Is more better? Do statewide increases in trauma centers reduce injury-related mortality?

Abstract

Objectives: Trauma centers are inconsistently distributed throughout the United States. It is unclear if new trauma centers improve care and decrease mortality. We tested the hypothesis that increases in trauma centers are associated with decreases in injury-related mortality (IRM) at the state level.

Methods: We used data from the American Trauma Society to geolocate every state-designated or American College of Surgeons-verified trauma center in all 50 states and the District of Columbia from 2014 to 2018. These data were merged with publicly available IRM data from the Centers for Disease Control and Prevention. We used geographic information systems methods to map and study the relationships between trauma center locations and state-level IRM over time. Regression analysis, accounting for state-level fixed effects, was used to calculate the effect of total statewide number of trauma center on IRM and year-to-year changes in statewide trauma center with the IRM (shown as deaths per additional trauma center per 100,000 population, p value).

Results: Nationwide between 2014 and 2018, the number of trauma center increased from 2,039 to 2,153. Injury-related mortality also increased over time. There was notable interstate variation, from 1 to 284 trauma centers. Four patterns in statewide trauma center changes emerged: static (12), increased (29), decreased (5), or variable (4). Of states with trauma center increases, 26 (90%) had increased IRM between 2014 and 2017, while the remaining 3 saw a decline. Regression analysis demonstrated that having more trauma centers in a state was associated with a significantly higher IRM rate (0.38, p = 0.03); adding new trauma centers was not associated with changes in IRM (0.02, p = 0.8).

Conclusion: Having more trauma centers and increasing the number of trauma center within a state are not associated with decreases in state-level IRM. In this case, more is not better. However, more work is needed to identify the optimal number and location of trauma centers to improve IRM.

Level of evidence: Epidemiologic, level III; Care management, level III.

Figure 1a.

Trauma Centers in the United States, 2014–2019. Map of state-designated trauma centers locations in the United from 2014–2019 as registered in the American Trauma Society’s Trauma Information Exchange Program (TIEP). Older years are represented with larger dots. Trauma centers which were added over the study period can be identified as smaller dots on the map.

Figure 1b.

Trauma Centers in the Southeastern United States, 2014–2019. This magnification of the map in Figure 1a demonstrates that adjacent states often have variable distributions of trauma centers.