Trauma Ecosystems: The Impact of Too Many Trauma Centers
- 18 Downloads
This report is intended to review the principals of US trauma system design and to examine the theorized and observed effects of trauma center over designation in a regional trauma system.
Quality trauma care is predicated on concentrating resources and experience in major trauma centers. Nearly all major US urban areas have at least one major trauma center. New techniques are available to measure a region's geospatial demand that better predict the optimal placement of system resources and the impact of new major trauma center designations in areas already served. Although concerns that over designation may decrease quality through dilution of experience, increased costs from duplication of services and variation in economic practices pose a larger threat to trauma system’s value.
Recent changes in patient populations, health care economics, and policy have made trauma center designations more financially desirable shifting the trauma system’s center of gravity from public health towards industry. New tools are available to aid in trauma system planning which should help designating authorities optimize regional major trauma center allocation.
KeywordsTrauma Systems Trauma Center Trauma Economics Triage Value Geospatial
Compliance with Ethical Standards
Conflict of interest
David Ciesla declares that he has no conflicts of interest.
Human and Animal Rights
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.Accidental Death and Disability: The Neglected Disease of Modern Society. Washington (DC)1966Google Scholar
- 10.• Uribe-Leitz T, Esquivel MM, Knowlton LM, Ciesla D, Lin F, Hsia RY et al. The American College of Surgeons Needs-Based Assessment of Trauma Systems: Estimates for the State of California. J Trauma Acute Care Surg. 2017;82(5):861–6. https://doi.org/10.1097/ta.0000000000001408. This study demonstrtes the limitaiotns of the first version of the ACS COT Needs Based Assessment for Trauma Systems. PubMedGoogle Scholar
- 11.Ashley DW, Pracht EE, Garlow LE, Medeiros RS, Atkins EV, Johns TJ, et al. Evaluation of the Georgia trauma system using the American College of Surgeons Needs Based Assessment of Trauma Systems tool. Trauma Surg Acute Care Open. 2018;3(1):e000188. https://doi.org/10.1136/tsaco-2018-000188.PubMedPubMedCentralGoogle Scholar
- 12.Osler T, Rutledge R, Deis J, Bedrick E. ICISS: an international classification of disease-9 based injury severity score. J Trauma. 1996;41(3):380–6; (discussion 6–8).Google Scholar
- 13.Rutledge R, Osler T, Emery S, Kromhout-Schiro S. The end of the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS): iCISS, an International Classification of Diseases, ninth revision-based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival, hospital charges, and hospital length of stay. J Trauma. 1998;44(1):41–9.PubMedGoogle Scholar
- 14.• Ciesla DJ, Pracht EE, Tepas JJ, 3rd, Namias N, Moore FA, Cha JY et al. Measuring trauma system performance: Right patient, right place-Mission accomplished? J Trauma Acute Care Surg. 2015;79(2):263–8. https://doi.org/10.1097/ta.0000000000000660. This study describes the use of major trauma patient triage as a trauma system performance measure. PubMedGoogle Scholar
- 21.• Winchell RJ, Xu P, Mount LE, Huegerich R. Development of a Geospatial Approach for the Quantitative Analysis of Trauma Center Access. J Trauma Acute Care Surg. 2018. https://doi.org/10.1097/ta.0000000000002156. This study outlines the principals of the revised ACS COT Needs Based Assessment fo Trauma Systems. PubMedGoogle Scholar
- 26.Jenkins DH, Winchell RJ, Coimbra R, Rotondo MF, Weireter LJ, Bulger EM, et al. Position statement of the American College of Surgeons Committee on Trauma on the National Academies of Sciences, Engineering and Medicine Report, A National Trauma Care System: integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. J Trauma Acute Care Surg. 2016;81(5):819–23. https://doi.org/10.1097/TA.0000000000001217.PubMedGoogle Scholar
- 31.Celso B, Tepas J, Langland-Orban B, Pracht E, Papa L, Lottenberg L et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 2006;60(2):371–8; (discussion 8). https://doi.org/10.1097/01.ta.0000197916.99629.eb.Google Scholar
- 34.Nathens AB, Jurkovich GJ, Rivara FP, Maier RV. Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation. J Trauma. 2000;48(1):25–30; (discussion-1).Google Scholar
- 36.Maxson T, Mabry CD, Sutherland MJ, Robertson RD, Booker JO, Collins T, et al. Does the institution of a statewide trauma system reduce preventable mortality and yield a positive return on investment for taxpayers? J Am Coll Surg. 2017;224(4):489–99. https://doi.org/10.1016/j.jamcollsurg.2016.12.042.PubMedGoogle Scholar
- 39.Papa L, Langland-Orban B, Kallenborn C, Tepas JJ, 3rd, Lottenberg L, Celso B et al. Assessing effectiveness of a mature trauma system: Association of trauma center presence with lower injury mortality rate. J Trauma. 2006;61(2):261–6; (discussion 6–7). https://doi.org/10.1097/01.ta.0000221789.53864.ba.Google Scholar
- 41.Haas B, Stukel TA, Gomez D, Zagorski B, De Mestral C, Sharma SV et al. The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis. J Trauma Acute Care Surg. 2012;72(6):1510–5; (discussion 5–7). https://doi.org/10.1097/ta.0b013e318252510a.PubMedGoogle Scholar
- 43.Simons R, Kasic S, Kirkpatrick A, Vertesi L, Phang T, Appleton L. Relative importance of designation and accreditation of trauma centers during evolution of a regional trauma system. J Trauma. 2002;52(5):827–33; (discussion 33–4).Google Scholar
- 44.Ciesla DJ, Tepas JJ, 3rd, Pracht EE, Langland-Orban B, Cha JY, Flint LM. Fifteen-year trauma system performance analysis demonstrates optimal coverage for most severely injured patients and identifies a vulnerable population. J Am Coll Surg. 2013;216(4):687–95; (discussion 95–8). https://doi.org/10.1016/j.jamcollsurg.2012.12.033.PubMedGoogle Scholar
- 49.Barquist E, Pizzutiello M, Tian L, Cox C, Bessey PQ. Effect of trauma system maturation on mortality rates in patients with blunt injuries in the Finger Lakes Region of New York State. J Trauma. 2000;49(1):63–9; (discussion 9–70).Google Scholar
- 53.London JA, Battistella FD. Is there a relationship between trauma center volume and mortality? J Trauma. 2003;54(1):16–24; (discussion 1–5). https://doi.org/10.1097/01.ta.0000046313.79663.a4.
- 57.Demetriades D, Martin M, Salim A, Rhee P, Brown C, Chan L. The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Ann Surg. 2005;242(4):512–7; (discussion 7–9).Google Scholar
- 63.Richardson JD, Miller FB. Will future surgeons be interested in trauma care? Results of a resident survey. J Trauma. 1992;32(2):229–33; (discussion 33–5).Google Scholar
- 66.Spain DA, Bellino M, Kopelman A, Chang J, Park J, Gregg DL et al. Requests for 692 transfers to an academic level I trauma center: implications of the emergency medical treatment and active labor act. J Trauma. 2007;62(1):63–7; (discussion 7–8). https://doi.org/10.1097/ta.0b013e31802d9716.Google Scholar
- 70.Durham R, Pracht E, Orban B, Lottenburg L, Tepas J, Flint L. Evaluation of a mature trauma system. Ann Surg. 2006;243(6):775–83; (discussion 83–5). https://doi.org/10.1097/01.sla.0000219644.52926.f1.PubMedPubMedCentralGoogle Scholar
- 77.Ashley DW, Pracht EE, Medeiros RS, Atkins EV, NeSmith EG, Johns TJ et al. An analysis of the effectiveness of a state trauma system: treatment at designated trauma centers is associated with an increased probability of survival. J Trauma Acute Care Surg. 2015;78(4):706–12; (discussion 12–4). https://doi.org/10.1097/ta.0000000000000585.PubMedGoogle Scholar
- 78.Rodriguez JL, Christmas AB, Franklin GA, Miller FB, Richardson JD. Trauma/critical care surgeon: a specialist gasping for air. J Trauma. 2005;59(1):1–5; (discussion-7).Google Scholar
- 82.• Bai G, Anderson GF. US Hospitals Are Still Using Chargemaster Markups To Maximize Revenues. Health Aff (Millwood). 2016;35(9):1658–64. https://doi.org/10.1377/hlthaff.2016.0093. This study describes how economic practices of hospitals can result in increased revenue from outlier patients. PubMedGoogle Scholar
- 83.• Taheri PA, Maggio PM, Dougherty J, Neil C, Fetyko S, Harkins DR et al. Trauma center downstream revenue: the impact of incremental patients within a health system. J Trauma. 2007;62(3):615–9; (discussion 9–21). https://doi.org/10.1097/ta.0b013e31802ee532. This study describes the value of a trauma program to a healthcare system. Google Scholar
- 85.Boom In Trauma Centers Can Help Save Lives, But At What Price?. Kaiser Health News in collaboration withUSA today 2012. http://khn.org/news/trauma-centers/..
- 86.• Ciesla DJ, Pracht EE, Leitz PT, Spain DA, Staudenmayer KL, Tepas JJ, 3rd. The trauma ecosystem: The impact and economics of new trauma centers on a mature statewide trauma system. J Trauma Acute Care Surg. 2017;82(6):1014–22. https://doi.org/10.1097/ta.0000000000001442. This study describes the effect of additional trauma centers on a matrure trauma system’s performance and economics. PubMedGoogle Scholar
- 89.Newgard CD, Staudenmayer K, Hsia RY, Mann NC, Bulger EM, Holmes JF, et al. The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers. Health Aff (Millwood). 2013;32(9):1591–9. https://doi.org/10.1377/hlthaff.2012.1142.PubMedPubMedCentralGoogle Scholar
- 91.• Zogg CK, Schuster KM, Maung AA, Davis KA. Insurance status biases trauma-system utilization and appropriate interfacility transfer: national and longitudinal results of adult, pediatric, and older adult patients. Ann Surg. 2018;268(4):681–9. https://doi.org/10.1097/sla.0000000000002954. This study describes differential transfer of seriously injured patients to major trauma centers based on patient insurance status. PubMedGoogle Scholar
- 94.• Pracht EE, Langland-Orban B, Ryan JL. The Probability of Hospitalizations for Mild-to-Moderate Injuries by Trauma Center Ownership Type. Health Serv Res. 2018;53(1):35–48. https://doi.org/10.1111/1475-6773.12646. This study describes differential clinical practices by hospital ownership type. PubMedPubMedCentralGoogle Scholar
- 97.American College of Surgeons Committee on T: Statement on trauma center designation based upon system need. Bull Am Coll Surg. 2015;100(1):51–2.Google Scholar