Trauma Activation Fee Variations Across Hospital Ownership, Safety-net, American College of Surgeons Committee-on-Trauma Verification, and State Designation Status

Introduction: Trauma activation fees (TAF) are intended to offset the costs of trauma readiness yet remain unregulated. Prior studies have explored TAF variations across American College of Surgeons Committee on Trauma (ACS-COT)-verified centers, which represent a minority of US trauma centers. We aimed to characterize TAF variations across all US trauma centers, accounting for previously underexplored characteristics that may be associated with TAFs. Methods: This cross-sectional study evaluated all level I–III designated US trauma centers and their TAFs. We delineated each trauma center’s hospital [hospital ownership (for-profit or nonprofit), designation level (I/II or III), ACS-COT verification, and safety-net hospital status] and county-level characteristics (per capita income, Area Deprivation Index, years-of-potential-life-lost from fatal injury). Multivariable lasso regression evaluated the association between median TAFs and hospital ownership status, with trauma center designation level as an effect modifier. Results: Study cohort comprised 1014 trauma centers [N = 166 (16.4%) for-profit]. Across all designation levels and ACS-COT verification status, for-profit trauma centers had higher median TAFs compared with nonprofit counterparts. We did not find a statistically significant difference in TAFs over safety-net or ACS-COT-verified status. Multivariable lasso regression did not find a statistically significant association between hospital ownership status and TAFs [β = 4540 (−722 to 9810); P = 0.091], but a statistically significant interaction between hospital ownership status and trauma center designation level [β = 9090 (1270–16900); P = 0.003]. Conclusion: Nationwide analysis of over 1000 designated US trauma centers found wide heterogeneity in TAFs and an association between for-profit ownership status and higher TAF among level I and II trauma centers. Whether observed nationwide TAF heterogeneity characteristics warrant evaluating the role of TAF regulation deserves discussion.