'Unnecessary' Trauma Centers Could Harm Care Networks

As hospitals cash in on the lucrative fees that come with trauma center status, unregulated growth is diluting patient volumes and doing more harm than good, research shows.

The lightly regulated and poorly coordinated designation for trauma care centers in some states has created an oversaturated system in some regions that dilutes patient volumes and leads to worse outcomes, according to a study in the Annals of Surgery.

"It takes about three years for the impact of increased patient volume to translate into improved patient outcomes," said lead author Joshua Brown, MD, a research fellow in the Division of Trauma and General Surgery in the University of Pittsburgh Medical Center School of Medicine.

"Siphoning of patients through unregulated growth of unnecessary trauma centers can have a profound detrimental impact on patients that isn't immediately obvious. Before designating a new trauma center, serious consideration should be given to how that designation will affect patient volumes over time at trauma centers throughout the region," Brown said.

Brown and his colleagues at UPMC examined records of nearly 840,000 seriously injured patients seen at 287 trauma centers between 2000 and 2012.

The centers averaged 247 severely injured patients per year, and 90% of the cases involved blunt injury. The researchers compared the expected death rate for each center to the center's actual death rate, if everything involving each trauma patient's care had gone perfectly.

Each 1% increase in patient volume at a trauma center was associated with 73% better odds of a patient surviving. Conversely, each 1% decrease in volume was linked to a two-fold worsening in the odds of a patient surviving.

With too many trauma centers, Brown said, "you run the risk of diluting the volume. We saw on balance that when a trauma center increased volumes, you saw an improvement in outcomes. When centers decreased their volume, the worsening of their outcomes was actually worse than the benefit gained from another center increasing their volume. So, diluting that could potentially produce a net negative benefit in the overall system."

Brown says there has been a significant increase in the numbers of hospitals that have sought trauma center status, particularly in Texas and Florida. 

"The pendulum has swung. In the 1990s and the early 2000s being a trauma center was a money-losing prospect. So, the healthcare system has created some incentives to ensure access to trauma center care," he said.

Financial Incentives and Trauma Centers

"Now a lot of states will pay fairly large trauma team activation fees. It has created an incentive where trauma centers can make money by collecting these fees. So a number of these smaller Level 2 and 3 trauma centers have been popping up in some areas in the South and that has become a problem for the larger academic trauma centers in those areas."

Brown says it's time to re-evaluate and better coordinate how trauma center designations are awarded with an eye on the effect for the entire care delivery system in a particular region.

"The way it has been done is a hospital says 'we want to be a trauma center' and there are a number of boxes they need to check. If the county goes along with this most of the time the state or the accrediting agency will say 'you can be a trauma center,'" Brown said.

"We should shift that perspective to saying 'what is the overall impact on the trauma system that you are going to be part of? Is there a population center that will support a new trauma center, or are you going to be pulling volume from other trauma centers that could develop into a net negative impact on the overall trauma system?'" Brown said. "Taking the perspective on how the whole trauma system is impacted is the way to go."

While designating trauma center status should be a better regulated process, Brown says it's a job that should remain primarily in the hands of state and local governments.

"It needs to be done on a fairly local level," he said, "but support in terms of funding and legislation at the federal level can push some of these accreditation agencies in that direction to take this kind of perspective for the way they develop their trauma systems."