For trauma centers, it’s a zero sum game. The number of trauma patients in a given geographic location is fixed. (Actually, it goes up slowly over time as the population increases). So if a new center opens, those patients are redistributed. The new center gets more patients because they are now “designated.” And the existing centers get fewer because there are not as many patients left.
This is a phenomenon that is growing more widespread as more lower level trauma centers come online. Areas like Phoenix, Denver, and parts of Florida are particularly hard hit. Established Level I and II centers are complaining because their volumes are down, which can cause a hit to the financial bottom line.
Seems to make sense. But is it true? A time series analysis was carried out using Pennsylvania trauma system data to gauge the impact of opening new Level II and III centers on an existing Level I center. Ten years of data were gathered, looking at volume and mortality changes during the following sequence of designations:
- A new Level II opens 70 months into the study period
- A new Level III opens at 95 months, then closed 11 months later
- A new Level II and Level III open at 107 months
Here are the factoids, from the perspective of the Level I center:
- Volume at the Level I center grew slowly over the 70 months that no new trauma centers were operating
- Volume dropped 10% when the first Level II opened, and 13% when the Level II and III opened simultaneously
- There was no change when the temporarily accredited Level III opened
- Overall, the Level I center treated 1,903 fewer patients than expected after the other centers opened, an overall decrease of 10%
- Average injury severity and revised trauma score remained the same at the Level I, but mortality decreased (!)
Bottom line: More trauma centers generally equals fewer patients for existing ones. Unfortunately, the decision to become a trauma center these days, especially levels II and III, tends to be based on business factors. The American College of Surgeons Committee on Trauma (ACSCOT) released a position statement early this year regarding the designation of multiple trauma centers in a geographic location. They basically have left it up to the individual states or trauma systems to optimize placement or limit numbers. They also emphasize that the numbers need to support best patient care, not necessarily best business strategy. Unfortunately, politics will not let this happen. I believe that the tightening of verification requirements for centers that are verified by the ACSCOT (as in the new Orange book criteria) will serve to shake out the centers that barely meet them. But only time will tell.
- Impact of adding Level II and III trauma centers on volume and disease severity at a nearby Level I trauma center. J Trauma 77(5):764-768, 2015
- Statement on trauma center designation based upon system need. American College of Surgeons, Jan 2015.