title: Understanding the risk factors of trauma center closures: do financial pressure and community characteristics matter?
abstract: OBJECTIVE
  We analyze whether hazard rates of shutting down trauma centers are higher due to financial pressures or in areas with vulnerable populations (such as minorities or the poor).
  
  
  METHODS
  This is a retrospective study of all hospitals with trauma center services in urban areas in the continental US between 1990 and 2005, identified from the American Hospital Association Annual Surveys. These data were linked with Medicare cost reports, and supplemented with other sources, including the Area Resource File. We analyze the hazard rates of trauma center closures among several dimensions of risk factors using discrete-time proportional hazard models.
  
  
  RESULTS
  The number of trauma center closures increased from 1990 to 2005, with a total of 339 during this period. The hazard rate of closing trauma centers in hospitals with a negative profit margin is 1.38 times higher than those hospitals without the negative profit margin (P < 0.01). Hospitals receiving more generous Medicare reimbursements face a lower hazard of shutting down trauma centers (ratio: 0.58, P < 0.01) than those receiving below average reimbursement. Hospitals in areas with higher health maintenance organizations penetration face a higher hazard of trauma center closure (ratio: 2.06, P < 0.01). Finally, hospitals in areas with higher shares of minorities face a higher risk of trauma center closure (ratio: 1.69, P < 0.01). Medicaid load and uninsured populations, however, are not risk factors for higher rates of closure after we control for other financial and community characteristics.
  
  
  CONCLUSIONS
  Our findings give an indication on how the current proposals to cut public spending could exacerbate the trauma closure particularly among areas with high shares of minorities. In addition, given the negative effect of health maintenance organizations on trauma center survival, the growth of Medicaid managed care population should be monitored. Finally, high shares of Medicaid or uninsurance by themselves are not independent risk factors for higher closure as long as financial pressures are mitigated. Targeted policy interventions and further research on the causes, are needed to address these systems-level disparities.
authors.affiliation: Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, CA 93943, USA. yshen@nps.edu
authors.forename: Yu-Chu
authors.initials: YC
authors.lastname: Shen
authors.forename: Renee Y
authors.initials: RY
authors.lastname: Hsia
authors.forename: Kristen
authors.initials: K
authors.lastname: Kuzma
mesh_terms: D006271:Health Facility Closure / Q000639:trends*; D006278:Medicare / Q000191:economics; D016016:Proportional Hazards Models; D012111:Residence Characteristics; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D014193:Trauma Centers / Q000191:economics* / Q000458:organization & administration / Q000600:supply & distribution; D014481:United States; D014505:Urban Population
references.citation: Med Care. 2008 Feb;46(2):192-9
references.pmid: 18219248
references.citation: J Trauma. 2001 Aug;51(2):301-7
references.pmid: 11493788
references.citation: J Trauma. 1996 Nov;41(5):876-85
references.pmid: 8913220
references.citation: J Trauma. 1988 Jul;28(7):931-8
references.pmid: 3398091
references.citation: Ann Emerg Med. 2008 Mar;51(3):265-74, 274.e1-5
references.pmid: 17997503
references.citation: Health Econ. 2009 Mar;18(3):305-20
references.pmid: 18566971
references.citation: Am J Surg. 2004 Jan;187(1):7-13
references.pmid: 14706578
references.citation: J Health Econ. 1997 Aug;16(4):453-81
references.pmid: 10169101
references.citation: JAMA. 2005 Jun 1;293(21):2626-33
references.pmid: 15928284
references.citation: J Trauma. 1991 Jul;31(7):920-5; discussion 925-6
references.pmid: 2072430
references.citation: Am J Surg. 1999 May;177(5):371-4
references.pmid: 10365872
references.citation: Health Aff (Millwood). 2000 Jul-Aug;19(4):222-32
references.pmid: 10916978
references.citation: J Trauma. 1995 Jan;38(1):103-10
references.pmid: 7745638
references.citation: N Engl J Med. 2006 Jan 26;354(4):366-78
references.pmid: 16436768
references.citation: Med Care. 1978 Feb;16(2):140-51
references.pmid: 628234
references.citation: Health Aff (Millwood). 2004 Jan-Jun;Suppl Web Exclusives:W4-374-84
references.pmid: 15451955
references.citation: J Trauma. 1999 Sep;47(3 Suppl):S34-41
references.pmid: 10496608
references.citation: JAMA. 2000 Apr 19;283(15):1990-4
references.pmid: 10789667
references.citation: J Trauma. 2006 Feb;60(2):371-8; discussion 378
references.pmid: 16508498
references.citation: J Trauma. 1994 Jun;36(6):835-44; discussion 844-6
references.pmid: 8015006
references.citation: Med Care. 1981 May;19(5):547-66
references.pmid: 6971974
references.citation: J Spinal Cord Med. 2006;29(1):17-25
references.pmid: 16572561
references.citation: Am J Surg. 1987 Jul;154(1):79-87
references.pmid: 3605516
references.citation: Health Aff (Millwood). 2001 Jul-Aug;20(4):159-68
references.pmid: 11463072
references.citation: Rand J Econ. 2002 Autumn;33(3):524-48
references.pmid: 12585306
references.citation: J Trauma. 1992 Oct;33(4):539-46; discussion 546-7
references.pmid: 1433400
references.citation: Med Clin North Am. 2005 Sep;89(5):945-8, 947
references.pmid: 16129106
references.citation: J Trauma. 2007 Dec;63(6):1263-8; discussion 1268-70
references.pmid: 18212648
references.citation: JAMA. 2003 Mar 26;289(12):1515-22
references.pmid: 12672768
references.citation: JAMA. 1995 Feb 1;273(5):395-401
references.pmid: 7823385
references.citation: Health Aff (Millwood). 2005 Jul-Aug;24(4):1047-56
references.pmid: 16012145
references.citation: J Health Econ. 2003 Mar;22(2):243-69
references.pmid: 12606145
references.citation: Health Serv Res. 2001 Apr;36(1 Pt 2):191-221
references.pmid: 11327174
references.citation: Biometrics. 1978 Mar;34(1):57-67
references.pmid: 630037