LAKE BUENA VISTA, FLA. – Regionalized trauma care significantly reduces long-term mortality and maintains similar functional outcomes in patients with severe traumatic brain injury, a study showed.
Regionalization of trauma care is a health care strategy that attempts to improve outcomes for trauma patients by setting up a tiered, integrated system that aims to match the injured patient with the appropriate health care facility in a timely fashion. The Northern Ohio Trauma System (NOTS) was created in 2010 to manage trauma patients using the regionalization model.
In this study of outcomes in NOTS patients, longer-term follow-up of 3,496 severe traumatic brain injury (TBI) admissions showed 30-day mortality fell from 21% to 16% after regionalization (24% relative reduction; P value < .0001) and 6-month mortality declined from 24% to 20% (17% relative reduction; P = .004).
Dr. Michael Kelly
Multivariable logistic regression only strengthened the effect of regionalization on the primary outcome, lead study author Dr. Michael Kelly said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma (EAST).
The odds ratio for 30-day mortality was 0.74, representing a 26% relative mortality reduction, and 0.82 for 6-month mortality, representing an 18% relative reduction.
At last year’s EAST meeting, Dr. Kelly and his colleagues reported that hospital mortality declined from 19% (262/1,359 patients) to 14% (302/2,137) in patients with severe TBI after the creation of the NOTS in 2010.
Despite bucking the current trend of rising mortality in hospitalized TBI patients, particularly those with severe brain injuries, their previous results were criticized by some as incomplete because hospital mortality was used without functional status measures or long-term mortality, he said.
To bridge the knowledge gap, the investigators identified all TBI patients older than 14 years with a Head Abbreviated Injury Scale (AIS) ≥ 3 from 2008 to 2012 in the NOTS database and matched them to the Ohio death index and the regional TBI rehabilitation database. Overall Functional Independence Measure (FIM) scores and FIM score gains were compared in 414 patients who were discharged to the regional TBI rehabilitation unit.
As a general rule of thumb, an overall FIM score of 60 is equivalent to 4 hours of personal care assistance in a nursing facility–type setting, a score of 80 equals 2 hours of personalized care in a nursing facility, more than 80 means the patient is able to receive family care at home, and ≥ 100 means minimal burdens in personal care, said Dr. Kelly of the MetroHealth Medical Center, Cleveland, and Cleveland Clinic.
A gain of 22 points is considered a minimal clinically important difference (MCID) for the overall FIM score. The MCID is 17 points for a FIM motor subscale gain, 3 for a FIM cognitive subscale gain, and has not been established for the FIM social subscale.
Overall FIM scores were similar before and after regionalization of trauma care (RT) at admission (54 vs. 48; P = .2) and at discharge (92 vs. 89; P = .1), he said.
FIM scores were similar in both groups at admission and discharge on the cognitive and social subscale domains, but were significantly lower post RT on the motor subscale at admission (38 vs. 31; P = .02) and discharge (68 vs. 65; P = .03). These differences were not clinically significant, according to Dr. Kelly and senior study author Dr. Jeffrey Claridge, NOTS medical director.
Pre- and post-RT patients had similar overall FIM score gains (37 vs. 36; P = .6), motor subscale gains (both groups 29), and social subscale gains (both groups 1). FIM cognitive subscale gains were significantly lower post RT (6 vs. 5; P = .01), but this difference was also not clinically significant.
Notably, discharges to regional TBI rehabilitation increased from 9% before RT to 14% after RT, Dr. Kelly said. The percentage of patients who were discharged to a skilled nurse facility or long-term care facility remained stable at about 30%, as did the percentage discharged home at about 40%.
“Regionalization improves long-term survival and maintains similar functional outcomes for patients with severe traumatic brain injury,” he concluded.
Patrice Wendling/Frontline Medical News
Dr. Jeffrey Coughenour
Discussant Dr. Jeffrey Coughenour of the University of Missouri Health System in Columbia said it appears regionalization is working, but added, “While we are saving more lives, what kind of lives are we saving? A question that has ever increasing implications for patients and payers evaluating the care we provide.”
He praised the investigators for using the FIM scale rather than the Glasgow Outcome Scale to try and answer this question, but said more information is needed on whether FIM scores improved in more challenging patients such as those with an AIS score of 4 or 5 or those entering rehabilitation after discharge to a skilled nursing or long-term care facility.