title: Do trauma center levels matter in older isolated hip fracture patients?
abstract: BACKGROUND
  Younger, multi-trauma patients have improved survival when treated at a trauma center. Many regions now propose that older patients be triaged to a higher level trauma centers (HLTCs-level I or II) versus lower level trauma centers (LLTCs-level III or nondesignated TC), even for isolated injury, despite the absence of an established benefit in this elderly cohort. We therefore sought to determine if older isolated hip fracture patients have improved survival outcomes based on trauma center level.
  
  
  METHODS
  A retrospective cohort of 1.07 million patients in The Nationwide Emergency Department Sample from 2006-2010 was used to identify 239,288 isolated hip fracture patients aged ≥65 y. Multivariable logistic regression was performed controlling for patient- and hospital-level variables. The main outcome measures were inhospital mortality and discharge disposition.
  
  
  RESULTS
  Unadjusted logistic regression analyses revealed 8% higher odds of mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.16) and 10% lower odds of being discharged home (OR, 0.90; 95% CI, 0.80-1.00) among patients admitted to an HLTC versus LLTC. After controlling for patient- and hospital-level factors, neither the odds of mortality (OR, 1.06; 95% CI, 0.97-1.15) nor the odds of discharge to home (OR, 0.98; 95% CI, 0.85-1.12) differed significantly between patients treated at an HLTC versus LLTC.
  
  
  CONCLUSIONS
  Among patients with isolated hip fractures admitted to HLTCs, mortality and discharge disposition do not differ from similar patients admitted to LLTCs. These findings have important implications for trauma systems and triage protocols.
authors.affiliation: Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland; Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Howard
authors.initials: H
authors.lastname: Nelson-Williams
authors.affiliation: Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Lisa
authors.initials: L
authors.lastname: Kodadek
authors.affiliation: Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Joseph
authors.initials: J
authors.lastname: Canner
authors.affiliation: Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Eric
authors.initials: E
authors.lastname: Schneider
authors.affiliation: Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Division of Acute Care Surgery and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: David
authors.initials: D
authors.lastname: Efron
authors.affiliation: Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Department of Surgery, Anesthesiology / Critical Care Medicine (ACCM), Emergency Medicine, Johns Hopkins University, Baltimore, Maryland; Health Policy & Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Elliott
authors.initials: E
authors.lastname: Haut
authors.affiliation: Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland.
authors.forename: Babar
authors.initials: B
authors.lastname: Shafiq
authors.affiliation: Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts.
authors.forename: Adil
authors.initials: A
authors.lastname: Haider
authors.affiliation: Department of Surgery, Center for Surgical Trials and Outcomes Research, Johns Hopkins University, Baltimore, Maryland; Division of Acute Care Surgery and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland. Electronic address: cvelopu1@jhmi.edu.
authors.forename: Catherine Garrison
authors.initials: CG
authors.lastname: Velopulos
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006620:Hip Fractures / Q000401:mortality*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: Discharge disposition; Geriatric trauma; Isolated hip fracture; Mortality; Trauma center; Triage