The relationship between state-level funding, designated trauma centers, and trauma-related mortality

Background: In the U.S., the leading cause of death in the first four decades of life is related to traumatic injury. However, trauma centers face multiple challenges to remain financially viable, which may impede access to and quality of care for trauma injured patients. The aim of this study was to examine if associations exist, at the state level, between funding, the number of trauma centers, and trauma-related mortality. Methods: State-level trauma-related funding information was obtained for all 50 states from 2008 to 2017. The number of designated trauma centers, trauma-related mortality and Medicaid expansion per state per year were obtained for the same period. Fixed effects panel regression analysis was used to test the study's two hypotheses. Results: Contrary to our hypotheses, an incremental increase in state-level trauma care funding was not significantly associated with the number of trauma hospitals, nor was the number of trauma hospitals within a state significantly associated with the state's age-adjusted mortality rate. However, we did find there was an increase of 23% (b=0.23, P=0.01) in Level 1 trauma hospitals in states that expanded Medicaid compared to pre-expansion. In addition, each additional Level 3 trauma hospital was associated with a 0.19-point increase (b=0.19, P=0.03) in trauma-related mortality, in contrast to Level 4 hospitals where each additional one was associated with a 0.25-point decrease (b=-0.25, P<0.001) in trauma-related mortality. Conclusions: State-level funding as a direct payment source was not found to have a significantly positive relationship with the number of total trauma hospitals. Currently, only 18 states in the U.S. fund designated trauma hospitals directly. Medicaid expansion did have a significant impact on the number of designated trauma hospitals by increasing the number of Level 1 trauma hospitals, which provide the highest level of care for trauma patients. Medicaid expansion, as an alternate source of state funding, can have a positive impact on the number of designated trauma hospitals available for the care of injured patients. The increasing trauma mortality rate over the study period and the decline in the number of higher-level designated trauma centers are concerning trends that warrant continued study by researchers. In addition, this study provides support for continuing discussions to urge policymakers to consider, at a minimum, alternative funding of inclusive regionalized trauma systems for improving both access to and quality of care for trauma-injured patients.