Due to the distance from and accessibility to high-volume trauma centers, children in rural areas may have worse pediatric traumatic brain injury (TBI) results. This study aimed to assess the effects of institutional TBI volume and sociodemographics on outcomes in children from rural and urban areas. In the 2012–2015 National Inpatient Sample database, patients aged 0–19 years old with ICD-9 codes for TBI were found. 

A total of 19,736 patients (median age 11 years, interquartile range [IQR] 2–16 years, 66% male, 55% Caucasian) were identified. Overall, patients in rural areas had more severe All Patient Refined Diagnosis Related Groups injuries (median 2 [IQR 1–3] vs 1 [IQR 1–2], p < 0.001) and required more intracranial monitoring (6% vs 4%, p < 0.001). Rural-dwelling patients had more medical complications (6% vs. 4%, p < 0.001), mortality (6% vs 4%, p < 0.001), and LOS (median 2 days [IQR 1–4 days] vs. 2 days [IQR 1–3 days], p < 0.001), according to univariate analysis. After adjusting for injury severity, mechanism, and hospital characteristics, multivariate analysis revealed that rural-dwelling status was not associated with LOS for urban-dwelling patients. Cost for rural and urban-dwelling patients was not linked with medical problems, disposition, or mortality for either demographic.


Overall, rural-dwelling pediatric TBI patients have worsening injury severity, mortality, and in-hospital complications, but these differences vanish if injury severity and mechanism are taken into account. After controlling for these factors, the volume of institutional TBI does not affect clinical outcomes for children living in rural or metropolitan areas. Improving TBI outcomes for rural-dwelling children may require addressing the fundamental reasons for greater injury severity at hospital presentation.