Pediatric Trauma Center Access, Regional Injury Burden, and Socioeconomic Disadvantage

Abstract

This cross-sectional study assesses whether populations in socioeconomically disadvantaged regions in the US lack timely access to pediatric trauma centers.

Traumatic injury is the leading cause of pediatric mortality in the US.¹ Prompt access to pediatric trauma centers (PTCs) is a key determinant of outcomes, yet disparities in access persist.² We evaluated contemporary nationwide disparities in PTC access, hypothesizing that pediatric patients (aged <18 years) in socioeconomically disadvantaged regions lack timely access.

Methods

Detailed study method information is available in the eMethods in Supplement 1. According to the Common Rule, this cross-sectional study was exempt from ethics review because it was not human participant research. This study followed the STROBE reporting guideline.

Geolocations of American College of Surgeons–verified level 1 to 3 PTCs were obtained using 2019 Trauma Exchange Information Program data. We assumed site of injury to be the population centroid of each Census Block Group (BG) using the 2019 American-Community-Survey. Air travel time was determined by dividing the total flight path by air ambulance velocity. For ground travel time, Valhalla (Mapzen) was used to compute the optimal driving route from each BG to its nearest PTC. Air and ground travel times accounted for nationally representative call-to-takeoff, arrival, and on-scene times.^3,4

State-specific fatal and total pediatric injuries in 2019 were obtained using Web-based Injury Statistics Query and Reporting System and Healthcare Cost and Utilization Project FastStat. BG-level injuries were estimated by multiplying state-level injuries by the ratio of BG-to-state pediatric population. We estimated and plotted the proportion of national injuries occurring among BGs within 60 minutes of a PTC for each state.

Using the 2020 Neighborhood Atlas dataset, we identified the national percentile of each BG Area Deprivation Index (ADI). Mann-Whitney U test was used to analyze the difference in median ADI level between BGs with and without 60-minute access to a PTC (level 1, level 1-3). After grouping BGs by ADI percentile, Jonckheere-Terpstra test was used to evaluate the trend between median travel time to a PTC and ADI percentile group. Two-sided P < .05 indicated statistical significance. Data were analyzed between July and August 2023 using Python 3.11.0 (Python Software Foundation).

Results

The 2019 US pediatric population was 73 088 675 individuals, with 5 215 243 nonfatal and 8875 fatal injuries. Nationally, 66.8% and 77.4% of fatal pediatric injuries were estimated to occur in BGs within 60 minutes of a level 1 and level 1 to 3 PTC, respectively. For total pediatric injuries, 72.9% and 83.4% were estimated to occur in BGs within 60 minutes of a level 1 and level 1 to 3 PTC, respectively.

Many southern states bore a higher national fatal injury burden despite a lower proportion of their populations having 60-minute access to a PTC (Figure 1). The difference in median ADI percentile among BGs with and without 60-minute access to a level 1 PTC was 27.0 (43.0 vs 70.0; P < .001) and level 1-3 PTCs was 25.7 (46.3 vs 72.0; P < .001). Trends between ADI percentiles and travel time to the nearest level 1 and level 1 to 3 PTC were statistically significant (Figure 2).

Figure 1. Percent of National Fatal Injury Burden vs Percent of Pediatric Population With 60-Minute Access to a Pediatric Trauma Center (PTC).

States are categorized by US Census Bureau regions. Gray dotted lines indicate medians (eg, top right quadrant denotes states with better access to PTC and higher injury burden, bottom right quadrant denotes states with poorer access to PTC and higher injury burden).

Figure 2. Travel Time to Level 1 and Levels 1 to 3 Pediatric Trauma Centers (PTCs) Among Census Block Groups (BGs).

For Area Deprivation Index (ADI), the range from 0 to 100 percentile indicates from least disadvantaged to most disadvantaged. The BGs were grouped by ADI percentile at 5% intervals. All comparisons are statistically significant at P < .001. The whiskers indicate 95% CIs.

Discussion

We found that some states with high fatal pediatric injury burden disproportionately lack timely PTC access and observed increased travel time to PTCs in socioeconomically disadvantaged regions. Treatment at PTCs has been associated with lower mortality (particularly for those aged ≤16 years),⁵ whereas many adult trauma centers have suboptimal readiness to manage injuries in children.⁶

A limitation is that this study was unable to capture intrastate variations in injury burden. Future studies should identify strategies to optimize geographic distribution of PTCs and maximize pediatric readiness among all trauma centers to mitigate socioeconomic access disparities.

Supplement 1.

eMethods. Air Travel Time, Ground Travel Time, Fatal and Nonfatal Injuries, and Area Deprivation Index

eReferences

Supplement 2.

Data Sharing Statement