State Trauma Center Designation Criteria and Expansion of For-Profit vs Nonprofit Trauma Centers

Importance Trauma center designation in the US is determined by state-specific criteria, whereas the optional American College of Surgeons Committee on Trauma (ACS-COT) standards provide a nationally recognized benchmark for optimal trauma care. The number of trauma centers continues to expand, yet access disparities persist. The degree of alignment between state designation criteria and ACS-COT standards as well as its implications for recent patterns of for-profit and nonprofit center expansion remain unexplored. Objective To quantify the concordance between each state’s trauma center designation criteria and ACS-COT standards, and to evaluate its correlation with expansion of for-profit and nonprofit trauma centers. Design, Setting, and Participants This cross-sectional study used data from the Trauma Information Exchange Program database for all designated trauma centers in the 50 states and the District of Columbia from January 1, 2013, to December 31, 2022. Data were analyzed from January to September 2024. Exposure State-specific trauma center designation criteria. Main Outcomes and Measures The primary outcome was concordance, defined as the proportion of ACS-COT standards reflected in each state’s trauma center designation criteria. Correlations (Spearman rank [ r s ]) of concordance with the expansion of for-profit and nonprofit trauma centers from 2013 to 2022 were calculated. Results The study cohort comprised 464 trauma centers (389 nonprofit [83.8%] and 75 for-profit [16.2%]) that gained designation between 2013 and 2022. State trauma center designation criteria concordance with ACS-COT standards varied between 31.1% and 100%. Overall mean (SD) concordance was highest for level I trauma centers with the highest resource capacity (92.5% [15.6%]) and lowest for level IV trauma centers with low resource capacity (78.5% [28.2%]). Among the 464 trauma centers, 380 (81.9%) were level III or IV centers with lower resource capacity. States with lower concordance between their designation criteria and ACS-COT standards had a statistically significant correlation with expansion of for-profit trauma centers ( r s = −0.39; P = .004) but not with expansion of nonprofit trauma centers. Conclusions and Relevance In this cross-sectional study of state trauma center designation criteria and their alignment with ACS-COT standards, states’ designation criteria and trauma center expansion patterns varied widely. Lower concordance between state designation criteria and ACS-COT standards was correlated with for-profit trauma centers, whereas this pattern was not observed for nonprofit trauma centers. These findings highlight the importance of understanding how regulatory environments may shape trauma system development.