title: Mortality Among Injured Children Treated at Different Trauma Center Types.
abstract: OBJECTIVE
  Trauma is the leading cause of death among US children. Whether pediatric trauma centers (PTCs), mixed trauma centers (MTCs), or adult trauma centers (ATCs) offer a survival benefit compared with one another when treating injured children is controversial. Ascertaining the optimal care environment will better inform quality improvement initiatives and accreditation standards.
  
  
  OBJECTIVE
  To evaluate the association between type of trauma center (PTC, MTC, or ATC) and in-hospital mortality among young children (5 years and younger), older children (aged 6-11 years), and adolescents (aged 12-18 years).
  
  
  METHODS
  In this retrospective cohort study, injured children aged 18 years or younger who were hospitalized in the United States from January 1, 2010, to December 31, 2013, were observed for the duration of their admission until discharge or death. We included patients with an Abbreviated Injury Score of 2 or greater in at least 1 body region. Random-intercept multilevel regression was used to evaluate the association between center type and in-hospital mortality after adjusting for confounders. Stratified analyses in young children, older children, and adolescents were performed. We conducted secondary analyses limited to patients with severe injuries (Injury Severity Score ≥25). Both analyses were performed between January 1 and August 31, 2014. Data were derived from 252 US level I and II trauma centers voluntarily participating in the American College of Surgeons adult or pediatric Trauma Quality Improvement Program.
  
  
  METHODS
  In-hospital mortality.
  
  
  RESULTS
  We identified 175 585 injured children. Crude mortality rates were 2.3% for children treated at ATCs, 1.8% for children treated at MTCs, and 0.6% for children treated at PTCs. After adjustment, children had higher odds of dying when treated at ATCs (odds ratio [OR], 1.57; 95% CI, 1.15-2.14) and MTCs (OR, 1.45; 95% CI, 1.05-2.01) compared with those treated at PTCs. In stratified analyses, young children had higher odds of death when treated at ATCs vs PTCs (OR, 1.78; 95% CI, 1.05-3.40), but there was no association between center type and mortality among older children (OR, 1.17; 95% CI, 0.65-2.11) and adolescents (OR, 1.23; 95% CI, 0.82-1.85). Results were similar in analyses of severely injured children: those treated at ATCs (OR, 1.75; 95% CI, 1.25-2.44) and MTCs (OR, 1.62; 95% CI, 1.15-2.29) had higher odds of death when compared with those treated at PTCs.
  
  
  CONCLUSIONS
  Injured children treated at ATCs and MTCs had higher in-hospital mortality compared with those treated at PTCs. This association was most evident in younger children and remained significant in severely injured children. Quality improvement initiatives geared toward ATCs and MTCs are required to provide optimal care to injured children.
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Chethan
authors.initials: C
authors.lastname: Sathya
authors.affiliation: Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Aziz S
authors.initials: AS
authors.lastname: Alali
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada3Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Wales
authors.affiliation: Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada4Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Damon C
authors.initials: DC
authors.lastname: Scales
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada5Sunnybrook Research Institute, Sunnybrook Health Sc.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Karanicolas
authors.affiliation: Division of General and Thoracic Surgery, Children's National Health System, Washington, DC.
authors.forename: Randall S
authors.initials: RS
authors.lastname: Burd
authors.affiliation: Division of General and Thoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Nance
authors.affiliation: Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Wei
authors.initials: W
authors.lastname: Xiong
authors.affiliation: Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada5Sunnybrook Research Institute, Sunnybrook Health Sc.
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D014193:Trauma Centers; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality*