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Regional variations in cost of trauma care in the United States: Who is paying more?

Obirieze, Augustine C. MBBS, MPH; Gaskin, Darrell J. PhD; Villegas, Cassandra V. MD, MPH; Bowman, Stephen M. PhD; Schneider, Eric B. PhD; Oyetunji, Tolulope A. MD, MPH; Haut, Elliott R. MD; Efron, David T. MD; Cornwell, Edward E. III MD; Haider, Adil H. MD, MPH

Journal of Trauma and Acute Care Surgery: August 2012 - Volume 73 - Issue 2 - p 516–522
doi: 10.1097/TA.0b013e31825132a0

BACKGROUND The study of regional variations in costs of care has been used to identify areas of savings for several diseases and conditions. This study investigates similar potential regional differences in the cost of adult trauma care using an all-payer, nationally representative sample.

METHODS Trauma patients aged 18 to 64 years in the 2006–2008 Nationwide Inpatient Sample were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes. Those with isolated diagnoses for five index conditions (ICs): blunt splenic injury, liver injury, tibia fracture, moderate traumatic brain injury, and pneumothorax/hemothorax were selected. Cost was estimated from charges using a cost-to-charge ratio. Generalized linear modeling was used to compare the mean cost for treating these ICs between US regions (Northeast, South, Midwest, and West), adjusting for hospital factors (size, teaching status, and location), patient demographics, injury severity, length of stay, Charlson comorbidity index, local wage index, and payer. Relative mean cost (RC) was calculated using Northeast as the reference, and sampling weights were applied to obtain regional estimates. Differences in adjusted mortality between regions were also assessed.

RESULTS Adjusted relative costs were estimated for 62,678 patients (South: 28,536; West: 12,975; Midwest: 11,450; and Northeast: 9,717). Mean costs for liver injury were 22% higher in the Midwest compared with the Northeast (RC: 1.22; 95% confidence interval [CI]: 1.10–1.35). Similarly higher costs were seen with other regions and ICs (RC for blunt splenic injury in the South: 1.18; 95% CI: 1.07–1.31; RC for pneumothorax/hemothorax in the West: 1.31; 95% CI: 1.22–1.41). No differences in adjusted mortality by region were noted overall.

CONCLUSION Even after controlling for factors known to influence medical care cost, as well as controlling for geographic differences in pricing, significant regional differences exist in the cost of trauma care. Exploring these variations may assist in identifying potential areas for cost savings.

LEVEL OF EVIDENCE Economic analysis, level II.

From the Department of Surgery (A.C.O., T.A.O., E.E.C.), Outcomes Research Center, Howard University College of Medicine, Washington, DC; Department of Health Policy and Management (D.J.G., S.M.B.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; and Department of Surgery (C.V.V., E.B.S., E.R.H., D.T.E., A.H.H.), Center for Surgical Trials and Outcomes Research, Johns Hopkins School of Medicine, Baltimore, Maryland.

Submitted: December 10, 2011, Revised: March 10, 2012, Accepted: February 20, 2012.

Supported by National Institutes of Health/NIGMS K23GM093112-01; American College of Surgeons C. James Carrico Fellowship for the study of Trauma and Critical Care.

Presented at 25th annual meeting of the Eastern Association for the Surgery of Trauma, January 10–14, 2012, Lake Buena Vista, Florida.

Address for reprints: Adil H. Haider, MD, MPH, FACS, Department of Surgery, Center for Surgery Trials and Outcomes Research, Johns Hopkins School of Medicine, 600 N Wolfe St, Halsted 610, Baltimore, MD 21212; email:

© 2012 Lippincott Williams & Wilkins, Inc.