Outcomes of transferred versus directly admitted pediatric traumatic brain injury patients in urban teaching hospitals: A propensity score–matched analysis

BACKGROUND Teaching hospitals serve as referral centers for pediatric trauma care. However, the impact of interhospital transfer on outcomes in pediatric traumatic brain injury (TBI) within urban teaching hospitals remains unclear. Hence, we examined whether transferred pediatric TBI patients to urban teaching hospitals experienced different outcomes from directly admitted patients, hypothesizing that results would be comparable. METHODS We conducted a cross-sectional study of pediatric TBI hospitalizations from 2016 to 2021 using the National Inpatient Sample database. Patients were categorized as direct admissions or transfers. Propensity score matching (1:2 with replacement) was performed using demographic, clinical, and hospital-level variables. Outcomes included in-hospital mortality, medical complications, length of stay (LOS), and postdischarge rehabilitation referral. RESULTS Out of 28,548 total patients, 15,324 were successfully matched with 7,239 (47.2%) interhospital transfers. Baseline demographics, clinical, and hospital characteristics were well balanced between the two groups (all standardized mean differences <10%). Unadjusted in-hospital mortality was similar between transferred and directly admitted patients (3.6% vs. 3.4%, p = 0.49). However, transferred patients experienced longer LOS (median, 2 days; interquartile range, 1–6; p < 0.001), fewer discharges to rehabilitation (5.7% vs. 6.7%, p < 0.001), and higher complications (deep vein thrombosis, 1.2 vs. 0.9; p = 0.04; urinary tract infection, 1.6 vs. 1.1; p = 0.005). After multivariable adjustment, transfer status was not associated with mortality (odds ratio OR, 1.06; 95% confidence interval CI, 0.89–1.28) and rehabilitation discharge (OR, 0.92; 95% CI, 0.80–1.06). However, transfer remained independently associated with longer LOS (OR, 1.31; 95% CI, 1.24–1.39) and higher complications (OR, 1.25; 95% CI, 1.09–1.44). CONCLUSION Interhospital transfer was not associated with mortality or rehabilitation discharge among pediatric TBI patients treated at urban teaching hospitals. However, longer LOS and higher complications among transferred patients raise equity and system efficiency concerns. While statistically significant, these differences were modest and may not be clinically meaningful, warranting further research with more granular data. LEVEL OF EVIDENCE Original article, cross-sectional study; Level III.