Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation

Payer Status: The Unspoken Triage Criterion

BACKGROUND

The cost of uncompensated trauma care is a significant barrier to trauma system development. Trauma center designation may burden an institution with an unprofitable mix of underinsured, severely injured patients. Concerns about inadequate reimbursement may motivate interhospital transfers on the basis of insurance status rather than medical necessity, potentially undermining the effectiveness of the system. We set out to explore whether this phenomenon exists in a mature trauma system.

METHODS

Trauma patients receiving definitive care at Level III or IV trauma centers were compared with patients transferred from these centers to the only Level I regional center. Insurance status was classified as either commercial or noncommercial. Logistic regression was used to determine the independent predictors of transfer after adjusting for differences in injury severity.

RESULTS

Only 12% of 2,008 patients initially evaluated at Level III/IV centers were transferred to the Level I center, an indicator of the effectiveness of prehospital triage protocols in the region. The presence of specific complex injuries, younger age, male gender, and insurance status were all associated with an increased likelihood of transfer. Insurance status was an independent predictor of transfer: patients without commercial insurance were 2.4 (95% confidence interval, 1.6-3.6) times more likely to be transferred to a Level I facility than patients with commercial insurance after adjusting for differences in injury severity.

CONCLUSION

Insurance status influences the decision to transfer to higher levels of care. These findings suggest that the financial burden of a trauma system may be inequitably distributed. This inequitable distribution may be necessary for trauma system sustainability and calls for the development of disproportionate reimbursement strategies to support regional referral centers.

Trauma systems

Trauma is one of the major causes of death and disability in modern society, particularly for the young. Organized trauma systems reduce mortality and morbidity from trauma. An effective trauma system addresses all aspects of trauma care, from prevention to rehabilitation. Well-developed trauma systems are currently available only to a minority of the world's population. Trauma systems in developed nations have much potential for improvement.

Advances in the management of pediatric trauma

BACKGROUND

Numerous important advances have been made in the management of trauma in childhood in prevention, prehospitalization and intrahospital care, postoperative management, and rehabilitation. As with adult trauma care, the development of trauma systems has impacted greatly on morbidity and mortality in injured children.

DATA SOURCES

Recent literature was searched for information regarding selected aspects of pediatric trauma care where significant improvements in outcome have occurred. The specific areas selected because of their contribution to improved outcomes include changes in the organization of care including the establishment of trauma centers and trauma systems, understanding trauma physiology as a basis for care, selective management of blunt trauma, management of burn injury, and prevention.

CONCLUSION

Because of the various advances in the understanding of the effects of injury that have been translated to improved approaches to treatment, overall treatment mortality in childhood has dropped 45% over the last 20 years and mortality with burn injury has been reduced by half in patients with over 60% of body surface burn and almost eliminated below that level unless there are additional circumstances. Nonetheless, trauma is still the leading cause of death in childhood, so continuing commitment by pediatric surgeons to advancing trauma care for children is in order as well as providing education for adult surgeons willing to commit themselves to care of the injured child.