Does Policy Support Optimal Care of the Injured? Association Between Rigor of State Trauma Center Designation Criteria and Proliferation of For and Not-For-Profit Trauma Centers

Introduction: Trauma center (TC) designation may confer financial benefits to hospitals. We aimed to evaluate the correlation between the rigor of state-specific TC designation criteria and proliferation of not-for-profit and for-profit TCs. We hypothesized that less stringent state criteria correlate with proliferation of for-profit TCs, but not with not-for-profit TCs.

Methods: Newly designated TCs (2013-19) were identified using the Trauma Information Exchange Program and their for-profit status using CMS data. We quantified each state’s TC designation criteria rigor by the proportion of American College of Surgeons Committee on Trauma verification criteria state regulations mandated. We evaluated proliferation of for-profit TCs using the proportion of each state’s newly designated for-profit TCs among all newly designated for-profit TCs nationwide and all newly designated TCs statewide. We similarly evaluated not-for-profit TC proliferation. Kendall’s rank correlation evaluated the correlation between criteria rigor and TC proliferation (alpha:0.05).

Results: 422 hospitals (N=75; 18% for-profit) obtained TC designation. States with less stringent TC designation criteria significantly correlated with both measures of for-profit proliferation: proportion of newly designated for-profit TCs nationwide [tau:0.28, p-value:0.02] and of newly designated TCs statewide [tau:0.28, p-value:0.03]). No correlations were found between less stringent criteria and not-for-profit TC proliferation (nationwide proportion [tau: 0.16, p-value:0.16], statewide proportion [tau: 0.02, p-value:0.83]). 

Conclusion: States with less stringent TC designation criteria correlated with proliferation of for-profit TCs, but not with not-for-profit TCs. Considering previous studies highlighting for-profit TC’s higher activation fees and expansion into regions with lower injury burden, our study encourages increased oversight to ensure TC proliferation prioritizes addressing patient needs.