Urban/Rural disparities in Oregon pediatric traumatic brain injury

Megan J. Leonhard, Dagan A. Wright, Rongwei Fu, David P. Lehrfeld, Kathleen F. Carlson

Traumatic brain injury (TBI) greatly contributes to morbidity and mortality in the pediatric population. We examined potential urban/rural disparities in mortality amongst Oregon pediatric patients with TBI treated in trauma hospitals. We conducted a retrospective study of children ages 0-19 using the Oregon Trauma Registry for years 2009-2012. Geographic location of injury was classified using the National Center for Health Statistics Urban/Rural Classification Scheme. Incidence rates were calculated using Census data for denominators. Associations between urban/rural injury location and mortality were assessed using multivariable logistic regression, controlling for potential confounders. Generalized estimating equations were used to help account for clustering of data within hospitals. Of 2794 pediatric patients with TBI, 46.6 % were injured in large metropolitan locations, 24.8 % in medium/small metropolitan locations, and 28.6 % in non-metropolitan (rural) locations. Children with rural locations of injury had a greater annualized TBI incidence rate, at 107/100,000 children per year, than those from large metropolitan areas (71/100,000 per year). Compared to children injured in urban locations, those in rural locations had more than twice the crude odds of mortality (odds ratio [OR], 2.5; 95 % CI, 1.6-4.0). This association remained significant (OR, 1.8; 95 % CI, 1.04-3.3) while adjusting for age, gender, race, insurance status, injury severity, and type of TBI (blunt vs. penetrating). We observed higher rates of TBI and greater proportions of severe injury in rural compared to urban areas in Oregon. Rural children treated in the trauma system for TBI were more likely to die than urban children after controlling for demographic and injury factors associated with urban/rural residence. Further research is needed to examine treatment disparities by urban/rural location. Future work should also identify interventions that can reduce risk of TBI and TBI-related mortality among children, particularly those who live in rural areas.