauma care are a feasible alternative and may lead to improved outcomes for injured children.
Evaluating age in the field triage of injured persons
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Finally, our findings show that among the full, heterogeneous sample of injured patients (triage positive and triage negative), those at the ends of the age spectrum were less likely to have serious injury, illustrating the importance of accounting for other triage criteria when addressing the utility of age in field triage. There are multiple studies suggesting increased rates of undertriage and poor access to trauma care among elders5-8 and potentially among children.9 Our results were similar among patients older than 60 years, but not among children.
We evaluate trauma undertriage by age group, the association between age and serious injury after accounting for other field triage criteria and confounders, and the potential effect of a mandatory age triage criterion for field triage.
This was a retrospective cohort study of injured children and adults transported by 48 emergency medical services (EMS) agencies to 105 hospitals in 6 regions of the western United States from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including trauma registries, state discharge databases, and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score greater than or equal to 16. We assessed undertriage (Injury Severity Score ≥16 and triage-negative or transport to a nontrauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and nonlinear) between age and Injury Severity Score greater than or equal to 16, adjusted for important confounders. We also evaluated the potential influence of age on triage efficiency and trauma center volume.
Injured patients (260,027) were evaluated and transported by EMS during the 3-year study period. Undertriage increased for patients older than 60 years, reaching approximately 60% for those older than 90 years. There was a strong nonlinear association between age and Injury Severity Score greater than or equal to 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased undertriage at the expense of overtriage, with 1 patient with Injury Severity Score greater than or equal to 16 identified for every 60 to 65 additional patients transported to major trauma centers.
Trauma undertriage increases in patients older than 60 years. Although the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.
Comparing spatial accessibility to conventional medicine and complementary and alternative medicine in Ontario, Canada
2012, Health and Place
Citation Excerpt :
Studies that aim to compare the spatial accessibility of smaller geographic units commonly attach distance values to polygons such as census tracts, enumeration/dissemination areas or postal code/zip code areas. Straight line, ‘as the crow flies’, measurements between polygon centriods have been typical for nation-wide or province-/state-wide spatial accessibility analyses (Ng et al., 1999; Campbell et al., 2000; Tai et al., 2004; Pong and Pitblado, 2005; Roh and Moon, 2005; Rosenthal et al., 2005; Wang et al., 2008). Oleson et al. (2008) also employ ‘as the crow-flies’ distances, but utilize actual addresses.
Health care investigations rarely consider conventional medicine (CM) and complementary and alternative medicine (CAM) simultaneously and spatial accessibility empirical research that incorporates both CM and CAM locations is novel. In this study, residents within municipalities of the Ontario province of Canada are compared in terms of spatial accessibility to a range of health care supplier ‘destinations’. While areas with larger urban agglomerations generally exhibit superior levels of spatial accessibility to health care and diversity in medical service choice in comparison to more peripheral areas, considerable heterogeneity in accessibility occurs in both urban and rural settings. This study's identification of subtle spatial imbalances appends the literature by more precisely qualifying the typically reported ‘urban-rich, rural-poor’ assessment of health care service condition and also reinforces the need for policy-makers to appraise health care spatial accessibility differentials as a function of both CM and CAM endowment.
A multisite assessment of the American College of Surgeons Committee on trauma field triage decision scheme for identifying seriously injured children and adults
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Citation Excerpt :
It is possible that less established trauma and EMS systems may have different diagnostic accuracy for field triage. Although the accuracy of triage criteria among different age groups continues to be debated, our findings support results from other studies suggesting that undertriage is substantially worse among elders23,25,26 and, to a lesser extent, among children.24 Whether triage criteria are less sensitive or are applied more selectively to different age groups remains unclear.
The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort.
This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a “major trauma patient” was ISS ≥ 16.
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View all citing articles on Scopus

: Supervising editor: Kathy N. Shaw, MD, MSCE

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Funded by the Emergency Medicine Foundation Career Development Grant (2006-2007) Stanford Child Health Research Program (2007).

: NEW received a K23 grant from the National Institutes of Health-grant number 5K 23HD051595-02.

: Author contributions: NEW, PM, and PW were responsible for study concept and design. NEW, OS, KK-D, and PM were responsible for revising the article critically. NEW, OS, KK-D, and PW were responsible for analysis and interpretation of data. NEW was responsible for drafting of the article. NEW takes responsibility for the paper as a whole.

: Publication date: Available online June 18, 2008.

: Reprints not available from the authors.

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Pediatrics/original researchVariability in Pediatric Utilization of Trauma Facilities in California: 1999 to 2005

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and Methods

Characteristics of Study Subjects

Limitations

Discussion

J Pediatr Surg

Am J Emerg Med

A national evaluation of the effect of trauma-center care on mortality

N Engl J Med.

Systematic review of published evidence regarding trauma system effectiveness

J Trauma

Population-based research assessing the effectiveness of trauma systems

J Trauma

The effect of organized systems of trauma care on motor vehicle crash mortality

JAMA

Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation

J Trauma

Influence of a statewide trauma system on pediatric hospitalization and outcome

J Trauma

Do pediatric trauma centers have better survival rates than adult trauma centers?An examination of the National Pediatric Trauma Registry

J Trauma

Prediction of outcome in intensive care unit trauma patients: a multicenter study of Acute Physiology and Chronic Health Evaluation (APACHE), Trauma and Injury Severity Score (TRISS), and a 24-hour intensive care unit (ICU) point system

J Trauma

Trauma center utilization for children in California 1998-2004: trends and areas for further analysis

Acad Emerg Med

Payer status: the unspoken triage criterion

J Trauma

Public patient discharge data set

ICDMAP-90 Software and Users Guide

A population-based analysis of socioeconomic status and insurance status and their relationship with pediatric trauma hospitalization and mortality rates

Am J Public Health

Evaluating performance of statewide regionalized systems of trauma care

J Trauma

Pediatrics/original research
Variability in Pediatric Utilization of Trauma Facilities in California: 1999 to 2005