M. P. Jarman1, R. C. Castillo1, A. R. Carlini1, A. H. Haider2 1Johns Hopkins University School Of Public Health,Health Policy,Baltimore, MD, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA
Introduction: Treatment at a designated trauma center is proven to reduce mortality from traumatic injuries, but the majority of US residents in rural areas do not have timely access to Level I or II trauma centers. To date, no studies have used nationally representative date to quantify the impact of barriers to trauma care on injury mortality in rural populations.
Methods: We performed a retrospective analysis of 2006-2011 National Emergency Department Sample data to determine if mortality following traumatic injury differs across urban/rural classifications. Emergency department (ED) visits with ICD-9-CM codes for injuries (ICD-9-CM 800-959.9) as the primary or secondary diagnosis were included in these analyses, excluding superficial and foreign body injuries, late effects of injury, as well as records with missing urban/rural status or disposition from the ED (N=8,887,575). Mortality was defined as dying in the ED or in the hospital during the admission associated with the ED visit. Overall, 0.12% of ED encounters in the sample resulted in death (N=10,665) Odds of death were calculated using multiple logistic regression with patient residential urban/rural status, Injury Severity Score, comorbidities, trauma center designation, patient age, and patient gender as covariates. All analyses were performed using Stata 12.1.
Results: Residents from rural communities were 25% (p = 0.002) more likely to die of traumatic injury than non-rural residents, when controlling for severity, comorbidities, trauma center designation, age, and gender. Rural residents treated at Level I trauma centers were 3.06 times (p < 0.001) more likely to die of their injuries, compared to non-rural residents. Rural residents at Level II centers were 73% more likely to die (p = 0.002), and rural residents at Level IV centers were 13% more likely to die (p = 0.016), compared to non-rural residents. There was no statistically significant difference in mortality between rural and non-rural residents with treated at Level III (p = 0.151).
Conclusion: People living in rural communities are significantly more likely than non-rural residents to die following traumatic injury. This disparity is largest at Level I trauma centers decreases at lower level trauma centers. Distance and travel time to treatment likely play a significant role in injury outcomes for rural residents, but measures of distance and time generally not available for nationally representative data that also include measures or rural/urban residence. Future analyses should explore the interaction between time to treatment, level of care, and outcomes for rural residents.
