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Invited Critique |

Disparities in Access to Care: Does It Translate Into Worse Outcomes?  Comment on “Possible Geographical Barriers to Trauma Center Access for Vulnerable Patients in the United States”

Justin B. Dimick, MD, MPH
Arch Surg. 2011;146(1):52. doi:10.1001/archsurg.2010.301.
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Drs Hsia and Shen use US Census data to study access to certified trauma centers across the United States. They find both geographic and ethnic disparities in access to trauma centers. I completely support the authors' conclusion that we should be thoughtful about trauma center distribution. Their finding that vulnerable populations, who may be more likely to have traumatic injuries, have less access to trauma centers underscores this point. However, there is 1 key limitation of this study: the focus on access rather than outcomes of care. The authors use “easy” access (a <20-minute drive) to a trauma center as their outcome of interest. It is unclear whether differences in access according to this definition translate into real differences in patient outcome, which is what we really care about. Do patients who lack easy access experience unnecessary morbidity and mortality as a result? Because of the well-known geographic distribution of penetrating trauma, it is possible that trauma centers may already be optimally located (at least in terms of the rural-urban disparity). Most penetrating trauma occurs in urban centers, so it makes sense to locate trauma centers in these areas. Without data on outcomes, it is unclear how far the status quo is from the ideal distribution of trauma centers.

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