The Journal of Bone and Joint Surgery (American). 2008;90:101-109.
doi:10.2106/JBJS.F.01225
© 2008 The Journal of Bone and Joint Surgery, Inc.
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The Impact of Trauma-Center Care on Functional Outcomes Following Major Lower-Limb Trauma

Ellen J. MacKenzie, PhD1, Frederick P. Rivara, MD, MPH2, Gregory J. Jurkovich, MD2, Avery B. Nathens, MD, PhD, MPH3, Brian L. Egleston, MPP, PhD4, David S. Salkever, PhD5, Katherine P. Frey, MPH1 and Daniel O. Scharfstein, ScD1

1 Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Room 462, Baltimore, MD 21205. E-mail address for E.J. MacKenzie: emackenz{at}jhsph.edu
2 University of Washington, Harborview Medical Center, 325 9th Avenue, Box 359660, Seattle, WA 98140
3 St. Michael's Hospital, 30 Bond Street, Queen Wing 3-073, Toronto, ON M5B 1W8, Canada
4 Department of Biostatistics, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111-2497
5 University of Maryland at Baltimore County, Public Policy Building, 1000 Hilltop Circle, Room 418, Baltimore, MD 21250
Investigation performed at Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and University of Washington School of Medicine, Seattle, Washington

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention (R49/CCR316840) and the National Institute on Aging of the National Institutes of Health (R01/AG20361). Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: Although studies have shown that treatment at a trauma center reduces a patient's risk of dying following major trauma, important questions remain as to the effect of trauma centers on functional outcomes, especially among patients who have sustained major lower-limb trauma.

Methods: Domain-specific scores on the Medical Outcomes Study Short Form Health Survey (SF-36) supplemented by scores on the mobility subscale of the Musculoskeletal Function Assessment (MFA) and the Revised Center for Epidemiologic Studies Depression Scale (CESD-R) were compared among patients treated in eighteen hospitals with a level-I trauma center and fifty-one hospitals without a trauma center. Included in the study were 1389 adults, eighteen to eighty-four years of age, with at least one lower-limb injury with a score of ≥3 points according to the Abbreviated Injury Scale (AIS). To account for the competing risk of death, we estimated the survivors' average causal effect. Estimates were derived for all patients with a lower-limb injury and separately for a subset of patients without associated injuries of the head or spinal cord.

Results: For patients with a lower-limb injury resulting from a high-energy force, care at a trauma center yielded modest but clinically meaningful improvements in physical functioning and overall vitality at one year after the injury. After adjustment for differences in case mix and the competing risk of death, the average differences in the SF-36 physical functioning and vitality scores and the MFA mobility score were 7.82 points (95% confidence interval: 2.65, 12.98), 6.80 points (95% confidence interval: 2.53, 11.07), and 6.31 points (95% confidence interval: 0.25, 12.36), respectively. These results were similar when the analysis was restricted to patients without associated injuries to the head or spine. Treatment at a trauma center resulted in negligible differences in outcome for the subset of patients with injuries resulting from low-energy forces.

Conclusions: This study provides evidence that patients who sustain high-energy lower-limb trauma benefit from treatment at a level-I trauma center.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.


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