The impact of trauma-center care on mortality and function following pelvic ring and acetabular injuries

ABSTRACT
Background: Lower mortality and improved physical function following major polytrauma have been associated with treatment at level-1 trauma centers (TC) compared with that at non-trauma centers (NTC). This study investigates the impact of TC care on outcomes after pelvic and acetabular injuries.
Methods: Mortality and quality of life-related measures were compared among patients treated in 18 hospitals with level-1 trauma centers and 51 hospitals without trauma centers in 14 U.S. states. Complete data were obtained on 829 adult trauma patients (18-84 years old) with at least one pelvic ring or acetabular injury (OTA 61 or 62). We used inverse probability of treatment weighting to adjust for observable confounding.
Results: After adjustment for case mix, in-hospital mortality was significantly lower at TC versus NTC (RR 0.10, 95% CI 0.02-0.47), as was death by 90 days (RR 0.10, 95% CI 0.02-0.47), and one year (RR 0.21, 95% CI 0.06-0.76) for patients with more severe acetabular injuries (OTA 62-B or 62-C). Patients with combined pelvic ring and acetabular injuries treated at TC had lower mortality by 90 days (RR 0.34, 95% CI 0.14-0.82) and one year (RR 0.30 95% CI 0.14-0.68). Care at TC was also associated with mortality risk reduction for those with unstable pelvic ring injuries (OTA 61-B or 61-C) at one year (RR 0.21, 95%CI 0.06-0.76). Seventy-eight percent of included subjects discharged alive was available for interview at twelve months. Average absolute differences in SF-36 physical functioning and Musculoskeletal Functional Assessment at one year were 11.4 (95%CI 5.3 – 17.4) and 13.2 (1.7 – 24.7) respectively, indicating statistically and clinically significant improved outcomes with TC treatment for more severe acetabular injuries.
Conclusions: Mortality is reduced for patients with unstable pelvic and severe acetabular injuries when care is provided in a TC compared to NTC. Moreover, those with severe acetabular fractures experience improved physical function at one year. Patients with these injuries represent a well-defined subset of trauma patients that should be preferentially triaged or transferred to a Level-1 trauma center.