Immature patients in a mature system: Regional analysis of Florida's pediatric trauma system

BACKGROUND The state of Florida's trauma system is organized into seven regions, two of which lack designated pediatric trauma centers. Injured children residing in these regions often require transfer out of their home region for definitive care. The purpose of this study was to evaluate the effectiveness and efficiency of the current regionalization approach, focusing on variations between regions. METHODS Using the Florida Agency for Health Care Administration database, we identified all trauma patients 15 years old or younger admitted between 2009 and 2014. Patients with high-risk injury (ICD-9 Injury Severity Score < 0.85) who did not receive definitive treatment at a pediatric trauma center (PTC) were considered undertriaged. Outcomes of interest included mortality and long-term disability. Patients who were definitively treated at a facility outside their home region, but who had low risk injuries (ICD-9 Injury Severity Score > 0.9), required no procedures or ICU monitoring, and were discharged within 48 hours, were considered to have received potentially avoidable out-of-region treatment. Regions were compared, and patients treated in-region were compared to those treated out-of-region. Regression models were used to adjust for covariates. RESULTS Of 34,816 patients, 8% had high-risk injuries and the overall mortality rate was 1%. Risk-adjusted outcomes were generally similar across all regions. Regional rates of undertriage varied from 0.4% to 4.7% and were highest in regions lacking a PTC. Eleven percent of patients required definitive treatment outside their home region; these patients had higher hospital charges and stayed in the hospital 0.96 days longer (least-squares mean). Rates of potentially avoidable out-of-region treatment ranged from 7% to 12% in the two regions lacking a PTC. After adjustment for confounders, significant unexplained differences in potentially avoidable out-of-region treatment remained between these two regions (OR 2.0, 95% CI 1.6-2.6). CONCLUSIONS Florida's regionalized pediatric trauma system performs effectively, with low undertriage and acceptable outcomes. Out-of-region treatment, an inevitable byproduct of the current regionalization approach, imposes a measurable burden on the treating facility and patient/family. Unexplained variations in potentially avoidable out-of-region treatment suggest improvements can be made in system efficiency. LEVEL OF EVIDENCE Economic/decision study, level III.