Current patterns of trauma center proliferation have not led to proportionate improvements in access to care or mortality after injury: An ecologic study

Abstract

Background: Timely access to high-level (I/II) trauma centers (HLTCs) is essential to minimize mortality after injury. Over the last 15 years, there has been a proliferation of HLTC nationally. The current study evaluates the impact of additional HLTC on population access and injury mortality.

Methods: A geocoded list of HLTC, with year designated, was obtained from the American Trauma Society, and 60-minute travel time polygons were created using OpenStreetMap data. Census block group population centroids, county population centroids, and American Communities Survey data from 2005 and 2020 were integrated. Age-adjusted nonoverdose injury mortality was obtained from CDC Wide-ranging Online Data for Epidemiologic Research and the Robert Wood Johnson Foundation. Geographically weighted regression models were used to identify independent predictors of HLTC access and injury mortality.

Results: Over the 15-year (2005-2020) study period, the number of HLTC increased by 31.0% (445 to 583), while population access to HLTC increased by 6.9% (77.5-84.4%). Despite this increase, access was unchanged in 83.1% of counties, with a median change in access of 0.0% (interquartile range, 0.0-1.1%). Population-level age-adjusted injury mortality rates increased by 5.39 per 100,000 population during this time (60.72 to 66.11 per 100,000). Geographically weighted regression controlling for population demography and health indicators found higher median income and higher population density to be positively associated with majority (≥50%) HLTC population coverage and negatively associated with county-level nonoverdose mortality.

Conclusion: Over the past 15 years, the number of HLTC increased 31%, while population access to HLTC increased only 6.9%. High-level (I/II) trauma center designation is likely driven by factors other than population need. To optimize efficiency and decrease potential oversupply, the designation process should include population level metrics. Geographic information system methodology can be an effective tool to assess optimal placement.

Level of evidence: Prognostic and Epidemiological; Level IV.

Graphical abstract

Figure 1

Visualization of the percentage change in county-level access to ground HLTC care within 60 minutes between 2005 and 2020. Counties with increased coverage are lighter (yellow), decreased coverage darker (purple), and counties with constant coverage are in between (green).

Figure 2

Bivariate map comparing tertiles of county-level HLTC coverage and nonoverdose injury mortality. Counties with increased coverage are lighter blue, and those with higher injury mortality are darker red. Counties with high injury mortality and low HLTC coverage will be only dark red, while those with high coverage and low mortality will be only light blue. Counties falling in the middle are categorized by the respective hue in the legend.