A new pediatric trauma center quality benchmarking metric: Center-level variability in postinjury functional impairment using the Functional Status Scale (FSS)

BACKGROUND: Over 7 million children are injured annually in the United States, leading to 500,000 disability-adjusted life years. Functional outcomes after injury, however, are not routinely measured. Whether disability is modifiable by trauma center care remains unclear. The purpose of this study was to assess variability between trauma centers in functional impairment rates. METHODS: The “Assessment of Health-Related Quality of Life and Functional Outcomes after Pediatric Trauma” prospective observational dataset was analyzed. Functional status among injured children (≤14 y) was assessed at discharge and 6-month follow-up using the Functional Status Scale (FSS). Multivariable logistic regression was used to calculate variability in FSS explained by nonmodifiable patient and injury characteristics. Propensity score modeling was used to estimate the expected functional impairment rates for each trauma center based on age, GCS, injury mechanism, number of body regions injured, and the presence of serious body region–specific injuries. Observed impairment rates were used to calculate observed-to-expected (O:E) ratios for risk-adjusted comparison between centers. RESULTS: The cohort included 427 patients from seven centers. Functional impairment (FSS ≥ 7) occurred in 217 (51%) children at discharge and in 81 of 324 (25%) at follow-up. Patient and injury characteristics explained 55% of the variability in FSS at discharge and 14% at follow-up. Unadjusted functional impairment differed between centers at discharge (range 36–70%, p =0.03), but not significantly at 6-month follow-up (range 12–36%, p =0.06). One high-impairment outlier center O:E 1.38 (1.01, 1.84) at discharge and one low-impairment outlier center O:E 0.50 (0.23, 0.94) at 6-month follow-up were identified. CONCLUSIONS: Most functional impairment after pediatric injury is explained by patient and injury characteristics, but variability in functional impairment exists between trauma centers after adjusting for these factors. Differences in functional outcomes between centers suggest that these outcomes are modifiable and are associated with the quality of trauma center care. ( J Trauma Acute Care Surg . 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.) Level of Evidence: Prognostic/Epidemiological; Level III.