785 Variability in Withdrawal of Life Sustaining Treatment Decision for Patients With Severe Traumatic Brain Injury: An Analysis of 510 North American Trauma Centers

INTRODUCTION: Withdrawal of life sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex with a paucity of standardized guidelines to inform practice patterns. We hypothesized presence of variability in WLST decision-making across centers, which could have important implications for equitable trauma care provision. METHODS: This retrospective study utilized data from adult severe TBI patients treated at trauma centers participating in the Trauma Quality Improvement Program between 2017-2020. Multivariable hierarchical logistic regression was used to adjust for patient, injury and hospital attributes influencing WLST. Residual between-center variability was characterized using the median odds ratio. Disparate WLST practices were further assessed by ranking centers' tendencies for WLST and assessing mortality between quartiles. RESULTS: We identified a total of 85511 subjects with severe TBI treated across 510 trauma centers, of which 20,300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, white race, treatment in a non-profit trauma center or self-pay/ Medicare insurance status (compared to private insurance). Black race was associated with reduced tendency for WLST. Higher severity intracranial and extracranial injuries also increased likelihood for WLST.After adjustment for patient and hospital attributes, the median odds ratio was 1.44 (1.40-1.48 95%CI), suggesting substantial residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was a 1.37 (1.30-1.42 95%CI) increased adjusted odds of mortality between fourth versus first quartile centers. CONCLUSIONS: We highlighted the presence of disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a strong need for examination of center-level factors contributing to heterogenous WLST practices to ultimately improve equity of care provision for severe TBI patients.