Abstract
This cohort study assesses geographic distribution of for-profit and not-for-profit trauma centers in the US designated by their states between 2014 and 2018.
Despite the growing number of trauma centers in the US, geographic access disparity persists.1 While the American College of Surgeons Committee on Trauma’s designation process emphasizes the need to meet regional injury burden, gaining trauma center status may confer financial benefits and incentives to pursue designation.2 We evaluated profit status and geographic distribution of trauma centers designated by their respective states between 2014 and 2018. We hypothesize that, compared with not-for-profit hospitals, for-profit hospitals gain designation in regions with lower injury burden and in closer proximity to existing trauma centers.
Methods
This study followed the STROBE reporting guideline. Additional details are available in the eMethods in Supplement 1. This study did not meet criteria for review by the Stanford Institutional Review Board because it did not involve human participants. We evaluated all trauma centers (level I-V) newly designated by their states between January 1, 2014, and December 31, 2018, categorized as level I-II (centers with the highest capacity to treat injured patients) or level III-V (centers with more limited capacity) in this cohort study.3 We compiled data from the Trauma Information Exchange Program, Centers for Medicare & Medicaid Services, the Web-Based Injury Statistics Query and Reporting System, and the US Census Bureau to determine trauma center locations, for-profit status, charitability ratio (ratio of hospital income spent on charitable care relative to total expenses),1,2 profitability (net income),3 county-level injury-related mortality rate, and county median household income.
Statistical analyses were performed using R version 4.2.0. After assessing distribution normality using qq-plots, we evaluated continuous variables using t tests or Mann-Whitney tests. A multivariable linear model evaluated for-profit status and ground transport times between newly designated and existing trauma centers, with a priori-defined confounders. A 2-sided P < .05 determined statistical significance.
Results
There were 431 newly designated trauma centers between 2014 and 2018 (Table 1). Compared with not-for-profit trauma centers, for-profit trauma centers had higher charitability ratios (median [IQR]: 0.04 [0.005-0.06] vs 0.007 [0.003-0.01]; P < .001), higher net incomes in millions of US dollars (median [IQR]: $13.5 [$1.3-46.9] vs $0.8 [$−0.3 to 11.1]; P < .001), and were located in counties with lower injury-related mortality (median [IQR]: 91.0 [71.0-106.0] vs 96.7 [81.1-116.7] per 100 000 residents; P = .03).
Table 1. Characteristics of Trauma Centers Designated Between 2014 and 2018, by For-Profit Status and Trauma Center Level.
| Trauma center characteristic | Trauma center level | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| I-V (All trauma centers) | I-II (With highest capacity) | III-V (With limited capacity) | |||||||
| For profit | Not for profit | P value | For profit | Not for profit | P value | For profit | Not for profit | P value | |
| Designated between 2014 and 2018, No. | 76 | 355 | NA | 13 | 45 | NA | 63 | 310 | NA |
| Charitability ratio, median (IQR)a | 0.04 (0.005-0.06) | 0.007 (0.003-0.01) | <.001 | 0.06 (0.04-0.09) | 0.01 (0.005-0.016) | <.001 | 0.02 (0.003-0.05) | 0.006 (0.003-0.01) | <.001 |
| Net income, median (IQR), in millions, $ | 13.5 (1.3-46.9) | 0.8 (−0.3-11.1) | <.001 | 67.0 (33.8-75.9) | 33.1 (40.9-74.4) | .15 | 6.2 (0.5-32.7) | 0.7 (−0.4-6.04) | <.001 |
| Injury-related mortality rate, median (IQR)b | 91.0 (71.0-106.0) | 96.7 (81.1-116.7) | .03 | 80.7 (70.3-93.7) | 77.7 (65.2-93.7) | .76 | 94.3 (73.5-107.8) | 98.9 (82.5-119.5) | .03 |
| County average household income, median (IQR), in thousands, $ | 67.0 (56.3-74.0) | 66.8 (58.1-73.2) | .90 | 71.7 (57.5-79.2) | 76.6 (65.5-88.3) | .31 | 66.0 (56.3-73.4) | 65.4 (57.0-71.2) | .65 |
| Ground transport time to existing trauma center, mean (SD), min | 20.1 (12.7) | 29.3 (15.6) | <.001 | 18.9 (11.2) | 20.9 (14.9) | .62 | 20.3 (13.1) | 30.7 (15.4) | <.001 |
| Ground transport time to existing trauma center, of same category, mean (SD), minc | 21.3 (13.0) | 29.6 (15.7) | <.001 | 22.2 (13.2) | 20.4 (14.9) | .69 | 21.1 (13.1) | 31.3 (15.3) | <.001 |
Abbreviation: NA, not applicable.
Charitability ratio is the ratio of hospital income spent on charitable care relative to total hospital expenses.
Injury-related mortality is the mean injury-related deaths per 100 000 residents in the county per year.
Level I-II or level III-V trauma center.
Seventy trauma centers were designated as greater than 60 minutes from an existing trauma center; most were not-for-profit (n= 66 [94%]) and level III-V centers (n = 64 [91%]). There were 361 newly designated trauma centers within 60 minutes of an existing trauma center. Within this radius, for-profit trauma centers had shorter ground transport time to an existing trauma center compared with not-for-profit centers (mean [SD]: 20.1 [12.7] minutes vs 29.3 [15.6] minutes; P < .001). Multivariable regression found for-profit status was associated with shorter ground transport time to any existing trauma center (linear regression coefficient, −7.27; SE, 1.89; P < .001) and trauma center of the same category (linear regression coefficient, −5.98; SE, 2.09; P = .005) (Table 2).
Table 2. Multivariable Linear Regression Analysis of Ground Transport Time From Newly Designated Trauma Centers to Existing Trauma Centersa.
| Trauma center variable | Coefficient (SE) | P value |
|---|---|---|
| Trauma centers of any category | ||
| Intercept | 8.05 (3.12) | .01 |
| State designated trauma level I-II (vs III-V)b | 4.57 (2.19) | <.001 |
| Injury-related death rate (deaths/100 000) | 0.17 (0.03) | <.001 |
| For-profit status (vs not-for-profit) | −7.27 (1.89) | <.001 |
| Trauma centers of the same category | ||
| Intercept | 9.02 (3.39) | .008 |
| State designated trauma level I-II (vs III-V)b | 2.76 (0.89) | .07 |
| Injury-related death rate (deaths/100 000) | 0.17 (0.03) | <.001 |
| For-profit status (vs not-for-profit) | −5.98 (2.09) | .005 |
Distance to existing trauma centers was assessed as ground transportation time in minutes. A geospatial analysis tool (ArcGIS version 10.8.2; ESRI) computed ground transport times between each trauma center newly designated between 2014 and 2018 and the nearest existing trauma center (by ground transport time) designated prior to 2014.
State designated trauma level was treated as a categorical variable (I-II [with highest capacity] and III-V [with limited capacity]).
Discussion
Between 2014 and 2018, compared with not-for-profit hospitals, for-profit hospitals gained trauma center designation in regions with lower injury-related mortality burden and in proximity to existing trauma centers. Most newly designated trauma centers outside a 60-minute radius from an existing trauma center were not-for-profit hospitals. In concordance with prior studies, for-profit trauma centers had higher average charitability ratios but were more profitable.1,3 Our analysis is limited by use of surrogate markers for trauma care demand (injury-related mortality) and supply (trauma centers).
Trauma centers can be profitable and financial incentives may motivate trauma center designation. A recent study found for-profit centers charge higher trauma activation fees.4 Proliferation of trauma centers within 1 region could dilute trauma care volume at any individual center. Decreased trauma care volume has been associated with worse outcomes for injured patients.5 A critical need exists for a national trauma system to provide standardized oversight to ensure trauma centers are built where needed and mitigate overproliferation.6
eMethods
eReferences
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eMethods
eReferences
Data Sharing Statement