It's known as “trauma drama” in Florida. In Chicago, it's a “trauma desert.” In states from New Mexico to South Dakota, it's called the “trauma problem.” No matter how it's phrased, the label signifies the same public allegation. Trauma centers — presently increasing at quite a clip — often aren't created where they are most needed.
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The potential for profitability appears to be playing a role in the growth spurt, akin to the way revenue streams were generated by cardiac catheterization labs that add the capability for percutaneous coronary intervention, according to emergency physicians who are making trauma care the basis of their academic research.
“There is often a drive to open trauma centers — or any profit-making service line — because hospitals have identified it as a business strategy to either retain or attract new patients,” commented Renee Hsia, MD, who has been tracking the closure of trauma centers and emergency departments nationally and in her home state of California. (J Trauma 2010;68:217.) Data have shown that at least 20 percent of the population currently has to travel longer than ever before to receive appropriate trauma care.
These are generally patients less likely to have private insurance and more likely to be lower on the socioeconomic ladder. “I would guarantee you that those algorithms to determine a new hospital location are not based on need alone, [that] one of the most important factors is the patient-payer mix surrounding that area,” noted Dr. Hsia, an associate professor of clinical emergency medicine at the University of California, San Francisco. Few regulations, state or federal, force hospitals to open in an area based on need, she pointed out.
That, however, hasn't stopped the call for need-based trauma care from becoming one of this year's hot-button health issues, dividing legislatures and inciting lawsuits. A public demonstration in Chicago last fall pitted activists from the south side of the city against the University of Chicago. Protesters marched on the medical center, carrying mock coffins while calling for adult trauma care to be instituted there. They chanted, “How can you ignore while we're dying at your door?” The public outcry prompted the local media to dub the area a “trauma desert.” Such sentiment also spurred U.S. Rep. Bobby Rush (D-IL) to propose a new law for funding trauma care that would transform the urban “desert.”
The controversy in Florida erupted when HCA, a for-profit health care company, announced plans to open new trauma centers in the sunshine state. Four hospitals, claiming a likely detriment to their bottom line, filed suit, according to the Sept. 30 Miami Herald. The litigation is still in the courts. The Florida state legislature also started looking into current standards on trauma care, and by mid-January editorials — three of them appearing on the same day — began showing up in blogs and newspapers airing different views: one was from a sheriff's office calling for more trauma centers; another was a trauma surgeon arguing against any proposed relaxation of regulations; and the third was from the Florida Committee on Trauma opposed the possible deregulation of trauma care, an idea being bandied about by state legislators. (www.floridavoices.com.) Recurring headlines on coverage of the issue featured the same two-word descriptor: trauma drama.
Darwin Noel Ang, MD, PhD, the director of research for the University of South Florida-HCA Trauma Network, said HCA centers “have been built in response to an existing need. No one can dispute the fact that we are saving lives,” he stated, referring to figures from the network. An aggregate increase of 2,338 trauma patients was seen at state-approved trauma centers in 2012 compared with 2011, an overall increase of 4.8 percent.
“We develop trauma centers in places where the number of existing trauma centers simply has not kept pace with explosive population and traffic growth, leaving residents with traumatic injuries vulnerable at a time when minutes are the difference between life and death,” Dr. Ang said, adding that “traumatic injuries are a leading cause of death, and speed and quality of care are the two most important factors in determining whether a trauma patient survives.”
More than 200 trauma centers have opened in the past five years in more than 20 states, according to data collected by Kaiser Health News. Most of the newer centers reportedly are Level III, IV, or V where patients generally are stabilized for transfer. That can make quite a difference in terms of dollars.
Trauma and acute care surgery at one Level I trauma center, for example, were found to have the highest costs. But a closer look revealed that per-patient intensive-care costs comprised the highest single category, and non-trauma patients who required critical care had the highest per-patient expense. Proportionally and comparatively, trauma care costs less. In fact, stays in intensive care units were what drove up expenditures. (J Am Coll Surg 2013;216:607.)
The issue is also complicated by the fact that economic studies tend to measure trauma expenditures in ways that try to assess outcomes, but outcome metrics can be highly variable. Traditionally, cost-effectiveness is an examination of cost for one approach compared with the consequences of other solutions, a tough call to make when lives are at stake, as several investigators noted. (Economic Aspects of Trauma Care. Germany: Springer-Verlag; 2011.)
Nor are cost-benefit assessments any easier to perform in trauma care, for much the same reason: How is the price of survival to be determined? Some economists have proposed evaluating survival in terms of quality of life or return to productivity, an idea that has not caught on in medicine. Neither has cost-utility analysis. It focuses on how much disability accrues from injury even after surgical intervention or health that is restored post-treatment.
And, when for-profit hospitals surround nonprofit ones, the latter begin behaving a lot like the former. (J Health Econ 2009;28:924.) Still, this effect shouldn't be used to forecast the delivery of clinical care. For-profit hospitals routinely provide fewer unprofitable services compared with non-profit ones, and many are services disproportionately needed by the poor, according to Jill Horwitz, JD, PhD, a professor of law at the University of California, Los Angeles, who has made payer mix of hospitals her primary research. One conclusion she has reached after studying this “spillover” effect of for-profit health care institutions on non-profit ones in the same treatment area, is that “all of us, those with insurance or not, must trust health care organizations to give us high quality health care, regardless of profits.”
So how does lack of access to trauma care typically occur? Emergency medicine researchers at the University of Pennsylvania have documented that communities with the “trauma problem,” as some public health officials are calling it, are more rural, with disproportionately higher levels of poverty and uninsured individuals. Using death rates by injury as a measure, the Penn researchers have demonstrated that urban counties are proving safer than their rural counterparts: death risk from severe injury increases steadily by the degree to which counties can be characterized as rural. (Ann Emerg Med 2013;62:408.)
The results of another recent study documenting this are scheduled to be presented at the Society for Academic Emergency Medicine annual meeting this spring. Lead researcher Ariel Bowman, MD, observed that although there has been a jump in the number of designated trauma centers, “care has to be taken to ensure that the placement of such centers actually expands the access of the existing trauma system.”
“It must be remembered that access alone does not guarantee or assure capacity,” she said. “Without thoughtful planning, new trauma centers run the risk of simply reinforcing existing disparities in access without addressing the needs of vulnerable populations.”
Another recent finding: some trauma figures have simply slipped through the cracks. Gun wounds have long been a reason for trauma care at some inner-city Level I centers. A retrospective review of all patients treated for gunshot wounds at University Hospital in Newark, NJ, from January 2000 to January 2011 shows they can be the reason for “escalating mortality and health care costs.” (J Trauma Acute Care Surg 2014;76:2.) The study found that significant numbers of gunshot wounds — nearly a fifth — had escaped the trauma registry. The authors explained that federal funding mechanisms for studies on gun injuries largely dried up in the mid-1990s, leading to a “lack of reliable data and obstacles to serious research.”
Yet firearm injuries have accounted for more than 15 percent of the trauma patients in the hospital's emergency department over the past three decades. This kind of wound largely affects young men, just as it has historically, but the incidence of wounds has changed. Multiple wounds were not as common in the past as they are now; the percentage of patients at the Newark hospital with three or more wounds from gunshots increased from 10 percent to 23 percent over the 12-year study period.
This is not the only study, however, to shed a different light on how trauma care is recorded — or not — in some instances. Missing from some economic analyses are patient factors, according to researchers from the University of Florida at Gainesville and Howard University in Washington, DC. Investigators from those institutions, among others, have shown using a national sample that unreimbursed trauma care is actually lower than that of overall medical care. (J Surg Res 2013;184:444.) They also demonstrated how geographic patterns of pricing affect payment. Even after controlling for factors known to influence the cost of this kind of medical care and for geographical differences in pricing, significant regional differences were found to exist in cost. (J Trauma Acute Care Surg 2012;73:516.)
Other studies have shown that factors such as fiscal management and medical expertise can make a difference in cost, too, and these variances can sometimes be seen on a hospital-by-hospital basis. That is one reason that regionalization has become a topic of trauma study over the past few years. Some of the results of these studies seem counterintuitive. Cost-effectiveness was linked in one study more favorably to patients with higher injury severity compared with those of lower injury status as well as to younger versus older patients. (J Trauma 2010;69:1.) That may be because regionalization has been shown to cut costs. New triage techniques, enhanced by telemedicine and other improved communication systems, have helped keep trauma care costs down regionally.
The Arkansas Trauma Communication Center, for instance, which is overseen by triage personnel, advises on transport, something that was previously left to EMS providers, who took patients to the nearest hospital. (”Arkansas Trauma System Update,” Dec. 17, 2012; http://1.usa.gov/1mDWowa.) This past year, Mississippi was singled out for its effective use of telemedicine, which assists trauma injury decision-making in relatively remote locations, including in the field. (“Rural Trauma Care,” Patient-Centered Outcomes Resource Institute; http://bit.ly/1aSZN54.)
The Patient Protection and Affordable Care Act authorizes $100 million in annual grants to help defray substantial uncompensated care costs, allocations that aim to advance the mission of trauma centers and to provide monetary relief for them. Yet these “sorely needed funds,” which could be used “to strengthen the regionalized system,” the same system that has shown so much promise in the past decade, have yet to be appropriated by Congress, according to a policy study led by Brent Eastman, MD, the immediate past president of the American College of Surgeons. (Health Aff 2013;32:2091.) He and many others have called for the federal government to make funding available for that purpose, as the debate over trauma care rolls on.
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