Trauma center performance and outcome disparities in severe childhood traumatic brain injury: A Trauma Quality Improvement Program study including a causal mediation analysis

BACKGROUND: That Black children die at higher rates from traumatic injuries has been recognized for years, but race as a social construct cannot itself be a cause of death. The effect of race must be mediated.

METHODS: This observational, cross-sectional study was based on data from the Trauma Quality Improvement Program of the American College of Surgeons for the years 2014 through 2022. Severe traumatic brain injury was defined as an Abbreviated Injury Scale head score of 4 or greater. Exclusion criteria were age older than 18 years, transfer to another acute care facility, and discharge from a facility that treated 10 or fewer cases. The outcome was mortality. A probability of mortality was assigned to each case as a metric of injury severity. A ratio of observed to expected deaths was calculated as a metric of trauma center (TC) performance. Causal mediation analyses were performed to estimate the contributions of injury severity and TC performance to mortality disparities between Black and White children and between Hispanic and non-Hispanic White children.

RESULTS: There were 51,025 cases in the study sample. Raw mortality rates were 30.4% and 16.1% for Black and White children, respectively ( p < 0.0001), and 16.9% and 15.9% for Hispanic and non-Hispanic White children, respectively ( p = 0.0366). Injury severity mediated a 10.8% increment in the risk of mortality for Black children, and TC performance mediated another 0.4% increment. For Hispanic children, injury severity mediated a 1.2% increment in risk of mortality, and TC performance mediated a 0.4% protective effect.

CONCLUSION: Trauma center performance accounts for a small but highly significant increment to the mortality disparity between Black and White children with severe traumatic brain injury, but as in past work, injury severity makes a much greater contribution.

LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.