1
FUNCTIONAL AND LONG-TERM OUTCOMES IN SEVERE TRAUMATIC
BRAIN INJURY FOLLOWING REGIONALIZATION OF A TRAUMA SYSTEM
Authors: Kelly ML, MD1; Roach MJ, PhD2; Banerjee A, MD3; Steinmetz M, MD4; Claridge JA, MD3
Affiliations: 1Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, OH;
2
MetroHealth Medical Center, Center for Healthcare Research and Policy, Case Western Reserve
University School of Medicine, Cleveland, OH; 3MetroHealth Medical Center, Northern Ohio Trauma
System, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH
4
Department of Neurosurgery, MetroHealth Medical Center, Case Western Reserve University School of
Medicine, Cleveland, OH.
Background
We previously demonstrated that regionalization of trauma (RT) significantly reduced in-hospital mortality
from 19% to 14% in patients with severe traumatic brain injury (sTBI). However, functional and long-term
outcomes had not been assessed. We hypothesized that RT would be associated with improved functional
and long-term outcomes in sTBI patients.
Methods
All TBI patients >14 years with a Head Abbreviated Injury Scale ≥3 were identified from the RT database
and matched to the state death index and the regional TBI rehabilitation (TBIr) database. Data from 2008
through 2012 were analyzed before and after RT in 2010. For patients discharged to the TBIr unit, overall
Functional Independence Measure (FIM) scores and FIM score gains were compared pre- and post-RT.
Results
3,496 patients with sTBI were identified in the RT database; 1,359 pre-RT and 2,137 post-RT. The inhospital mortality rate for severe TBI patients decreased from 262 (19%) pre- to 302 (14%) post-RT
(p<0.0001) (Table 1). Discharges to the TBIr unit increased from 117 (9%) pre- to 297 (14%) post-RT
(p<0.0001), while discharges to home and non-TBIr units remained similar between time periods. Injury
Severity Scale (ISS) and Glasgow Coma Scale (GCS) scores for all patients remained similar between time
periods.
Table 2 shows a significant decrease in pre- vs. post-RT mortality at 30-days (21% vs. 16%, p<0.0001) and
6-months (24% vs. 20%, p=0.004). Multivariable logistic regression demonstrated RT to be an
independent predictor against mortality at 30-days (OR: 0.74; 95% CI: 0.60-0.91, C-stat=0.84) and 6months (OR: 0.82; 95% CI: 0.67-0.99, C-stat=0.82) (Table 3). RT was also an independent predictor for
discharge to the TBIr unit (OR: 1.78; 95% CI: 1.41-2.23, C-stat=0.65).
Overall FIM admission scores were similar pre- (median: 54; interquartile range: 30,65) and post-RT
(48;31,61) (p=0.2) and remained similar at discharge pre- (92;75,102) and post-RT (89;73,100) (p=0.1)
(Table 4). TBIr patients showed similar Overall FIM score gains pre- (37;26,46) and post-RT (36;24,49)
(p=0.6) (Table 5). FIM sub-scores for Motor were lower post-RT vs. pre-RT at both admission and
discharge, however, Motor sub-scores showed similar gains both pre- and post-RT.
Discussion
We had previously demonstrated that regionalization of trauma was associated with reduced in-hospital
mortality for patients with sTBI. However, our results were limited by a lack of long-term and functional
outcomes. Our more recent data suggests that RT is also independently associated with long-term survival,
increased TBIr admissions, and similar Overall FIM score improvements for patients admitted to a TBIr
unit. In short, RT saves more lives without exacerbating function-related morbidity in an sTBI population.
Michael L. Kelly, MD, MetroHealth Medical, Center, Northern Ohio Trauma
System, Department of Surgery, Case Western Reserve University School of
Medicine, Room H938A, Hamann Bldg, 2500 MetroHealth Dr, Cleveland, OH44109-1998; Phone:216778-1005;Fax: 216-778-1129;email: kellym8@ccf.org.
2
Our findings should be interpreted in the context of a reported increase in hospital mortality rates for
patients with sTBI.5 Recent studies suggest that RT improves trauma survival in a non-severe TBI
population (i.e. Head AIS<3)2,3 or in rural populations only.4 No studies, to our knowledge, have reported
both functional and long-term outcome improvements in sTBI patients after regionalization. Future studies
can build upon these findings and should examine longer-term functional outcomes outside of the TBIr unit
setting.
Table 1. Hospital discharge status pre- and post-RT (n=3496)
Pre-RT
Post-RT
P value**
(n=1359)
(n=2137)
Home
554 (41%)
925 (43%)
0.4
TBI Rehab
117 (9%)
297 (14%)
<0.0001*
SNF/LTAC/Other
426 (31%)
613 (29%)
0.2
Rehab
Died
262 (19%)
302 (14%)
<0.00018
LTAC = Long-term acute care facility; RT = Regionalized trauma system; Rehab = Rehabilitation unit;
SNF = Skilled nursing facility; TBI = Traumatic Brain Injury;
*Statistically significant
Table 2. Mortality for sTBI patients pre- and post-RT (n=3496)
Pre-RT
Post-RT
P value
(n=1359)
(n=2137)
In-hospital
262 (19%)
302 (14%)
<0.0001*
30-day
285 (21%)
343 (16%)
<0.0001*
6-month
320 (24%)
417 (20%)
0.004*
RT = Regionalized trauma system; TBI = Traumatic Brain Injury
*Statistically significant
Table 3. Logistic regression analysis for sTBI outcomes
Age
Male
TBIr admission
OR (95% CI)
30-day mortality
OR (95% CI)
6-month mortality
OR (95% CI)
0.99 (0.99-0.998)*
1.03 (1.02-1.03)*
1.03 (1.03-1.04)*
1.70 (1.32-2.19)*
1.31 (1.05-1.63)*
1.40 (1.14-1.72)*
AA race
0.76 (0.57-1.02)
1.43 (1.09-1.87)*
1.42 (1.10-1.84)*
ISS
1.02 (1.01-1.03)*
1.15 (1.13-1.16)*
1.14 (1.12-1.15)*
Reference
Reference
Reference
Government insurance
0.81 (0.62-1.06)
1.33 (1.03-1.73)*
1.47 (1.16-1.87)*
No insurance
1.20 (0.92-1.56)
1.61 (1.21-2.13)*
1.60 (1.23-2.10)*
1.78 (1.41-2.23)*
0.74 (0.60-0.91)*
0.82 (0.67-0.99)*
C-stat=0.65*
C-stat=0.84*
C-stat=0.82*
Insurance status
Private insurance
RT
C-statistic
Michael L. Kelly, MD, MetroHealth Medical, Center, Northern Ohio Trauma
System, Department of Surgery, Case Western Reserve University School of
Medicine, Room H938A, Hamann Bldg, 2500 MetroHealth Dr, Cleveland, OH44109-1998; Phone:216778-1005;Fax: 216-778-1129;email: kellym8@ccf.org.
3
AA = African American; CI = Confidence interval; ISS = Injury Severity Score; RT = Regionalized
Trauma System; OR = Odds ratio; TBI = Traumatic brain injury
*Statistically significant
Table 4. TBI rehabilitation admission and discharge FIM scores pre- and post-RT (n=414)
Discharge FIM scores
Admission FIM scores
Pre-RT
Post-RT
P
Pre-RT
Post-RT
P
(n=117)
(n=297)
value
(n=117)
(n=297)
value
54
48
92
89
0.1
Overall
0.2
(30,65)
(31,61)
(75,102)
(73,100)
38
31
65 (53,74) 0.03*
Motor
0.02* 68 (54,76)
(20,48)
(19,42)
0.8
Cognitive 11 (8,15) 12 (7,17)
0.2
18 (14,22) 18 (15,22)
3 (2,5)
5 (4,6)
0.5
Social**
3 (2,5)
0.4
5 (4,6)
FIM = Functional Independence Measure; RT = Regionalized trauma system
FIM scores are median (IQR)
*Statistically significant Mann-Whitney U test
**Missing 20 patients for social scores (13 pre and 7 post)
Table 5. TBI rehabilitation FIM score gains pre- and post-RT (n=414)
Pre-RT
Post-RT
FIM Gain
FIM Gain
P value*
(n=117)
(n=297)
Overall FIM
37 (26,46)
36 (24,49)
0.6
Motor FIM
29 (22,37)
29 (20,39)
0.8
Cognitive FIM
6 (4,9)
5 (3,8)
0.01*
Social FIM**
1 (0,2)
1 (1,2)
0.4
FIM = Functional Independence Measure; RT = Regionalized trauma system
FIM Gain scores are median (IQR)
*Statistically significant Mann-Whitney U test
**Missing 20 patients for social scores (13 pre and 7 post)
References
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Jun;255(6):1009-15.
3. Gabbe BJ, Biostat GD, Lecky FE, Bouamra O, Woodford M, Jenks T, et al. The effect of an organized
trauma system on mortality in major trauma involving serious head injury: A comparison of the united
kingdom and victoria, australia. Ann Surg. 2011 Jan;253(1):138-43.
4. Tiesman H, Young T, Torner JC, McMahon M, Peek-Asa C, Fiedler J. Effects of a rural trauma system
on traumatic brain injuries. J Neurotrauma. 2007 Jul;24(7):1189-97.
5. Farhad K, Khan HM, Ji AB, Yacoub HA, Qureshi AI, Souayah N. Trends in outcomes and
hospitalization costs for traumatic brain injury in adult patients in the united states. J Neurotrauma. 2013
Jan 15;30(2):84-90.
Michael L. Kelly, MD, MetroHealth Medical, Center, Northern Ohio Trauma
System, Department of Surgery, Case Western Reserve University School of
Medicine, Room H938A, Hamann Bldg, 2500 MetroHealth Dr, Cleveland, OH44109-1998; Phone:216778-1005;Fax: 216-778-1129;email: kellym8@ccf.org.