Understanding the Risk Factors of Trauma Center Closures

Abstract

Objectives We analyze whether hazard rates of shutting down trauma centers are higher due to financial pressures or in areas with vulnerable populations (such as minorities or the poor). Materials and Methods This is a retrospective study of all hospitals with trauma center services in urban areas in the continental US between 1990 and 2005, identified from the American Hospital Association Annual Surveys. These data were linked with Medicare cost reports, and supplemented with other sources, including the Area Resource File. We analyze the hazard rates of trauma center closures among several dimensions of risk factors using discrete-time proportional hazard models. Results The number of trauma center closures increased from 1990 to 2005, with a total of 339 during this period. The hazard rate of closing trauma centers in hospitals with a negative profit margin is 1.38 times higher than those hospitals without the negative profit margin (P < 0.01). Hospitals receiving more generous Medicare reimbursements face a lower hazard of shutting down trauma centers (ratio: 0.58, P < 0.01) than those receiving below average reimbursement. Hospitals in areas with higher health maintenance organizations penetration face a higher hazard of trauma center closure (ratio: 2.06, P < 0.01). Finally, hospitals in areas with higher shares of minorities face a higher risk of trauma center closure (ratio: 1.69, P < 0.01). Medicaid load and uninsured populations, however, are not risk factors for higher rates of closure after we control for other financial and community characteristics. Conclusions Our findings give an indication on how the current proposals to cut public spending could exacerbate the trauma closure particularly among areas with high shares of minorities. In addition, given the negative effect of health maintenance organizations on trauma center survival, the growth of Medicaid managed care population should be monitored. Finally, high shares of Medicaid or uninsurance by themselves are not independent risk factors for higher closure as long as financial pressures are mitigated. Targeted policy interventions and further research on the causes, are needed to address these systems-level disparities.

Do patients hospitalised in high-minority hospitals experience more diversion and poorer outcomes? A retrospective multivariate analysis of Medicare patients in California

“…The disparate amount of diversion experienced by minority-serving hospitals is concordant with previous literature, suggesting that there may be a fundamental misalignment in the supply and demand of emergency services at minority-serving hospitals relative to non-minority-serving hospitals. [31][32][33] Our findings add support to evidence 18 that policies to reduce ambulance diversion can improve access, treatment and outcomes for patients. However, in order to narrow the gap in disparities between black and white patients, more effort should be made to reduce the amount of ambulance diversion at minority-serving hospitals.…”

System-Level Health Disparities in California Emergency Departments: Minorities and Medicaid Patients Are at Higher Risk of Losing Their Emergency Departments

“…13,14,19,20,23-26 Using OSHPD's socioeconomic information of patients seen in each hospital, we created hospital-level aggregates for each year to determine the racial/ethnic and insurance composition of the hospitals’ patient pool. Specifically, we used PDD information to identify patients’ race/ethnicity to calculate the proportion of white non-Hispanics, black non-Hispanics, Hispanics, and other (including Asian, Native American, Alaska Native, Hawaiian, Pacific Islanders, and unknown/masked), and also to calculate the proportions of Medicare, Medicaid (specifically, Medi-Cal, which is California's Medicaid program), uninsured, privately insured, and other forms of insurance (i.e., VA, Tricare, Champus, Workers Compensation etc.).…”

“…Based on previous literature describing characteristics associated with decreased access to care we a priori included the following predictor variables:percent race/ethnicity, percent insurance status, total ED visits of the hospital, hospital discharges, trauma center status based on EMSA designation (Level I or II = yes; all others = no), teaching affiliation (yes/no), hospital ownership (for-profit, not-for-profit, and county), operating margin, and location in an urban county. 20,23,28-36 Individual patient-level data were aggregated into hospital-level proportions of race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, and other non-Hispanic) and insurance status (% with Medicare, Medi-Cal, uninsured, private insurance, and other). We log-transformed the annual number (in thousands) of ED visits and hospital discharges because of skew in these variables.…”

The association of trauma center closures with increased inpatient mortality for injured patients

“…8,10,11 The trend is not new. In fact, trauma center closures have been accelerating over the past two decades; between 1999 and 2005, 390 of the 1,125 US trauma centers (30%) closed.…”