title: The impact of trauma-center care on functional outcomes following major lower-limb trauma.
abstract: BACKGROUND
  Although studies have shown that treatment at a trauma center reduces a patient's risk of dying following major trauma, important questions remain as to the effect of trauma centers on functional outcomes, especially among patients who have sustained major lower-limb trauma.
  
  
  METHODS
  Domain-specific scores on the Medical Outcomes Study Short Form Health Survey (SF-36) supplemented by scores on the mobility subscale of the Musculoskeletal Function Assessment (MFA) and the Revised Center for Epidemiologic Studies Depression Scale (CESD-R) were compared among patients treated in eighteen hospitals with a level-I trauma center and fifty-one hospitals without a trauma center. Included in the study were 1389 adults, eighteen to eighty-four years of age, with at least one lower-limb injury with a score of >/=3 points according to the Abbreviated Injury Scale (AIS). To account for the competing risk of death, we estimated the survivors' average causal effect. Estimates were derived for all patients with a lower-limb injury and separately for a subset of patients without associated injuries of the head or spinal cord.
  
  
  RESULTS
  For patients with a lower-limb injury resulting from a high-energy force, care at a trauma center yielded modest but clinically meaningful improvements in physical functioning and overall vitality at one year after the injury. After adjustment for differences in case mix and the competing risk of death, the average differences in the SF-36 physical functioning and vitality scores and the MFA mobility score were 7.82 points (95% confidence interval: 2.65, 12.98), 6.80 points (95% confidence interval: 2.53, 11.07), and 6.31 points (95% confidence interval: 0.25, 12.36), respectively. These results were similar when the analysis was restricted to patients without associated injuries to the head or spine. Treatment at a trauma center resulted in negligible differences in outcome for the subset of patients with injuries resulting from low-energy forces.
  
  
  CONCLUSIONS
  This study provides evidence that patients who sustain high-energy lower-limb trauma benefit from treatment at a level-I trauma center.
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 462, Baltimore, MD 21205, USA. emackenz@jhsph.edu
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: Mackenzie
authors.forename: Frederick P
authors.initials: FP
authors.lastname: Rivara
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
authors.forename: Brian L
authors.initials: BL
authors.lastname: Egleston
authors.forename: David S
authors.initials: DS
authors.lastname: Salkever
authors.forename: Katherine P
authors.initials: KP
authors.lastname: Frey
authors.forename: Daniel O
authors.initials: DO
authors.lastname: Scharfstein
mesh_terms: D000203:Activities of Daily Living; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D015601:Injury Severity Score; D007869:Leg Injuries / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration*; D011336:Probability; D011379:Prognosis; D020127:Recovery of Function; D018570:Risk Assessment; D014193:Trauma Centers; D016896:Treatment Outcome