Geographic distribution of trauma burden, mortality and services in the United States: does availability correspond to patient need?

Background The association between the need of trauma care and trauma services has not previously been characterized. We compared the distribution of trauma admissions to state-level availability of trauma centers (TCs), Surgical Critical Care (SCC) providers, and SCC fellowships; and assessed the association between trauma-care provision and state-level trauma mortality. Study Design We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality-rates. Normalized densities (per-million-population, PMP) were calculated and generalized linear models used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per capita income, and age-adjusted mortality-rates. Results There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP) and 1,987 TCs across the country, of which 521 were Level 1 or 2 (1.65 PMP). There was substantial variation between the top-five vs. bottom-five states in terms of L1/L2TCs and SCC surgeon availability (~8.0:1.0), despite showing less variation in trauma admissions density (1.5:1.0). The distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p<0.001), and inversely associated with per-capita income (p<0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC providers PMP, there was a decrease of 618 deaths/year Conclusions There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and the location of L1/L2TCs. In the wake of efforts to regionalize TCs, further efforts are needed to address disparities in the provision of quality care to trauma patients.