Possible Geographical Barriers to Trauma Center Access for Vulnerable Patients in the United States

Abstract

Objective To study whether traditionally vulnerable populations have worse geographic access to trauma centers. Design A cross-sectional analysis using data from the American Hospital Association Annual Survey from 2005 linked with zip code–level data from the US Census. We used a multinomial logit model to examine the odds of having difficult as opposed to easy access to trauma centers for a given subgroup of vulnerable populations. Setting and Participants Population in rural and urban communities as defined by zip codes in the United States. Main Outcome Measures Each community’s distance to the nearest trauma center (levels I–III). Results In urban areas, 67% of the population had easy access to trauma centers and 12% had difficult access compared with 24% and 31% in rural areas, respectively. Areas with higher shares of the following vulnerable population groups had higher risks (odds ratios) of facing difficult access to trauma center services in 2005: foreign born in urban areas (1.65 for a medium share and 2.18 for a high share [both P < .01]); African American in urban and rural areas (1.25 for a medium share and 1.35 for a high share, respectively [both P < .05]); and near-poor in urban and rural areas (1.52 [P < .05] and 1.69 [P < .01] for a high share, respectively). Conclusions A significant segment of the US population (representing 38.4 million people) does not have access to trauma care within 1 hour of driving time. Moreover, certain vulnerable groups are at higher risk than others for worse access to trauma centers. Stakeholders and health care planners should consider these factors in the development of trauma systems because a mismatch of potential need and access could signal inefficiencies in the delivery of care.

Rural risk: Geographic disparities in trauma mortality

“…Due to the geographic distribution of various demographic groups in the US, this disparity may disproportionately impact racial minorities and people living in poverty. 6 Little is known about the causal pathway for this disparity. Time to treatment is presumed to be a significant factor in trauma outcomes, 41 and would disparately impact rural populations, 5,6 but evidence for the relationship between pre-hospital time and mortality is widely variable.…”

“…6 Little is known about the causal pathway for this disparity. Time to treatment is presumed to be a significant factor in trauma outcomes, 41 and would disparately impact rural populations, 5,6 but evidence for the relationship between pre-hospital time and mortality is widely variable. 30,32,[42][43][44][45][46][47][48][49][50][51][52] Other factors, such as community-level wealth and insurance coverage, [53][54][55] may also contribute to geographic disparities in injury mortality.…”

“…The NEDS does not include any measure of distance or travel time. Distance and travel time are closely related to rural residence status, 5,6 and may determine time to definitive care and the trauma designation of the treating hospital. Finally, the NEDS only contains data on ED encounters for patients who are alive upon arrival, and does not include pre-hospital deaths.…”

“…5 Geographic barriers to trauma care are more likely to impact racial minorities and people living in poverty, 6 paralleling established racial and socioeconomic disparities in trauma mortality. [7][8][9][10][11][12] Rural residents face elevated risk of traumatic injury compared to non-rural residents, 13,14 and injury mortality rates are higher in rural communities than in urban and suburban settings.…”

Mortality Rates are Similar after Hip Fractures for Rural and Urban Patients

“…Alternatively, there are concerns regarding how the limited availability of surgical specialists in rural areas might impact outcomes in emergent conditions such as trauma or hip fracture when the time to presentation and treatment is important. This issue was highlighted in an article by Hsia and Shen [15] (with a comment by Dimick [10]), who reported that more than 38 million Americans did not have access to a trauma center within a 1-hour drive. Our investigation suggests that although rural patients with fractures do need to travel farther, they do not appear to have worse outcomes because of this need to travel.…”