From 2001 to 2007, 69 million people in the US (24% of the population) had to travel farther to the nearest trauma center, with almost 16 million having to travel an additional 30 minutes or more. This deterioration in geographical access has been more acute in communities with high shares of poor, uninsured, and African American populations.
Our findings reveal that rural communities have a higher risk of experiencing declines in geographical access than urban communities. This is concerning because, at baseline, residents in these areas already must travel farther to reach their nearest trauma center. As our results and prior studies demonstrate, rural communities suffer from a lack of generalist and specialist physician presence.(33
) These findings are in the context of an even worsening situation for patients needing emergency care in rural areas. In fact, 11.3% of rural hospitals closed from 1990–1999, while the number of emergency visits to rural hospitals rose over 20%.(34
Despite the emphasis on decreasing disparities in the healthcare system, we show that geographical access to trauma centers, measured by driving times, has not improved. Indeed, geographic access to these services has deteriorated for vulnerable populations. Trauma centers provide expensive care to higher proportions of vulnerable populations and have lower cost recovery when compared with hospitals without trauma centers.(8
) Because urban and suburban trauma centers are usually considered unprofitable, they often depend on public financing mechanisms to survive. There are no federal or state mandates for trauma centers or their locations.
In times of increasing economic hardship, it is possible that some trauma center closures might be due to coordination and consolidation of health care centers in order to improve efficiency and patient outcomes. We therefore cannot assume that closures are uniformly harmful to the community. Optimizing patient outcomes may therefore require better coordination of trauma services at the regional level.(37
) The purpose of this analysis is to document how geographic access to trauma centers has changed over time, with the understanding that financial pressures and other documented market factors are predictors of trauma center survival.(10
Trauma center closures are less often predicated on purposeful evaluation of health outcomes and desire to shut down poor-performers, and more often the result of financial hardships and an inability to offer a wide selection of services (7
) especially in communities that need it most. It is important to note that a decreased number of trauma centers does not imply poorer care for these populations, depending on the ability of the system to triage and transport (including aeromedical) patients to the most appropriate facilities.
Our findings provide evidence that poor and African American communities and rural dwellers are disproportionately affected by deteriorating trauma care access. Over the past 2 decades, disparities in health indicators such as mortality from traumatic injuries have worsened for vulnerable populations including black, Hispanic and low-income groups.(39
) Deteriorating access to emergency care, such as trauma systems, could create systemic disparities of care for vulnerable patients.(40
We do not attempt to draw causal relationships but only to substantiate concerns about associations of increased trauma center closures in vulnerable communities and to alert policymakers about them. Potential policy implications could include bolstering financing mechanisms, such as reimbursement for injuries, specifically for hospitals that see a larger proportion of African American, uninsured, or poor populations. For rural areas, it is critical that agreements between existing trauma centers be created to potentially increase access to aeromedical transport.
It is important to build upon this research, which looks at the changes in geographic placement of trauma centers, to study how trauma center closures affect patient outcomes. The overall goal is to progress toward a healthcare system that provides equitable, competent, cost-effective acute care. While this does not equate to establishing a trauma center in every city, it does require careful examination of the effects of closures on individual communities -not simply as dictated by market forces or pressures. The goal of our research is to provide an empirical basis on which policymakers and healthcare providers can rely to establish regionalization schemes designed to provide efficient and equitable access to life-saving care.