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J Am Coll Surg. 2018 May;226(5):741-751.e2. doi: 10.1016/j.jamcollsurg.2018.01.055. Epub 2018 Mar 1.

Comparative Effectiveness of Initial Treatment at Trauma Center vs Neurosurgery-Capable Non-Trauma Center for Severe, Isolated Head Injury.

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Department of Surgery, New York-Presbyterian Weill Cornell Medicine, New York, NY. Electronic address:
Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY.
Department of Statistics, University of Pennsylvania, Philadelphia, PA.
Department of Surgery, Division of Traumatology and Surgical Critical Care, University of Pennsylvania, Philadelphia, PA.
Departments of Emergency Medicine and Epidemiology, Biostatistics, and Informatics, University of Pennsylvania, Philadelphia, PA.



Head injury is an increasing contributor to death and disability, particularly among the elderly. Older patients are less likely to be treated at trauma centers, and head injury is the most common severe injury treated at non-trauma centers. We hypothesized that patients initially triaged to trauma centers would have lower rates of mortality and higher rates of discharge home without services than those treated at non-trauma centers.


We used the State Emergency Department and Inpatient Databases (2011 to 2012) for 6 states to conduct a retrospective cohort study of patients with severe, isolated head injury. Combined, these databases capture all visits to non-federal emergency departments. We compared in-hospital mortality and discharge status for all adults and for the subgroup aged 65 years or older who initially presented to either a trauma center or a neurosurgery-capable non-trauma center. To account for selection bias, we used differential distance from patients' homes to a trauma center as an instrumental variable and performed a multivariable matched analysis.


Of 62,198 patients who presented with severe, isolated head injury, 44.2% presented to non-trauma centers and 55.8% to trauma centers. In multivariable matched instrumental variable analysis, initial presentation to a trauma center was associated with no significant difference in overall mortality (-1.06%; 95% CI -3.36% to 1.19%), but a 5.8% higher rate of discharge home (95% CI 1.7% to 10.0%). Among patients aged 65 years or older, initial presentation to a trauma center was associated with a 3.4% reduction in mortality (95% CI 0.0% to 7.1%).


Patients with isolated, severe head injury have better outcomes if initially treated in designated trauma centers. As 40% of such patients were triaged to non-trauma centers, there are major opportunities for improving outcomes.

[Available on 2019-05-01]

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