Access Delayed Is Access Denied: Relationship Between Access to Trauma Center Care and Pre-Hospital Death Zain G. Hashmi, MBBS, Molly P. Jarman, PhD,

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Access Delayed Is Access Denied: Relationship Between Access to Trauma Center Care and Pre-Hospital Death Zain G. Hashmi, MBBS, Molly P. Jarman, PhD, Tarsicio Uribe-Leitz, MD, MPH, Eric Goralnick, MD, MS, Craig D. Newgard, MD, MPH, Ali Salim, MD, FACS, Edward Cornwell, MD, FACS, Adil H. Haider, MD, MPH, FACS Journal of the American College of Surgeons Volume 228, Issue 1, Pages 9-20 (January 2019) DOI: 10.1016/j.jamcollsurg.2018.09.015 Copyright © 2018 American College of Surgeons Terms and Conditions

Figure 1 State-level variation in (A) age-adjusted mortality rate per 100,000 population, (B) the ratio of pre-hospital to in-hospital deaths, and (C) access to Level I/II trauma center within 1 hour. Arkansas was a significant low-outlier, with 6.1% of population with access to Level I/II trauma center within 1 hour. Journal of the American College of Surgeons 2019 228, 9-20DOI: (10.1016/j.jamcollsurg.2018.09.015) Copyright © 2018 American College of Surgeons Terms and Conditions

Figure 2 Correlation between (A) age-adjusted mortality rate and proportion of population with access to Level I/II trauma center within 1 hour, (B) ratio of pre-hospital to in-hospital deaths and proportion of population with access to Level I/II trauma center within 1 hour, and (C) ratio of pre-hospital to in-hospital deaths and age-adjusted mortality rate. Dotted box identifies states with both higher than national average ratio of pre-hospital to in-hospital deaths and age-adjusted mortality rate, ie high pre-hospital burden states. Journal of the American College of Surgeons 2019 228, 9-20DOI: (10.1016/j.jamcollsurg.2018.09.015) Copyright © 2018 American College of Surgeons Terms and Conditions

Figure 3 Correlation between ratio of pre-hospital to in-hospital deaths and age-adjusted mortality rate for (A) urban deaths and (B) rural deaths. Each point on the scatter plot represents a US state. Journal of the American College of Surgeons 2019 228, 9-20DOI: (10.1016/j.jamcollsurg.2018.09.015) Copyright © 2018 American College of Surgeons Terms and Conditions

Figure 4 (A) Map depicting states with high pre-hospital burden of trauma deaths (defined as those with higher than national average pre-hospital to in-hospital death ratio, and age-adjusted mortality rate). (B) Proportion of population with access to a trauma center in high pre-hospital burden states vs all other states. States with both higher than national average ratio of pre-hospital to in-hospital deaths and age-adjusted mortality rate were classified as high pre-hospital burden states. ∗p < 0.01. Journal of the American College of Surgeons 2019 228, 9-20DOI: (10.1016/j.jamcollsurg.2018.09.015) Copyright © 2018 American College of Surgeons Terms and Conditions