As of about 10 years ago, every state in the US has implemented a state trauma system. The way these systems are funded and their sources vary widely. Most receive their funds via some combination of a line item in the budget, grants, or fees levied on state residents. The total per capita funding amount can be calculated based on the total dollars received divided by the state population.

The per capita funding across the US varies widely. Some provide very little assistance while others are much more generous. I have visited trauma centers in nearly every state and have witnessed the difficulties many state trauma systems face due to funding shortfalls.

Does financial support have an impact on trauma care? A better question is, do state systems have an impact on trauma care? The literature on that last question tells us the answer is a resounding yes. We assume that having some money improves what the system can do. But that’s just an assumption. Until now.

The group at Northwestern University did a deep dive into the financial support of state trauma systems to address this question. Their goal was to measure the impact of it on something easily measurable: mortality. They selected five states to study based upon their broad geographic and demographic variability and the availability of comprehensive data for analysis.

Two states (MA, NY) allocated $0.00 per capita trauma funding, and three provided between $0.09 and $1.80 per capita.  The authors analyzed data from comprehensive patient encounter databases from these states. Their primary goal was to compare mortality differences between the two levels of support. They were also able to link ED and inpatient encounters and analyze triage decisions for appropriateness.

Here are the factoids:

• Nearly a quarter of a million patients with ISS > 15 were analyzed over a study period of two years
• Median age was 72 and ISS was 17 (older with significant injuries)
• Trauma mortality was significantly decreased in the states that provided financial support compared with those that did not (odds ratio 0.75)
• All triage levels were associated with a similar decrease in mortality (appropriate triage to a Level I or II center, undertriage admitted to a Level III or IV center, and re-triage (emergent transfer from an ED to a Level I or II center))
• The best improvement in mortality was seen in re-triaged patients in funded states (odds ratio of 0.63)

The authors concluded that state system funding was associated with lower mortality in severely injured patients and that increasing funding may facilitate it.

Bottom line: Several papers have been written showing the benefit of having a trauma system, and all of the US has bought into this concept. However, funding of these systems varies widely by state. The assumption (up to now) has been that just having a system is enough. This abstract goes a step further and suggests that actually paying for it is important, too. 

The authors performed quite of bit of data manipulation and used some sophisticated statistical tools that I am not familiar with. However, the authors are certainly qualified, and I am going to assume that the analysis was sound. 

The one important point to keep in mind is that this paper is one of the first of its kind but can only show association, not causation. Nevertheless, it is an important contribution to the trauma system literature. It will definitely prompt additional research which will hopefully corroborate the results. This line of work should give state systems the ammunition to approach their legislatures to open the pocketbook and improve the outcomes of their residents. Mortality reductions of 25-37% cannot be ignored!

Here are my questions and comments for the authors/presenters:

1. Please explain the data sources you used and the analysis (briefly). These are very comprehensive databases and appear to contain a wealth of data. Tell us why you chose them, how you linked them, and explain your analyses.
2. Why limit your analyses to these five states? Could you have found some with even higher levels of support that would drive your point home even better?
3. Be sure to provide more detail on your analysis of triage status. There are some important lessons to be learned here regarding state triage criteria vs mortality.
4. Are you planning any additional similar studies? This is important work that will help state systems obtain a more appropriate level of support.

This is an intriguing abstract that should prompt additional research regarding state trauma system funding. 

Reference: THE IMPACT OF STATE TRAUMA FUNDING ON TRIAGE AND MORTALITY OF TRAUMA PATIENTS. Plenary paper #38, AAST 2022.