Impact of trauma centers on survival in older vs younger adults: A propensity-weighted comparison of level 1 and level 3 trauma centers in the NTDB.

Abstract

Research has demonstrated improved outcomes for younger adults with severe injury [injury severity score (ISS) >15] treated at a Level 1 trauma center (L1TC). There is limited research comparing L1TCs to Level 3 TCs (L3TC) in both younger and older adults. The purpose of this study was to compare mortality rates for all age and injury severity groups at L1TCs and L3TCs. All trauma patients aged 18 to 89 years, admitted 2017-2023, were selected from the Trauma Quality Program Participant Use File files, excluding burns, transfers-in, and transfers-out. Inverse propensity score weighting balanced 14 baseline characteristics (eg, age, sex, comorbidities, frailty, ISS, Glasgow Coma Scale, vital signs, TBI status), with top 500 extreme weights trimmed. L1TC patients were compared with L3TC patients on total mortality (death+hospice) using multivariable logistic regression. This analysis examined multiple patient subsets. All analyses were stratified by younger adults (18-64 y) and older adults (65-89 y). A total of 526 L1/3TCs submitted 2,788,401 patients (median age, 55 y; median ISS, 9; 88.2% blunt; 5.2% total mortality). After balancing, L1TC patients had significantly lower adjusted odds (95% CI) of total mortality overall than L3TCs in younger [0.83 (0.81-0.85)] and older adults [0.95 (0.93-0.97)]. For the various subsets, the adjusted odds ratio for younger adults at L1TCs ranged from 0.64 to 0.87 and from 0.83 to 1.06 for older adults. In older adults, most absolute percentage differences in mortality between L1TCs and L3TCs were small (<1%) except for Glasgow Coma Scale 3 to 8 (6.7%) and ISS >25 (1.3%), both favoring L1TCs. While younger adults experienced a substantial survival advantage at L1TCs overall and in all subsets, these data suggest that only certain subsets of older adults (eg, severe TBI and ISS >25) might benefit from transfer to L1TCs. Other subsets of older adults may, therefore, be successfully managed at L3TCs, highlighting important complementary roles of L1TCs and L3TCs in the care of older adult trauma patients. (J Trauma Acute Care Surg 2026;00:000-000 Copyright © 2026 Wolters Kluwer Health, LLC. All rights reserved.). Therapeutic/Care Management; Level III.