Joseph H. Piatt

Background: Many large data sets are limited in their usefulness for trauma epidemiology by a paucity of clinical data reflecting injury severity. Software packages have been developed for extrapolation of diagnostic codes to Injury Severity Scores commonly used in trauma research. The aim of this project was to evaluate one recently upgraded package, ICDPICR2. Methods: Data were taken from the Trauma Quality Improvement Program (TQIP) for 2022. The inclusion criterion was an Abbreviated Injury Scale (AIS) head score of 1 or greater. The ICDPICR2 package in R was used to calculate AIS body region scores and Injury Severity Scores (ISS) from the diagnostic codes in TQIP. Performance of actual and mapped scores in common epidemiological applications were compared. Results: There were 337,148 files with valid AIS head scores and known hospital discharge status. Cohen’s kappa statistics for AIS head scores and binned ISS were only fair at 0.310 and 0.280, respectively. Beyond an ISS of 15, mapped ISS underestimated actual ISS. Mapped AIS head scores and ISS had low sensitivity in identification of severe injuries, 54% and 23%, respectively. Discrimination of withdrawal of care, hospital morality and home discharge was poorer for mapped scores than for actual, and models of length of stay based on mapped scores had worse fit. Mapped scores yielded very different parameter estimates from actual scores in illustrative regression models. Conclusions: Limitations of the reliability of ICDPICR2 in administrative data sets must be anticipated. Parameter estimates from regression models constructed from mapped scores are not a reliable basis for hypothesis testing.

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.

OBJECTIVE: Hydrocephalus is a lifelong condition punctuated in most cases by unpredictable hospital admissions for surgical maintenance. It occupies more of the attention of the pediatric neurosurgeon than any other condition. Benchmarks for the measurement of outcomes are of interest to patients, their families, and the healthcare system. Compared to other metrics, 30-day outcomes require modest resources to collect, are conceptually transparent, and are responsive to process improvement. METHODS: The National Surgical Quality Improvement Program–Pediatric of the American College of Surgeons was queried for operations for hydrocephalus in the years 2013 through 2020. Demographic data and data regarding comorbidities were collected. Thirty-day rates of return to the operating room, of shunt infection, and of readmission to hospital were analyzed on a univariate basis and in multivariate models. RESULTS: There were 29,098 surgical procedures in the sample, including 10,135 shunt insertions, 16,420 shunt revisions, and 2543 endoscopic third ventriculostomies. The overall 30-day reoperation rate was 10.3%. The most powerful associations were with the nature of the index procedure and with a history of extreme prematurity. The 30-day shunt infection rate was 1.80%. The major associations were with young age, major cardiac risk factors, nutritional support, and ventilator dependence. The 30-day readmission rate was 17.2%. The nature of the index procedure, current malignancy, nutritional support, and recent steroid administration were major associations. Comorbidities negatively associated with these outcomes were highly prevalent. CONCLUSIONS: Precise benchmarks for important 30-day outcomes have been calculated from a very large sample of operations for hydrocephalus in childhood.

OBJECTIVE: Accurate triage of minor head injuries remains a challenge for mature trauma systems. More than one-third of trauma transfers are overtriaged, and minor head injuries predominate. Overtriage is inefficient, wasteful of resources, and burdensome for families. The authors studied overtriage at the sole level I pediatric trauma center (PTC) in a small state with a view toward improvement of processes. METHODS: Data on transfer patients were extracted from an institutional trauma registry over an 8-year period. Three definitions of overtriage were examined: one based on transfer criteria from the American College of Surgeons Committee on Trauma, one based on resource utilization, and one adapted to the regional environment of the PTC. Associations of demographic, geographic, clinical, and social factors with overtriage were examined. RESULTS: There were 1754 unique patients transferred from the emergency departments (EDs) of other institutions to the PTC. Thirty-six percent of transfers were overtriaged by all 3 criteria, and 23% of all transfers were minor head injuries overtriaged by all criteria. Infants were more likely to be overtriaged than other age groups. Among racial categories, Black patients were least likely to be overtriaged. Patients with commercial insurance were more likely to be overtriaged. Overtriaged patients averaged shorter trips from the referring ED to the PTC, even though the PTC was farther from their homes. These observations suggest a sensitivity to social expectations in the exercise of ED physician judgments about transfer. CONCLUSIONS: More than one-third of all transfers to the study PTC were overtriaged, and almost one-quarter of all transfers were overtriaged minor head injuries. Minor head injuries are a potentially rewarding focus for system-wide quality improvement, but the interplay of social factors with ED physician judgments must be recognized.

"Letter to the Editor. Sensitivity, specificity, and abusive head injury" published on 24 May 2024 by American Association of Neurological Surgeons.

OBJECTIVE Hydrocephalus is a chronic, treatable, but in most cases incurable condition characterized by long periods of stability punctuated by crises. Patients in crisis usually seek care in an emergency department (ED). How patients with hydrocephalus use EDs has received almost no epidemiological study. METHODS Data were taken from the National Emergency Department Survey for 2018. Visits by patients with hydrocephalus were identified by diagnostic codes. Neurosurgical visits were identified by codes for imaging of the brain or skull or by neurosurgical procedure codes. Visits and dispositions were characterized by demographic factors for neurosurgical and unspecified visits by using methods for analysis of complex survey designs. Associations among demographic factors were assessed using latent class analysis. RESULTS There were an estimated 204,785 ED visits by patients with hydrocephalus in the United States in 2018. Roughly 80% of patients with hydrocephalus who visited EDs were adults or elders. By a ratio of 2:1, patients with hydrocephalus visited EDs much more often for unspecified reasons than for neurosurgical reasons. Patients with neurosurgical complaints had more costly ED visits, and if they were admitted they had longer and more costly hospitalizations than did patients with unspecified complaints. Only 1 in 3 patients with hydrocephalus who visited an ED was sent home regardless of whether the complaint was neurosurgical. Neurosurgical visits ended in transfer to another acute care facility more than 3 times as often as unspecified visits. Odds of transfer were more strongly associated with geography and, specifically, with proximity to a teaching hospital than with personal or community wealth. CONCLUSIONS Patients with hydrocephalus make heavy use of EDs, and they make more visits for reasons unrelated to their hydrocephalus than for neurosurgical reasons. Transfer to another acute care facility is an adverse clinical outcome that is much more common after neurosurgical visits. It is a system inefficiency that might be minimized by proactive case management and coordination of care.

Macrocephaly is present in 2.3% of children with important neurosurgical conditions in the differential diagnosis. The objective of this study was to identify clinical associations with actionable imaging findings among children with head imaging for macrocephaly. We conducted a case-control study of head imaging studies ordered for macrocephaly among children 24 months and younger in a multistate children’s health system. Four neurosurgeons reviewed the images, determining cases to be a ‘concern’ if neurosurgical follow-up or intervention was indicated. Electronic health records were reviewed to collect patient-level data and to determine if surgery was performed. Controls were matched 3:1 to cases of ‘concern’ in a multivariate model using conditional logistic regression. In the study sample (n = 1293), 46 (4%) were concern cases, with 15 (1%) requiring surgery. Significant clinical factors associated with neurosurgical concern were bulging fontanel [aOR 7.47, (95% CI: 2.28–24.44), P < 0.001], prematurity [aOR 21.26, (95% CI: 3.76–120.21), P < 0.001], any delay [aOR 2.67, (95% CI: 1.13–6.27), P = 0.03], and head-weight Z-score difference (W_diff, defined as the difference between the Z-scores of head circumference and weight) [aOR 1.70, (95% CI: 1.22–2.37), P = 0.002]. Head imaging for macrocephaly identified few patients with findings of concern and fewer requiring surgery. A greater head-weight Z-score difference appears to represent a novel risk factor for neurosurgical follow-up or intervention.

"Letter to the Editor. Overlapping confidence intervals" published on 20 May 2022 by American Association of Neurological Surgeons.

BACKGROUND: Military neurosurgeons have long known that tangential cranial gunshot wounds can be associated with intracranial complications out of proportion to the external appearance of the injury. This phenomenon seems not to have been described in infancy. OBSERVATIONS: An infant suffered a massive, acute subdural hemorrhage from a contralateral tangential gunshot wound that did not facture the skull. LESSONS: Similar to adults, infants are subject to catastrophic intracranial injury from gunshots that do not penetrate the skull. The nature of the injury in this case reflected distinctive aspects of the tissue characteristics and proportions of the infant head.