Skip to main content

Trauma Ecosystems: The Impact of Too Many Trauma Centers



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.

Recent Findings

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.

This is a preview of subscription content, access via your institution.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Mullins RJ. A historical perspective of trauma system development in the United States. J Trauma. 1999;47(3 Suppl):S8–14.

    CAS  PubMed  Article  Google Scholar 

  2. 2.

    Accidental Death and Disability: The Neglected Disease of Modern Society. Washington (DC)1966

  3. 3.

    Mullins RJ, Mann NC. Introduction to the academic symposium to evaluate evidence regarding the efficacy of trauma systems. J Trauma. 1999;47(3 Suppl):S3–7.

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Branas CC, MacKenzie EJ, Williams JC, Schwab CW, Teter HM, Flanigan MC, et al. Access to trauma centers in the United States. JAMA. 2005;293(21):2626–33.

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    West JG, Williams MJ, Trunkey DD, Wolferth CC, Jr. Trauma systems. Current status–future challenges. JAMA. 1988;259(24):3597-600.

    CAS  PubMed  Article  Google Scholar 

  6. 6.

    Cryer HG, Hiatt JR. Trauma system: the backbone of disaster preparedness. J Trauma. 2009;67(2 Suppl):S111–3.

    PubMed  Article  Google Scholar 

  7. 7.

    Nathens AB, Cryer HG, Fildes J. The American College of Surgeons Trauma Quality Improvement Program. Surg Clin North Am. 2012;92(2):441-54, x-xi.

    PubMed  Article  Google Scholar 

  8. 8.

    Hemmila MR, Cain-Nielsen AH, Jakubus JL, Mikhail JN, Dimick JB. Association of Hospital Participation in a Regional Trauma Quality Improvement Collaborative With Patient Outcomes. JAMA Surg. 2018;153(8):747–56.

    PubMed  PubMed Central  Article  Google Scholar 

  9. 9.

    Moore L, Lavoie A, Bourgeois G, Lapointe J. Donabedian’s structure-process-outcome quality of care model: validation in an integrated trauma system. J Trauma Acute Care Surg. 2015;78(6):1168–75.

    PubMed  Article  Google Scholar 

  10. 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. This study demonstrtes the limitaiotns of the first version of the ACS COT Needs Based Assessment for Trauma Systems.

    PubMed  Article  Google Scholar 

  11. 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.

    PubMed  PubMed Central  Article  Google Scholar 

  12. 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).

    CAS  Article  Google Scholar 

  13. 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.

    CAS  PubMed  Article  Google Scholar 

  14. 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. This study describes the use of major trauma patient triage as a trauma system performance measure.

    PubMed  Article  Google Scholar 

  15. 15.

    Minei JP, Schmicker RH, Kerby JD, Stiell IG, Schreiber MA, Bulger E, et al. Severe traumatic injury: regional variation in incidence and outcome. Ann Surg. 2010;252(1):149–57.

    PubMed  PubMed Central  Article  Google Scholar 

  16. 16.

    Eastman AB. Wherever the dart lands: toward the ideal trauma system. J Am Coll Surg. 2010;211(2):153–68.

    PubMed  Article  Google Scholar 

  17. 17.

    Jansen JO, Morrison JJ, Wang H, Lawrenson R, Egan G, He S, et al. Optimizing trauma system design: the GEOS (Geospatial Evaluation of Systems of Trauma Care) approach. J Trauma Acute Care Surg. 2014;76(4):1035–40.

    PubMed  Article  Google Scholar 

  18. 18.

    Horst MA, Gross BW, Cook AD, Osler TM, Bradburn EH, Rogers FB. A novel approach to optimal placement of new trauma centers within an existing trauma system using geospatial mapping. J Trauma Acute Care Surg. 2017;83(4):705–10.

    PubMed  Article  Google Scholar 

  19. 19.

    Horst MA, Jammula S, Gross BW, Bradburn EH, Cook AD, Altenburg J, et al. Development of a trauma system and optimal placement of trauma centers using geospatial mapping. J Trauma Acute Care Surg. 2018;84(3):441–8.

    PubMed  Article  Google Scholar 

  20. 20.

    Jansen JO, Moore EE, Wang H, Morrison JJ, Hutchison JD, Campbell MK, et al. Maximizing geographical efficiency: an analysis of the configuration of Colorado’s trauma system. J Trauma Acute Care Surg. 2018;84(5):762–70.

    PubMed  Article  Google Scholar 

  21. 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. This study outlines the principals of the revised ACS COT Needs Based Assessment fo Trauma Systems.

    PubMed  Article  Google Scholar 

  22. 22.

    Harmsen AM, Giannakopoulos GF, Moerbeek PR, Jansma EP, Bonjer HJ, Bloemers FW. The influence of prehospital time on trauma patients outcome: a systematic review. Injury. 2015;46(4):602–9.

    CAS  PubMed  Article  Google Scholar 

  23. 23.

    Jarman MP, Curriero FC, Haut ER, Pollack Porter K, Castillo RC. Associations of distance to trauma care, community income, and neighborhood median age with rates of injury mortality. JAMA Surg. 2018;153(6):535–43.

    PubMed  PubMed Central  Article  Google Scholar 

  24. 24.

    Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care. 2006;10(2):198–206.

    PubMed  Article  Google Scholar 

  25. 25.

    Doumouras AG, Haas B, Gomez D, de Mestral C, Boyes DM, Morrison LJ, et al. The impact of distance on triage to trauma center care in an urban trauma system. Prehosp Emerg Care. 2012;16(4):456–62.

    PubMed  Article  Google Scholar 

  26. 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.

    PubMed  Article  Google Scholar 

  27. 27.

    Rogers FB, Madsen L, Shackford S, Crookes B, Charash W, Morrow P, et al. A needs assessment for regionalization of trauma care in a rural state. Am Surg. 2005;71(8):690–3.

    PubMed  Google Scholar 

  28. 28.

    Galanis DJ, Steinemann S, Rosen L, Bronstein AC, Biffl WL. Rural Level III centers in an inclusive trauma system reduce the need for interfacility transfer. J Trauma Acute Care Surg. 2018;85(4):747–51.

    PubMed  Article  Google Scholar 

  29. 29.

    Cales RH. Trauma mortality in Orange County: the effect of implementation of a regional trauma system. Ann Emerg Med. 1984;13(1):1–10.

    CAS  PubMed  Article  Google Scholar 

  30. 30.

    Mullins RJ, Mann NC. Population-based research assessing the effectiveness of trauma systems. J Trauma. 1999;47(3 Suppl):S59–66.

    CAS  PubMed  Article  Google Scholar 

  31. 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).

    Article  Google Scholar 

  32. 32.

    Twijnstra MJ, Moons KG, Simmermacher RK, Leenen LP. Regional trauma system reduces mortality and changes admission rates: a before and after study. Ann Surg. 2010;251(2):339–43.

    PubMed  Article  Google Scholar 

  33. 33.

    Porter A, Karim S, Bowman SM, Recicar J, Bledsoe GH, Maxson RT. Impact of a statewide trauma system on the triage, transfer, and inpatient mortality of injured patients. J Trauma Acute Care Surg. 2018;84(5):771–9.

    PubMed  Article  Google Scholar 

  34. 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).

    CAS  Article  Google Scholar 

  35. 35.

    Bailey J, Trexler S, Murdock A, Hoyt D. Verification and regionalization of trauma systems: the impact of these efforts on trauma care in the United States. Surg Clin North Am. 2012;92(4):1009–24, ix–x.

    PubMed  Article  Google Scholar 

  36. 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.

    PubMed  Article  Google Scholar 

  37. 37.

    Ashley DW, Pracht EE, Medeiros RS, Atkins EV, Nesmith EG, Johns TJ, et al. A Decade Evaluation of a State Trauma System: has Access to Inpatient Trauma Care at Designated Trauma Centers Improved? Am Surg. 2017;83(7):769–77.

    PubMed  Google Scholar 

  38. 38.

    Schechtman D, He JC, Zosa BM, Allen D, Claridge JA. Trauma system regionalization improves mortality in patients requiring trauma laparotomy. J Trauma Acute Care Surg. 2017;82(1):58–64.

    PubMed  Article  Google Scholar 

  39. 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).

    Article  Google Scholar 

  40. 40.

    Liberman M, Mulder DS, Jurkovich GJ, Sampalis JS. The association between trauma system and trauma center components and outcome in a mature regionalized trauma system. Surgery. 2005;137(6):647–58.

    PubMed  Article  Google Scholar 

  41. 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).

    PubMed  Article  Google Scholar 

  42. 42.

    Moore L, Champion H, Tardif PA, Kuimi BL, O’Reilly G, Leppaniemi A, et al. Impact of Trauma System Structure on Injury Outcomes: a Systematic Review and Meta-Analysis. World J Surg. 2018;42(5):1327–39.

    PubMed  Article  Google Scholar 

  43. 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. 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).

    PubMed  Article  Google Scholar 

  45. 45.

    Nathens AB, Jurkovich GJ, Cummings P, Rivara FP, Maier RV. The effect of organized systems of trauma care on motor vehicle crash mortality. JAMA. 2000;283(15):1990–4.

    CAS  PubMed  Article  Google Scholar 

  46. 46.

    Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review of published evidence regarding trauma system effectiveness. J Trauma. 1999;47(3 Suppl):S25–33.

    CAS  PubMed  Article  Google Scholar 

  47. 47.

    Nathens AB, Maier RV. The relationship between trauma center volume and outcome. Adv Surg. 2001;35:61–75.

    CAS  PubMed  Google Scholar 

  48. 48.

    Staudenmayer K, Weiser TG, Maggio PM, Spain DA, Hsia RY. Trauma center care is associated with reduced readmissions after injury. J Trauma Acute Care Surg. 2016;80(3):412–6; (discussion 6–8).

    PubMed  Article  Google Scholar 

  49. 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).

    CAS  Article  Google Scholar 

  50. 50.

    Pracht EE, Langland-Orban B, Tepas JJ 3rd, Celso BG, Flint L. Analysis of trends in the Florida Trauma System (1991-2003): changes in mortality after establishment of new centers. Surgery. 2006;140(1):34–43.

    PubMed  Article  Google Scholar 

  51. 51.

    Caputo LM, Salottolo KM, Slone DS, Mains CW, Bar-Or D. The relationship between patient volume and mortality in American trauma centres: a systematic review of the evidence. Injury. 2014;45(3):478–86.

    PubMed  Article  Google Scholar 

  52. 52.

    Nathens AB, Jurkovich GJ, Maier RV, Grossman DC, MacKenzie EJ, Moore M, et al. Relationship between trauma center volume and outcomes. JAMA. 2001;285(9):1164–71.

    CAS  PubMed  Article  Google Scholar 

  53. 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).

  54. 54.

    Glance LG, Osler TM, Dick A, Mukamel D. The relation between trauma center outcome and volume in the National Trauma Databank. J Trauma. 2004;56(3):682–90.

    PubMed  Article  Google Scholar 

  55. 55.

    Marx WH, Simon R, O’Neill P, Shapiro MJ, Cooper AC, Farrell LS et al. The relationship between annual hospital volume of trauma patients and in-hospital mortality in New York State. J Trauma. 2011;71(2):339–45; (discussion 45–6).

    Article  Google Scholar 

  56. 56.

    Tepas JJ, 3rd, Pracht EE, Orban BL, Flint LM. High-volume trauma centers have better outcomes treating traumatic brain injury. J Trauma Acute Care Surg. 2013;74(1):143–7; (discussion 7–8).

    PubMed  Article  Google Scholar 

  57. 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).

  58. 58.

    Cudnik MT, Newgard CD, Sayre MR, Steinberg SM. Level I versus Level II trauma centers: an outcomes-based assessment. J Trauma. 2009;66(5):1321–6.

    PubMed  Article  Google Scholar 

  59. 59.

    Alkhoury F, Courtney J. Outcomes after severe head injury: a National Trauma Data Bank-based comparison of Level I and Level II trauma centers. Am Surg. 2011;77(3):277–80.

    PubMed  Google Scholar 

  60. 60.

    Rogers FB, Osler T, Lee JC, Sakorafas L, Wu D, Evans T, et al. In a mature trauma system, there is no difference in outcome (survival) between Level I and Level II trauma centers. J Trauma. 2011;70(6):1354–7.

    PubMed  Article  Google Scholar 

  61. 61.

    Brown JB, Rosengart MR, Kahn JM, Mohan D, Zuckerbraun BS, Billiar TR, et al. Impact of volume change over time on trauma mortality in the United States. Ann Surg. 2017;266(1):173–8.

    PubMed  Article  Google Scholar 

  62. 62.

    Tepas JJ, 3rd, Kerwin AJ, Ra JH. Unregulated proliferation of trauma centers undermines cost efficiency of population-based injury control. J Trauma Acute Care Surg. 2014;76(3):576–9; (discussion 9–81).

    PubMed  Article  Google Scholar 

  63. 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).

    CAS  Article  Google Scholar 

  64. 64.

    Kim PK, Dabrowski GP, Reilly PM, Auerbach S, Kauder DR, Schwab CW. Redefining the future of trauma surgery as a comprehensive trauma and emergency general surgery service. J Am Coll Surg. 2004;199(1):96–101.

    PubMed  Article  Google Scholar 

  65. 65.

    Esposito TJ, Crandall M, Reed RL, Gamelli RL, Luchette FA. Socioeconomic factors, medicolegal issues, and trauma patient transfer trends: Is there a connection? J Trauma. 2006;61(6):1380–6; (discussion 6–8).

    Article  Google Scholar 

  66. 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).

    Article  Google Scholar 

  67. 67.

    Ciesla DJ, Sava JA, Street JH 3rd, Jordan MH. Secondary overtriage: a consequence of an immature trauma system. J Am Coll Surg. 2008;206(1):131–7.

    PubMed  Article  Google Scholar 

  68. 68.

    Sorensen MJ, von Recklinghausen FM, Fulton G, Burchard KW. Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system. JAMA Surg. 2013;148(8):763–8.

    PubMed  Article  Google Scholar 

  69. 69.

    Taheri PA, Butz DA, Lottenberg L, Clawson A, Flint LM. The cost of trauma center readiness. Am J Surg. 2004;187(1):7–13.

    PubMed  Article  Google Scholar 

  70. 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).

    PubMed  PubMed Central  Article  Google Scholar 

  71. 71.

    Rotondo MF, Bard MR, Sagraves SG, Toschlog EA, Schenarts PJ, Goettler CE, et al. What price commitment: what benefit? The cost of a saved life in a developing level I trauma center. J Trauma. 2009;67(5):915–23.

    PubMed  Article  Google Scholar 

  72. 72.

    Mabry CD, Kalkwarf KJ, Betzold RD, Spencer HJ, Robertson RD, Sutherland MJ, et al. Determining the hospital trauma financial impact in a statewide trauma system. J Am Coll Surg. 2015;220(4):446–58.

    PubMed  PubMed Central  Article  Google Scholar 

  73. 73.

    Aucar JA, Hicks LL. Economic modeling comparing trauma and general surgery reimbursement. Am J Surg. 2005;190(6):932–40.

    PubMed  Article  Google Scholar 

  74. 74.

    Koval KJ, Tingey CW, Spratt KF. Are patients being transferred to level-I trauma centers for reasons other than medical necessity? J Bone Joint Surg Am. 2006;88(10):2124–32.

    PubMed  Article  Google Scholar 

  75. 75.

    Ciesla DJ, Cha JY, Smith JS, 3rd, Llerena LE, Smith DJ. Implementation of an acute care surgery service at an academic trauma center. Am J Surg. 2011;202(6):779–85; (discussion 85–6).

    PubMed  Article  Google Scholar 

  76. 76.

    MacKenzie EJ, Weir S, Rivara FP, Jurkovich GJ, Nathens AB, Wang W, et al. The value of trauma center care. J Trauma. 2010;69(1):1–10.

    PubMed  Article  Google Scholar 

  77. 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).

    PubMed  Article  Google Scholar 

  78. 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).

    Article  Google Scholar 

  79. 79.

    Fortune JB, Wohltmann C, Margold B, Callahan CD, Sutyak J. Maximizing reimbursement from trauma response fees (UB-92: 68X)—lessons learned from a hospital comparison. J Trauma. 2005;58(3):482–6.

    PubMed  Article  Google Scholar 

  80. 80.

    Taheri PA, Butz DA, Watts CM, Griffes LC, Greenfield LJ. Trauma services: a profit center? J Am Coll Surg. 1999;188(4):349–54.

    CAS  PubMed  Article  Google Scholar 

  81. 81.

    Hemmila MR, Jakubus JL, Maggio PM, Wahl WL, Dimick JB, Campbell DA Jr, et al. Real money: complications and hospital costs in trauma patients. Surgery. 2008;144(2):307–16.

    PubMed  PubMed Central  Article  Google Scholar 

  82. 82.

    • Bai G, Anderson GF. US Hospitals Are Still Using Chargemaster Markups To Maximize Revenues. Health Aff (Millwood). 2016;35(9):1658–64. This study describes how economic practices of hospitals can result in increased revenue from outlier patients.

    PubMed  Article  Google Scholar 

  83. 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). This study describes the value of a trauma program to a healthcare system.

    Article  Google Scholar 

  84. 84.

    Knowlton LM, Morris AM, Tennakoon L, Spain DA, Staudenmayer KL. Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals. J Am Coll Surg. 2018;227(2):172–80.

    PubMed  Article  Google Scholar 

  85. 85.

    Boom In Trauma Centers Can Help Save Lives, But At What Price?. Kaiser Health News in collaboration withUSA today 2012.

  86. 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. This study describes the effect of additional trauma centers on a matrure trauma system’s performance and economics.

    PubMed  Article  Google Scholar 

  87. 87.

    Billeter AT, Miller FB, Harbrecht BG, Bowen W, Stephens MJ, Postel GC, et al. Interhospital transfer of blunt multiply injured patients to a level 1 trauma center does not adversely affect outcome. Am J Surg. 2014;207(4):459–66.

    PubMed  Article  Google Scholar 

  88. 88.

    Byrne JP, Mann NC, Hoeft CJ, Buick J, Karanicolas P, Rizoli S et al. The impact of short prehospital times on trauma center performance benchmarking: An ecologic study. J Trauma Acute Care Surg. 2016;80(4):586–94; (discussion 94–6).

    PubMed  Article  Google Scholar 

  89. 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.

    PubMed  PubMed Central  Article  Google Scholar 

  90. 90.

    Staudenmayer KL, Hsia RY, Mann NC, Spain DA, Newgard CD. Triage of elderly trauma patients: a population-based perspective. J Am Coll Surg. 2013;217(4):569–76.

    PubMed  Article  Google Scholar 

  91. 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. This study describes differential transfer of seriously injured patients to major trauma centers based on patient insurance status.

    PubMed  Article  Google Scholar 

  92. 92.

    Bai G, Anderson GF. Extreme Markup: the Fifty US Hospitals With The Highest Charge-To-Cost Ratios. Health Aff (Millwood). 2015;34(6):922–8.

    PubMed  Article  Google Scholar 

  93. 93.

    Bai G, Anderson GF. Market Power: price Variation Among Commercial Insurers For Hospital Services. Health Aff (Millwood). 2018;37(10):1615–22.

    PubMed  Article  Google Scholar 

  94. 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. This study describes differential clinical practices by hospital ownership type.

    PubMed  PubMed Central  Article  Google Scholar 

  95. 95.

    Ryan JL, Pracht EE, Langland-Orban B. Association of trauma alert response charges with volume and hospital ownership type in Florida. Health Serv Res Manag Epidemiol. 2018;5:2333392818797793.

    PubMed  PubMed Central  Article  Google Scholar 

  96. 96.

    Bai G. California’s Hospital Fair Pricing Act reduced the prices actually paid by uninsured patients. Health Aff (Millwood). 2015;34(1):64–70.

    PubMed  Article  Google Scholar 

  97. 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.

Download references

Author information



Corresponding author

Correspondence to David J. Ciesla.

Ethics declarations

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.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical collection on Trauma Surgery.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ciesla, D.J. Trauma Ecosystems: The Impact of Too Many Trauma Centers. Curr Surg Rep 7, 10 (2019).

Download citation


  • Trauma Systems
  • Trauma Center
  • Trauma Economics
  • Triage
  • Value
  • Geospatial