Influx of trauma centers could hurt, not help
More trauma centers means better medical care for people who suffer serious injuries, right?
Not so much, University of Pittsburgh researchers say.
Accredited trauma centers are designed to treat people with the most serious injuries, but too many trauma centers in a given area dilutes admissions at any one center, dramatically reducing a patient’s odds of surviving, the University of Pittsburgh School of Medicine study found.
Think of it this way: for every 1 percent fewer patients treated at a trauma center, the chances of survival dropped by two-fold, according to the study by research fellow and physician Joshua Brown and others.
And every 1 percent increase in trauma center volume was associated with a 73 percent better odds of patient survival.
“What surprised us, and we looked at it both ways, was the net effect was worse with the lower numbers,” Dr. Brown said. “The solution is really more of a shift in how we design trauma systems, as it functions as a whole.”
The Pitt study comes amid a boom in the number of trauma centers statewide, with 17 hospitals, mostly in central and eastern Pennsylvania, seeking accreditation. The interest in accreditation coincides with the number of people without health insurance declining, due to the implementation of the Affordable Care Act.
The more operations performed, the better the surgeon, according to an axiom applied to many kinds of medical care. But trauma care is different because it requires an institutional commitment, beyond the individual doctor’s experience, which can erode when the number of cases decline, Dr. Brown said. Unlike emergency rooms, trauma centers are required to have surgeons and other specialists immediately available to treat people who have been seriously injured in falls or shootings or car crashes.
For the study, the medical records were reviewed for nearly 840,000 seriously injured patients who were treated at 287 trauma centers between 2000 and 2012. The centers averaged 247 severely injured patients per year and 90 percent of the cases involved blunt trauma.
The researchers compared the expected death rate at each center, had everything involving care had gone perfectly, to the trauma center’s actual death rate. They found that patient volume was linked to how well the patient did after treatment.
“Granting unnecessary designation to a trauma center in a region that doesn’t have the patient volume to support it not only hurts patient outcomes at that new center, but it will likely lead to a decline in patient outcomes at other nearby centers,” senior study author and physician Jason Sperry said in a prepared statement.
The Pitt study was done as the number of hospitals seeking trauma center status is booming in Pennsylvania. A dozen hospitals are seeking accreditation as level four trauma centers, a designation created in 2008, while four hospitals are seeking level two accreditation and the 233-bed Meadville Medical Center in Crawford County is seeking level three accreditation.
Pennsylvania has 34 trauma centers, including four in Allegheny County alone.
“There is a lot of interest” in accreditation, said Pennsylvania Trauma Systems Foundation executive director Juliet Altenburg. “We do not have a needs assessment requirement in Pennsylvania and could be at risk for trauma centers to develop close to each other.”
Problems surface when trauma centers are opened for economic rather than medical reasons, according to a 2014 statement by the committee on trauma of the American College of Surgeons, a nonprofit professional group. “The problem arises when a lead agency passively allows health care organizations and hospital groups to establish new trauma centers in areas that yield an economic advantage while ignoring areas of true need.”
And trauma centers don’t come cheap. A 2009 survey by the Hospital and Healthsystem Association of Pennsylvania, a Harrisburg-based trade group, found that the average trauma center spent $1.25 million a year for required physician specialists, technology, training and education to meet accreditation requirements.
But the economics of running a trauma center may be improving. Obamacare means that far fewer people are admitted to the hospital without insurance, replacing the population of uninsured that once comprised the mainstay of trauma patients, experts say. In addition, trauma centers can charge an “activation fee” to cover the costs of alerting medical specialists.
Pennsylvania doesn’t restrict where level one and two trauma centers are located, where the most advanced care is provided, and other levels are limited only by geographic limits that are outlined in state legislation, Ms. Altenburg said.
“In an ideal world, we would like to see a needs assessment process, but we’re stifled by the legislation,” she said. “Absolutely, it’s the right thing to do.”