title: The association of trauma center closures with increased inpatient mortality for injured patients.
abstract: BACKGROUND
  Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed.
  
  
  METHODS
  We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure.
  
  
  RESULTS
  The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51).
  
  
  CONCLUSIONS
  Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure.
  
  
  METHODS
  Prognostic and epidemiologic, level III.
authors.affiliation: From the Departments of Emergency Medicine (R.Y.H.), Medicine (J.M.), and Epidemiology and Biostatistics (C.M.), University of California, San Francisco; and Ecologic Institute (T.S.), San Mateo, California; Department of Surgery (M.C.), Northwestern University, Chicago, Illinois; and RAND (A.L.K.), Washington, District of Columbia.
authors.forename: Renee Y
authors.initials: RY
authors.lastname: Hsia
authors.forename: Tanja
authors.initials: T
authors.lastname: Srebotnjak
authors.forename: Judith
authors.initials: J
authors.lastname: Maselli
authors.forename: Marie
authors.initials: M
authors.lastname: Crandall
authors.forename: Charles
authors.initials: C
authors.lastname: McCulloch
authors.forename: Arthur L
authors.initials: AL
authors.lastname: Kellermann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002140:California / Q000453:epidemiology; D016001:Confidence Intervals; D005260:Female; D006271:Health Facility Closure / Q000639:trends*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007297:Inpatients; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012189:Retrospective Studies; D014193:Trauma Centers / Q000458:organization & administration*; D014947:Wounds and Injuries / Q000401:mortality* / Q000628:therapy; D055815:Young Adult