Abstract
Context:
The halo effect describes the improved surgical outcomes at trauma centers for nontrauma conditions.
Objective:
To determine whether level 1 trauma centers have improved inpatient mortality for common but high-acuity nonsurgical diagnoses (eg, acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia [PNA]) compared with non–level 1 trauma centers.
Methods:
The authors conducted a population-based, retrospective cohort study analyzing data from the Healthcare Cost and Utilization Project State Inpatient Database and the American Hospital Association Annual Survey Database. Patients who were admitted with AMI, CHF, and PNA between 2006-2011 in Florida and California were included. Level 1 trauma centers were matched to non–level 1 trauma centers using propensity scoring. The primary outcome was risk-adjusted inpatient mortality for each diagnosis (AMI, CHF, or PNA).
Results:
Of the 190,474 patients who were hospitalized for AMI, CHF, or PNA, 94,037 patients (49%) underwent treatment at level 1 trauma centers. The inpatient mortality rates at level 1 trauma centers vs non–level 1 trauma centers for patients with AMI was 8.10% vs 8.40%, respectively (P=.73); for patients with CHF, 2.26% vs 2.71% (P=.90); and for patients with PNA, 2.30% vs 2.70% (P=.25).
Conclusion:
Level 1 trauma center designation was not associated with improved mortality for high-acuity, nonsurgical medical conditions in this study.
Trauma centers have improved outcomes for moderate to severely injured patients when compared with non–trauma centers.
1 Trauma centers in each state are categorized by the American College of Surgeons and by their particular state into levels of care based on a variety of requirements, such as their commitment, admission volume, physician coverage, hospital infrastructure and services, data collection, and quality improvement programs.
1
The various requirements for trauma centers often overlap with those for the provision of care for other surgical conditions. The “halo effect” implies that the infrastructure associated with trauma center designation will also improve outcomes for other surgical diagnoses. This effect has been best demonstrated in patients with a ruptured abdominal aortic aneurysm (AAA), for whom the trauma center has been associated with improved mortality.
3,4 Decreased mortality at trauma centers has been attributed to well-developed surgical systems and overall enhanced surgical expertise related to the higher volumes.
5-7
The halo effect of trauma centers has not been shown to benefit patients who require less severe surgical procedures, such as appendectomy,
8 colectomy for diverticulitis,
9 and other emergency general surgery procedures.
10,11 Most likely, given the more frequent presentation and limited resource needs associated with these less severe surgical diagnoses, the expanded resources and experience level of trauma center staff are unnecessary. Since the proposal of the halo effect, studies
3,4,8-10 have only investigated its applicability to surgical diagnoses. It is unclear whether the infrastructure of a trauma center benefits patients with high-acuity, nonsurgical diagnoses.
Therefore, the objective of the present study was to compare mortality outcomes for common, but high-acuity, nonsurgical diagnoses of acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia (PNA) at hospitals with a level 1 trauma center with equivalent hospitals without level 1 trauma centers.
12,13