From the Departments of Emergency Medicine (R.Y.H.), Medicine (J.M.), and Epidemiology and Biostatistics (C.M.), University of California, San Francisco; and Ecologic Institute (T.S.), San Mateo, California; Department of Surgery (M.C.), Northwestern University, Chicago, Illinois; and RAND (A.L.K.), Washington, District of Columbia.
J Trauma Acute Care Surg. 2014 Apr;76(4):1048-54. doi: 10.1097/TA.0000000000000166.
Trauma centers are an effective but costly element of the US health care infrastructure. Some Level I and II trauma centers regularly incur financial losses when these high fixed costs are coupled with high burdens of uncompensated care for disproportionately young and uninsured trauma patients. As a result, they are at risk of reducing their services or closing. The impact of these closures on patient outcomes, however, has not been previously assessed.
We performed a retrospective study of all adult patient visits for injuries at Level I and II, nonfederal trauma centers in California between 1999 and 2009. Within this population, we compared the in-hospital mortality of patients whose drive time to their nearest trauma center increased as the result of a nearby closure with those whose drive time did not increase using a multivariate logit-linked generalized linear model. Our sensitivity analysis tested whether this effect was limited to a 2-year period following a closure.
The odds of inpatient mortality increased by 21% (odds ratio, 1.21; 95% confidence interval, 1.04-1.40) among trauma patients who experienced an increased drive time to their nearest trauma center as a result of a closure. The sensitivity analyses showed an even larger effect in the 2 years immediately following a closure, during which patients with increased drive time had 29% higher odds of inpatient death (odds ratio, 1.29; 95% confidence interval, 1.11-1.51).
Our results show a strong association between closure of trauma centers in California and increased mortality for patients with injuries who have to travel further for definitive trauma care. These adverse impacts were intensified within 2 years of a closure.
Prognostic and epidemiologic, level III.
创伤中心是美国医疗保健基础设施中一个有效的但昂贵的元素。一些一级和二级创伤中心经常在固定成本高的情况下出现财务损失，同时还要承担不成比例的年轻和无保险创伤患者的大量无偿护理负担。因此，它们有减少服务或关闭的风险。然而，这些关闭对患者结局的影响以前尚未得到评估。
我们对 1999 年至 2009 年期间加利福尼亚州一级和二级非联邦创伤中心所有因受伤就诊的成年患者进行了回顾性研究。在这一人群中，我们使用多变量对数链接广义线性模型，比较了因附近创伤中心关闭而导致最近创伤中心的行车时间增加的患者与行车时间未增加的患者的院内死亡率。我们的敏感性分析测试了这种影响是否仅限于关闭后 2 年内。
由于附近创伤中心关闭而导致最近创伤中心的行车时间增加的创伤患者，其住院死亡率增加了 21%（比值比，1.21；95%置信区间，1.04-1.40）。敏感性分析显示，在关闭后的 2 年内，这种影响更大，行车时间增加的患者住院死亡的几率增加了 29%（比值比，1.29；95%置信区间，1.11-1.51）。
我们的研究结果表明，加利福尼亚州创伤中心的关闭与受伤患者的死亡率之间存在很强的关联，这些患者因需要更远的距离接受确定性创伤护理而导致死亡率增加。这些不利影响在关闭后 2 年内加剧。
预后和流行病学，三级。
