Complex Orthopaedic Trauma Is Shifting Away From Level I to Non–Level I Trauma Centers: An Analysis of the National Trauma Data Bank

An increasing number of fellowship-trained orthopaedic trauma surgeons are working in non–Level I centers. This study aimed to examine trends of management of complex orthopaedic trauma in Level I centers versus non–Level I centers and its potential effect on patient outcomes. METHODS: Data from the National Trauma Data Bank from 2008 to 2017 were analyzed. Non–Level I to Level I center ratios for complex fractures and complication rates, median hours to procedure for time-sensitive fractures, and uninsured/underinsured rates of Level I and non–Level I centers were recorded. RESULTS: Three hundred one thousand patients were included. A statistically significant downward trend was identified in the percent of all complex orthopaedic trauma at Level I centers and per-hospital likelihood of seeing a complex orthopaedic fracture in a Level I versus non–Level I hospital. Per-hospital complication rates were consistently lower in non–Level I hospitals after controlling for injury severity and payer mix. Time-sensitive fractures were treated earlier in non–Level I centers. DISCUSSION: This study demonstrates a reduction of complex trauma treatment in Level I centers that did not translate to adverse effects on patient outcomes. Policymakers should notice this trend to ensure the continued quality of orthopaedic trauma training and maintenance of expertise in complex fracture management.