Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need?

Arturo J Rios-Diaz,David Metcalfe,Olubode A Olufajo,Cheryl K Zogg,Brian Yorkgitis,Mansher Singh,Adil H Haider,Ali Salim

doi:10.1016/j.jamcollsurg.2016.08.569

Abstract

The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality. We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates. There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year. There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients.

Highlights

Trauma continues to be the leading cause of death among Americans aged 1-441
11 Results Trauma burden The annual national burden of injured patients admitted to hospitals was 1,345,024, of which 2.4% died in-hospital, 43.8% were discharged to live independently in their own home, 41.4% to a nursing home or other inpatient facility, 9.6% to home health care, and 0.7% against medical advice
In generalized linear regression models testing the independent association of trauma admissions density and trauma centers (TCs) density, Surgical Critical Care (SCC) provider density, per-capita income, and age-adjusted mortality rate, there was an increase of 75 trauma admissions (95%CI: 15.9-134.0; p=0.013) for every unit increase in SCC provider per million population (PMP)

Summary

Introduction

Trauma continues to be the leading cause of death among Americans aged 1-441. Despite advances in medical care, there was a 23% increase in traumatic deaths over the last decade[2]. The mechanisms by which trauma systems reduce trauma mortality are not clear but may include pre-hospital emergency medical services, timely triage and transport, definitive medical care, and rehabilitation.[5] Designated trauma centers (TCs) are fundamental components of organized trauma systems These facilities provide a number of specialized resources, including a surgical critical care (SCC) workforce, that is likely to be involved in managing the most severely injured patients. Study Design: We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality-rates. Normalized densities (per-million-population, PMP) were calculated and generalized linear models used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per capita income, and ageadjusted mortality-rates.

Methods

Results

Discussion

Conclusion