title: Geographic Distribution of Trauma Burden, Mortality, and Services in the United States: Does Availability Correspond to Patient Need?
abstract: The association between the need for trauma care and trauma services has not been characterized previously. We compared the distribution of trauma admissions with state-level availability of trauma centers (TCs), surgical critical care (SCC) providers, and SCC fellowships, and assessed the association between trauma care provision and state-level trauma mortality.
  
  
  
  We obtained 2013 state-level data on trauma admissions, TCs, SCC providers, SCC fellowship positions, per-capita income, population size, and age-adjusted mortality rates. Normalized densities (per million population [PMP]) were calculated and generalized linear models were used to test associations between provision of trauma services (higher-level TCs, SCC providers, and SCC fellowship positions) and trauma burden, per-capita income, and age-adjusted mortality rates.
  
  
  
  There were 1,345,024 trauma admissions (4,250 PMP), 2,496 SCC providers (7.89 PMP), and 1,987 TCs across the country, of which 521 were Level I or II (1.65 PMP). There was considerable variation between the top 5 and bottom 5 states in terms of Level I/Level II TCs and SCC surgeon availability (approximately 8.0/1.0), despite showing less variation in trauma admission density (1.5/1.0). Distribution of trauma admissions was positively associated with SCC provider density and age-adjusted trauma mortality (p ≤ 0.001), and inversely associated with per-capita income (p < 0.001). Age-adjusted mortality was inversely associated with the number of SCC providers PMP. For every additional SCC provider PMP, there was a decrease of 618 deaths per year.
  
  
  
  There is an inequitable distribution of trauma services across the US. Increases in the density of SCC providers are associated with decreases in mortality. There was no association between density of trauma admissions and location of Level I/Level II TCs. In the wake of efforts to regionalize TCs, additional efforts are needed to address disparities in the provision of quality care to trauma patients.
authors.affiliation: Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA. Electronic address: arturo.riosdiaz@jefferson.edu.
authors.forename: Arturo J
authors.initials: AJ
authors.lastname: Rios-Diaz
authors.affiliation: Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.
authors.forename: David
authors.initials: D
authors.lastname: Metcalfe
authors.affiliation: Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA.
authors.forename: Olubode A
authors.initials: OA
authors.lastname: Olufajo
authors.affiliation: Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA.
authors.forename: Cheryl K
authors.initials: CK
authors.lastname: Zogg
authors.affiliation: Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Brian
authors.initials: B
authors.lastname: Yorkgitis
authors.affiliation: Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Mansher
authors.initials: M
authors.lastname: Singh
authors.affiliation: Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.affiliation: Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Trauma, Burn and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Harvard TH Chan School of Public Health, Boston, MA.
authors.forename: Ali
authors.initials: A
authors.lastname: Salim
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D017281:Cost of Illness; D003422:Critical Care / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D014193:Trauma Centers / Q000706:statistics & numerical data / Q000600:supply & distribution*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D000078329:Workforce; D014947:Wounds and Injuries / Q000453:epidemiology* / Q000628:therapy*; D055815:Young Adult