====== Regionalization ======

Regionalization is the tendency to form decentralized regions.
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There is a growing body of [[evidence]] suggesting that [[regionalization]] of subspecialty procedures to high-volume centres may limit patient morbidity and mortality, such as in patients undergoing [[clipping]]
or endovascular coiling for ruptured and [[unruptured intracranial aneurysm]]s, evacuation of intracerebral hemorrhage, carotid endarterectomy (CEA), resection of supratentorial brain tumours, resection of vestibular schwannomas, microvascular decompression for neurovascular compression syndromes, and decompression for lumbar stenosis
((Nuno M, Patil CG, Lyden P, et al. The effect of transfer and hospital
volume in subarachnoid hemorrhage patients. Neurocrit Care.
2012;17:312-23.))
((Pandey AS, Gemmete JJ, Wilson TJ, et al. High subarachnoid
hemorrhage patient volume associated with lower mortality and
better outcomes. Neurosurgery. 2015;77:462-70.))
((Vespa P, Diringer MN. The Participants in the International
Multi-disciplinary Consensus Conference on the Critical Care
Management of Subarachnoid Hemorrhage. High-volume
centers. Neurocrit Care. 2011;15:369-72.))
((Barker FG, Amin-Hanjani S, Butler WE, et al. In-hospital
mortality and morbidity after surgical treatment of unruptured
intracranial aneurysms in the United States, 1996-2000: the
effect of hospital and surgeon volume. Neurosurgery. 2003;52:
995-1009.))
((Cowan JA, Dimick JB, Thompson BG, et al. Surgeon volume as an
indicator of outcomes after carotid endarterectomy: an effect
independent of specialty practice and hospital volume. J Am Coll
Surg. 2002;195:814-21.))
((Patil CG, Alexander AL, Gephart MG, et al. A population-based
study of inpatient outcomes after operative management of
nontraumatic intracerebral hemorrhage in the United States.
World Neurosurg. 2011;78:640-5.))
((Hastan D, Vandenbroucke JP, van der Mey AG. A meta-analysis of
surgical treatment for vestibular schwannoma: is hospital
volume related to preservation of facial function? Otol Neurotol.
2009;30:975-80.))
((Trinh VT, Davies JM, Berger MS. Surgery for primary supratentorial
brain tumors in the United States, 2000-2009: effect of provider
and hospital caseload on complication rates. J Neurosurg.
2015;122:280-96.))
((Englot DJ, Ouyang D, Wang DD, et al. Relationship between
hospital surgical volume, lobectomy rates, and adverse
perioperative events in US epilepsy centers. J Neurosurg.
2013;118:169-74.))
((Kalkanis SN, Eskander EN, Carter BS, et al. Microvascular decompression
surgery in the United States, 1996 to 2000: mortality
rates, morbidity rates, and the effects of hospital and surgeon
volumes. Neurosurgery. 2003;52:1251-62.))
((Wang DD, Ouyang D, Englot DJ, et al. Trends in surgical treatment
for trigeminal neuralgia in the United States of America from
1988-2008. J Clin Neurosci. 2013;20:1538-45.))
((Dasenbrock HH, Clarke MJ, Witham TF, et al. The impact of provide
volume on the outcomes after surgery for lumbar spinal stenosis.
Neurosurgery. 2012;70:1346-54.)).

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To test the hypothesis that RT would be associated with earlier time to surgery and decreased length of stay (LOS).

Traumatic spine injury (TSI) patients >14 yr were identified using International Classification of Diseases Ninth Revision Clinical Modification diagnostic codes. Data from 2008 through 2012 were analyzed before and after RT in 2010.

RESULTS:
A total of 4072 patients were identified; 1904 (47%) pre-RT and 2168 (53%) post-RT. Injury severity scores, Spine [[Abbreviated Injury Scale]] scores, and the percentage of TSIs with spinal cord injury (tSCI) were similar between time periods. Post-RT TSIs demonstrated a lower median intensive care unit (ICU) LOS (0 vs 1 d; P < 0.0001), underwent spine surgery more frequently (13% vs 11%; P = 0.01), and had a higher rate of spine surgery performed within 24 h of admission (65% vs 55%; P = 0.02). In patients with tSCI post-RT, ICU LOS was decreased (1 vs 2 d; P < 0.0001) and ventilator days were reduced (average days: 2 vs 3; P = 0.006). The post-RT time period was an independent predictor for spine surgery performed in less than 24 h for all TSIs (odds ratio [OR] 1.52, 95% confidence interval [CI]: 1.04-2.22, C-stat = 0.65). Multivariate linear regression analysis demonstrated an independent effect on reduced ICU LOS post-RT for TSIs (OR -1.68; 95% CI: -2.98 to 0.39; R2 = 0.74) and tSCIs (OR -2.42, 95% CI: -3.99-0.85; R2 = 0.72).

CONCLUSION:
RT is associated with increased surgical rates, earlier time to surgery, and decreased ICU LOS for patients with TSI
((Kelly ML, He J, Roach MJ, Moore TA, Steinmetz MP, Claridge JA. Regionalization
of Spine Trauma Care in an Urban Trauma System in the United States: Decreased
Time to Surgery and Hospital Length of Stay. Neurosurgery. 2018 Oct 16. doi:
10.1093/neuros/nyy452. [Epub ahead of print] PubMed PMID: 30329091.
)).

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RT was associated with reduced long-term mortality, increased TBIr admissions, and similar FIM score improvements for patients with sTBI
((Kelly ML, Roach MJ, Banerjee A, Steinmetz MP, Claridge JA. Functional and
long-term outcomes in severe traumatic brain injury following regionalization of 
a trauma system. J Trauma Acute Care Surg. 2015 Sep;79(3):372-377. PubMed PMID:
26307868.
)).