Does the Availability of Craniofacial Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-level Analysis

Abstract

BACKGROUND: Prior studies suggest that trauma services are inequitably distributed throughout the United States. However, it is unknown whether this trend applies to the burden of craniofacial trauma. We aimed to describe the geographical distribution of craniofacial trauma, craniofacial surgeons and training positions nationwide. METHODS: State-level data were obtained on craniofacial trauma admissions (Healthcare Cost and Utilization Project [HCUPnet] databases), craniofacial surgeons (plastic and reconstructive [PR], head and neck, and oral-maxillo-facial surgeons; American Board of Medical Specialties and American Association of Oral and Maxillofacial Surgeons data), craniofacial surgery fellowship positions (American Medical Association FREIDA and National Resident Matching Program data), population size, and household income (US Census data) for 2016–2017. Normalized densities (per million population [PMP]) were ascertained. State-level variation in densities were compared between highest and lowest quartiles using Kruskal–Wallis tests. Risk-adjusted generalized linear models were used to determine the independent association between craniofacial surgeon density, training positions, and income with craniofacial trauma density. RESULTS: There were 790,415 craniofacial trauma admissions (2,447 PMP), 28,004 craniofacial surgeons (86.7 PMP), and 746 craniofacial training positions (2.3 PMP) nationwide. There was significant state-level variation in the density PMP of craniofacial trauma (median, 1,999.6 versus 2,983.5; P < 0.01), surgeon (70.8 versus 98.7; P < 0.01), training positions (0 versus 3.5; P < 0.01) between lowest and highest quartiles. Distribution of surgeons was not associated with craniofacial trauma density (P = 0.27) and was positively associated with income and training positions density (P < 0.01). Subanalysis of specialties revealed that only the distribution of PR surgeons was positively associated with craniofacial trauma density, yielding an increase in 5.6 PR surgeons/PMP for every increase of 1,000 craniofacial trauma admissions/PMP (P < 0.01). CONCLUSIONS: There is an uneven state-level distribution of craniofacial surgeons across the United States that is associated with income. Head and neck and oral-maxillo-facial craniofacial surgeons’ location does not follow the craniofacial trauma care need whereas PR surgeons’ location does. As we move toward regionalization of trauma care, further work will be necessary to close the gap between workforce availability and clinical need.