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Kutzer KM, Kiwinda LV, Yang D, Mitchell JK, Luo EJ, Harman EJ, Hendren S, Bradley KE, Lau BC. Insurance Payor Status and Outcomes in Pediatric Sports-Related Injuries: A Rapid Review. Clin Pract 2025; 15:52. [PMID: 40136588 PMCID: PMC11940847 DOI: 10.3390/clinpract15030052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Revised: 02/17/2025] [Accepted: 02/24/2025] [Indexed: 03/27/2025] Open
Abstract
Introduction: The rise in youth sports participation has led to an increase in pediatric sports-related injuries in the United States, contributing to growing healthcare costs and exacerbating socioeconomic disparities. Insurance payor status is a critical factor influencing access to care, treatment delays, and health outcomes. This study examines the association between insurance payor status and outcomes in pediatric sports-related injuries. Methods: A systematic review of the Medline database was conducted. Included studies reported insurance payor status and pediatric sports orthopedic patient outcomes following surgery. Outcomes included time to be seen by a provider, treatment access, complication and revision rates, postoperative Emergency Department (ED)/Urgent Care utilization, readmission rates, hospital length of stay, pain, functional scores, discharge destinations, return to activity, and follow-up. Results: A total of 35 studies comprising 535,891 pediatric patients were included. Publicly insured or uninsured patients consistently experienced significant delays in accessing care, with average wait times for clinic visits, imaging, and surgery up to six times longer compared to privately insured patients. These delays were associated with worsened injury severity, higher rates of postoperative complications, and poorer functional outcomes. Publicly insured patients were less likely to receive advanced treatments such as bracing or physical therapy, further compounding disparities. Minority groups faced delays even when controlling for insurance status. Conclusions: Public and uninsured pediatric patients face systemic barriers to timely and equitable care, resulting in worse outcomes following sports-related injuries. Future research should explore targeted solutions to ensure equitable care for this vulnerable population.
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Affiliation(s)
- Katherine M. Kutzer
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (L.V.K.); (D.Y.); (E.J.L.)
| | - Lulla V. Kiwinda
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (L.V.K.); (D.Y.); (E.J.L.)
| | - Daniel Yang
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (L.V.K.); (D.Y.); (E.J.L.)
| | - John Kyle Mitchell
- Department of Orthopaedic Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA;
| | - Emily J. Luo
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA; (L.V.K.); (D.Y.); (E.J.L.)
| | - Emily J. Harman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA; (E.J.H.); (K.E.B.); (B.C.L.)
| | - Stephanie Hendren
- Medical Center Library & Archives, Duke University School of Medicine, Durham, NC 27710, USA;
| | - Kendall E. Bradley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA; (E.J.H.); (K.E.B.); (B.C.L.)
| | - Brian C. Lau
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA; (E.J.H.); (K.E.B.); (B.C.L.)
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Shah MP, Douglas AG, Sauer BM, Richie MB, Douglas VC, Josephson SA, Guterman EL. Differences in Interfacility Transfer from Emergency Department and Inpatient Services for Inpatient Neurologic Care. Neurohospitalist 2024; 14:406-412. [PMID: 39308471 PMCID: PMC11412452 DOI: 10.1177/19418744241273205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024] Open
Abstract
Introduction Interhospital transfer is an important mechanism for improving access to specialized neurologic care but there are large gaps in our understanding of interhospital transfer for the management of non-stroke-related neurologic disease. Methods This observational study included consecutive patients admitted to an adult academic general neurology service via interhospital transfer from July 1, 2015 to July 1, 2017. Characteristics of the referring hospital and transferred patients were obtained through the American Hospital Association Directory, a hospital transfer database maintained by the accepting hospital, and the electronic medical record. The analyses used descriptive statistics to examine the cohort overall and compare characteristics of patients transferred from an emergency department and inpatient service. Results 504 patients were admitted via interhospital transfer during the study period. Of these, 395 patients (78.4%) were transferred because the referring hospital lacked capability, and 139 patients (27.6%) were transferred from an emergency department as opposed to inpatient service. Seizures was the most common diagnosis (23.8%). Patients who were transferred from an emergency department had a higher proportion covered by Medicaid (44.6%) than those transferred from an inpatient service (28.8%) and had a shorter median length of stay (3 days; IQR 2-7 vs 7 days; IQR 4-12). Conclusions The majority of observed interhospital non-stroke neurologic transfers occurred to improve access to specialized neurological care for patients, though patients transferred from the ED, as opposed to an inpatient service, had lower health care utilization, and this will be important to consider when developing systems of care and in future research.
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Affiliation(s)
- Maulik P. Shah
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Anne G. Douglas
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Brian M. Sauer
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Megan B. Richie
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Vanja C. Douglas
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - S. Andrew Josephson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
| | - Elan L. Guterman
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
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Utter GH. Trauma Secondary Overtriage and Cost. JAMA Netw Open 2024; 7:e2434123. [PMID: 39302683 DOI: 10.1001/jamanetworkopen.2024.34123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2024] Open
Affiliation(s)
- Garth H Utter
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, University of California, Davis, Medical Center, Sacramento
- Outcomes Research Group, University of California, Davis, Medical Center, Sacramento
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Hayashi J, Abella M, Nunez D, Alter N, Kim J, Rosander A, Elkbuli A. National analysis of over and under-triage rates in relation to trauma population risk factors and associated outcomes across various levels trauma centers. Injury 2024; 55:111215. [PMID: 37979283 DOI: 10.1016/j.injury.2023.111215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Over and under-triage represent a misallocation of resources that can affect patient outcomes. The purpose of this study is to evaluate over and under-triage rates in relation to risk factors and associated outcomes of trauma patients nationwide. METHODS A retrospective cohort study using the Trauma Quality Improvement Program from 2017 to 2020. Multivariable regression models were used to assess predictors of over-triage (activation when unnecessary) and under-triage (limited activation when full activation was necessary). RESULTS 22.2 % (32,782) of the study population were over-triaged and 20.3 % (29,996) were under-triaged. Most over-triaged patients were Black, with Medicaid, or had a penetrating injury, whereas most under-triaged patients were White, with private/commercial insurance, or had a blunt injury. With covariates adjusted for, Pacific Islander (p = 0.024) and American Indian patients (p = 0.015) were associated with higher odds of over-triage, and Hispanic patients had higher odds of under-triage (p<0.001). Patients with Medicare (p<0.001) had higher odds of over-triage, and patients with private/commercial insurance (p<0.001) had higher odds of under-triage compared to Medicaid patients. Patients in level II (p<0.001) and level III (p<0.001) trauma hospitals were associated with higher odds of over-triage. CONCLUSION Pacific Islander and American Indian patients, Medicare, and level II and III trauma centers are at increased risk of over-triage rates, while Hispanic and privately insured trauma patients had a higher risk for under-triage. Future studies should further investigate factors contributing to poor outcomes linked to under-triage practices and methods to improve consistency and standardization of triage tools across various levels of trauma centers.
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Affiliation(s)
| | | | - Denise Nunez
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona, USA
| | - Noah Alter
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Jason Kim
- NOVA Southeastern University, Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Abigail Rosander
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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Aldridge JR, Quinn SA, Peine BS, Irish WD, Toschlog EA. A Statewide Analysis of Predictors of Trauma Center Transfer: The Burden of Non-Clinical Factors. Am Surg 2023; 89:3702-3709. [PMID: 37133202 DOI: 10.1177/00031348231173938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVES There is a perception, with mixed literary support, that patients are transferred from community hospitals to tertiary medical centers for non-clinical reasons (ie, payor, race, and admission time). Over-triage risks unequally burdening the tertiary medical centers within a trauma system. This study aims to identify potential non-clinical factors associated with the transfer of injured patients. METHODS Using the 2018 North Carolina State Inpatient Database, patients with a primary diagnosis of spine, rib or extremity fractures, or TBI were identified using ICD-10-CM code and admission type of "Urgent," "Emergency," or "Trauma." Patients were divided into cohorts of "retained" (at community hospital) or "transferred" (Level-1 or 2 trauma centers). RESULTS 11,095 patients met inclusion criteria; 2432 (21.9%) patients made up the transfer cohort. The mean ISS for all retained patients was 2.2 (±.9) and 2.9 (±1.4) for all transferred patients. The transfer cohort was younger (mean age 66 v 75.8), underinsured, and more likely to be admitted after 1700 (P < .001). Similar differences were seen regardless of injury pattern. CONCLUSIONS Patients transferred to trauma centers were more likely to be underinsured and be admitted outside of normal business hours. These transferred patients had longer lengths of stay and higher mortality rates. Across all cohorts, similar ISS suggests that a portion of the transfers could be managed at a community hospital. After hours transfers suggest a need for more robust community hospital coverage. Intentional triage of the injured patient encourages appropriate utilization of resources and is crucial to maintaining high-functioning trauma centers and systems.
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Affiliation(s)
- Joshua R Aldridge
- Department of Surgery, East Carolina University, Greenville, NC, USA
| | - Seth A Quinn
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Brandon S Peine
- Department of Surgery, East Carolina University, Greenville, NC, USA
| | - William D Irish
- East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - Eric A Toschlog
- East Carolina University Brody School of Medicine, Greenville, NC, USA
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Asti L, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients. J Surg Res 2023; 283:161-171. [PMID: 36410232 DOI: 10.1016/j.jss.2022.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers. METHODS Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles. RESULTS Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage. CONCLUSIONS In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.
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Affiliation(s)
- Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Deena J Chisolm
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210
| | - Henry Xiang
- Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Center for Pediatric Trauma Research and Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Surgery, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Division of Epidemiology, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210.
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Complex Orthopaedic Trauma Is Shifting Away From Level I to Non-Level I Trauma Centers: An Analysis of the National Trauma Data Bank. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202302000-00005. [PMID: 36749712 PMCID: PMC9907928 DOI: 10.5435/jaaosglobal-d-22-00288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 02/08/2023]
Abstract
INTRODUCTION 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.
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The Implications of the Emergency Medical Treatment and Labor Act and the No Surprises Act for Plastic and Reconstructive Surgeons. Plast Reconstr Surg 2023; 151:443-449. [PMID: 36696334 DOI: 10.1097/prs.0000000000009864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
SUMMARY The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress in 1986 to protect uninsured patients against economic discrimination. Although this law has been established for several decades, recent passage of the No Surprises Act may invoke new implications for the health care system under EMTALA. Therefore, it is worthwhile to review EMTALA's applications to the practice of plastic surgery and review EMTALA in the context of the recently passed No Surprises Act. First, providers are mandated by EMTALA to administer a medical screening examination to any patient presenting for emergent care. Second, providers must administer medical stabilization if the medical screening examination reveals an emergent condition. If the hospital lacks specialized capabilities to provide stabilizing care, they are required to transfer the patient to a facility that can provide care. Although EMTALA's provisions protect patients and provide them with leverage to obtain emergency care, the act has been associated with out-of-network, or "surprise," medical bills for the insured population and, ultimately, may be detrimental to plastic surgeons in emergency settings. The concerns related to EMTALA within plastic surgery involve the overburdening of surgeons at tertiary care centers because of uncompensated care and high rates of interfacility transfers. In addition, the recent passage of the No Surprises Act to end out-of-network emergency bills may further impact care provided by plastic surgeons in emergency settings under EMTALA's mandate. Potential methods to address these concerns include increasing on-call reimbursement rates and implementation of emergency department telemedicine services.
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Zogg CK, Schuster KM, Maung AA, Davis KA. The extent to which geography explains one of trauma's troubling trends: Insurance-based differences in appropriate interfacility transfer. J Trauma Acute Care Surg 2022; 93:686-694. [PMID: 35293375 PMCID: PMC9470786 DOI: 10.1097/ta.0000000000003605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A growing body of literature suggests the persistence of a counterproductive triage pattern wherein uninsured adults with major injuries presenting to nontrauma centers (NTCs) are more likely than insured adults to be transferred. Geographic differences are frequently blamed. The objective of this study was to explore geography's influence on variations in insurance transfer patterns, asking whether differences in distance and travel time by road from NTCs to the nearest level 1 or 2 trauma center alter the effect. As a secondary objective, differences in neighborhood socioeconomic disadvantage were also assessed. METHODS Adults (16-64 years) with major injuries (Injury Severity Score, >15) presenting to NTC emergency departments (EDs) were abstracted from 2007 to 2014 state inpatient/ED claims. Differences in the risk-adjusted odds of admission versus transfer were compared using mixed-effect hierarchical logistic regression and spatial analysis. RESULTS A total of 48,283 adults presenting to 492 NTC EDs were included. Among them, risk-adjusted admission differences based on insurance status exist (e.g., private vs. uninsured odds ratio [95% confidence interval], 1.60 [1.45-1.76]). Spatial analysis revealed significant geographic variation ( p < 0.001). However, in contrast to expectations, the largest insurance-based discrepancies were seen in less disadvantaged NTCs located closer to larger trauma centers. Stratified analyses comparing the closest versus furthest distance, shortest versus longest travel time, and least versus most deprived populations agreed, as did sensitivity analyses restricting uninsured transfer patients to those who remained uninsured versus subsequently became insured. CONCLUSION Adults with major injuries presenting to NTCs were less likely to be transferred if insured. The trend persisted after accounting for differences in access to care, revealing that, while significant geographic variation in the phenomenon exists, geography alone does not explain the issue. Taken together, the findings suggest that additional and potentially subjective elements to insurance-based triage disparities at NTCs are likely to exist. LEVEL OF EVIDENCE Prognostic/Epidemiological, Level III.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Adrian A. Maung
- Department of Surgery, Yale School of Medicine, New Haven, CT
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Hagan MJ, Pertsch NJ, Leary OP, Sastry R, Ganga A, Xi K, Zheng B, Kondamuri NS, Camara-Quintana JQ, Niu T, Sullivan PZ, Abinader JF, Telfeian AE, Gokaslan ZL, Oyelese AA, Fridley JS. Influence of Sociodemographic and Psychosocial Factors on Length of Stay After Surgical Management of Traumatic Spine Fracture with Spinal Cord Injury. World Neurosurg 2022; 166:e859-e871. [PMID: 35940503 DOI: 10.1016/j.wneu.2022.07.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Identifying patients at risk of increased health care resource utilization is a valuable opportunity to develop targeted preoperative and perioperative interventions. In the present investigation, we sought to examine patient sociodemographic factors that predict prolonged length of stay (LOS) after traumatic spine fracture. METHODS We performed a cohort analysis using the National Trauma Data Bank tabulated during 2012-2016. Eligible patients were those who were diagnosed with cervical or thoracic spine fracture with spinal cord injury and who were treated surgically. We evaluated the effects of sociodemographic as well as psychosocial variables on LOS by negative binomial regression and adjusted for injury severity, injury mechanism, and hospital characteristics. RESULTS We identified 3856 eligible patients with a median LOS of 9 days (interquartile range, 6-15 days). Patients in older age categories, who were male (incidence rate ratio (IRR), 1.05; 95% confidence interval [CI], 1.01-1.09), black (IRR, 1.12; CI, 1.05-1.19) or Hispanic (IRR, 1.09; CI, 1.03-1.16), insured by Medicaid (IRR, 1.24; CI, 1.17-1.31), or had a diagnosis of alcohol use disorder (IRR, 1.12; CI, 1.06-1.18) were significantly more likely to have a longer LOS. In addition, patients with severe injury on Injury Severity Score (IRR, 1.32; CI, 1.14-1.53) and lower Glasgow Coma Scale (GCS) scores (GCS score 3-8, IRR, 1.44; CI, 1.35-1.55; GCS score 9-11, IRR, 1.40; CI, 1.25-1.58) on admission had a significantly lengthier LOS. Patients admitted to a hospital in the Southern United States (IRR, 1.09; CI, 1.05-1.14) had longer LOS. CONCLUSIONS Socioeconomic factors such as race, insurance status, and alcohol use disorder were associated with a prolonged LOS after surgical management of traumatic spine fracture with spinal cord injury.
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Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rahul Sastry
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Arjun Ganga
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kevin Xi
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | | | - Joaquin Q Camara-Quintana
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Tianyi Niu
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Patricia Zadnik Sullivan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jose Fernandez Abinader
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.
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Haug EC, Pehlivan H, Macdonell JR, Novicoff W, Browne J, Brown T, Cui Q. Higher cost of arthroplasty for hip fractures in patients transferred from outside hospitals vs primary emergency department presentation. World J Orthop 2022; 13:725-732. [PMID: 36159622 PMCID: PMC9453283 DOI: 10.5312/wjo.v13.i8.725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/23/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In 2016 Centers for Medicare and Medicaid Services proposed bundled payments for hip fractures to improve the quality and decrease costs of care. Patients transferred from other facilities may be imposing a financial risk on the hospitals that accept these patients.
AIM To determine the costs associated with patients that either presented to the emergency department or were transferred from another hospital or skilled nursing facility (SNF) with the diagnosis of a hip fracture requiring operative intervention.
METHODS A retrospective single institution review was conducted for all arthroplasty patients from 2010 to 2015. Inclusion criteria included a total or partial hip replacement for a hip fracture. Exclusion criteria included pathologic, periprosthetic, and fracture non-union. Data was collected to compare total observed costs for patients from the emergency department, patients from skilled nursing facilities, and patients from an outside hospital.
RESULTS A total of 223 patients met the inclusion criteria. 135 (60.54%) of these patients presented primarily to the emergency department, 58 patients (26.01%) were transferred from an outside hospital, and 30 patients (13.43%) were transferred from a SNF. Cost data analysis showed that outside hospital patients demonstrated significantly greater total cost for their hospitalization ($43302) compared to emergency department patients ($28875, P = 0.000) and SNF patients ($28282, P = 0.000).
CONCLUSION Patients transferred from an outside hospital incurred greater costs for their hospitalization than patients presenting from an emergency department or SNF. This is a strong argument for risk-adjustment models when bundling payments for the care of hip fracture patients.
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Affiliation(s)
- Emanuel C Haug
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - Hakan Pehlivan
- Department of Orthopedic Surgery, Preferred Pediatric Orthopedic Surgery, Ridgewood, NJ 07450, United States
| | - J Ryan Macdonell
- Department of Orthopedic Surgery, Asheville Orthopedic Associates, Asheville, NC 28801, United States
| | - Wendy Novicoff
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - James Browne
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - Thomas Brown
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
| | - Quanjun Cui
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA 22908, United States
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12
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Evans CS, Hart K, Self WH, Nikpay S, Thompson CM, Ward MJ. Burn related injuries: a nationwide analysis of adult inter-facility transfers over a six-year period in the United States. BMC Emerg Med 2022; 22:147. [PMID: 35974305 PMCID: PMC9380358 DOI: 10.1186/s12873-022-00705-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background US emergency department (ED) visits for burns and factors associated with inter-facility transfer are unknown and described in this manuscript. Methods We conducted a retrospective analysis of burn-related injuries from 2009–2014 using the Nationwide Emergency Department Sample (NEDS), the largest sample of all-payer datasets. We included all ED visits by adults with a burn related ICD-9 code and used a weighted multivariable logistic regression model to predict transfer adjusting for covariates. Results Between 2009–2014, 3,047,701 (0.4%) ED visits were for burn related injuries. A total of 108,583 (3.6%) burn visits resulted in inter-facility transfers occurred during the study period, representing approximately 18,097 inter-facility transfers per year. Burns with greater than 10% total body surface area (TBSA) resulted in a 10-fold increase in the probability of transfer, compared to burn visits with less than 10% TBSA burns. In the multivariable model, male sex (adjusted odds ratio [aOR] 2.4, 95% CI 2.3–2.6) was associated with increased odds of transfer. Older adults were more likely to be transferred compared to all other age groups. Odds of transfer were increased for Medicare and self-pay patients (vs. private pay) but there was a significant interaction of sex and payer and the effect of insurance varied by sex. Conclusions In a national sample of ED visits, burn visits were more than twice as likely to have an inter-facility transfer compared to the general ED patient population. Substantial sex differences exist in U.S. EDs that impact the location of care for patients with burn injuries and warrants further investigation. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00705-6.
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Affiliation(s)
- Christopher S Evans
- Information Services, ECU Health, Greenville, NC, USA.,Department of Emergency Medicine, East Carolina University, Greenville, NC, USA
| | - Kimberly Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sayeh Nikpay
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | | | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. .,VA Tennessee Valley Healthcare System, 1313 21st Ave South; Oxford House 312, Nashville, TN, 37232, USA.
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13
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Willer BL, Mpody C, Thakkar RK, Tobias JD, Nafiu OO. Association of Race With Postoperative Mortality Following Major Abdominopelvic Trauma in Children. J Surg Res 2022; 269:178-188. [PMID: 34571261 DOI: 10.1016/j.jss.2021.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/15/2021] [Accepted: 07/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma. MATERIALS AND METHODS We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were < 18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity. RESULTS We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P < 0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers. CONCLUSIONS Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio.
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Rajan K Thakkar
- Department of General Pediatric Surgery, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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14
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Kulaylat AN, Hollenbeak CS, Armen SB, Cilley RE, Engbrecht BW. The Association of Race, Sex, and Insurance With Transfer From Adult to Pediatric Trauma Centers. Pediatr Emerg Care 2021; 37:e1623-e1630. [PMID: 32569252 DOI: 10.1097/pec.0000000000002137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Our objective was to investigate whether racial/ethnic-based or payer-based disparities existed in the transfer practices of pediatric trauma patients from adult trauma center (ATC) to pediatric trauma center (PTC) in Pennsylvania. METHODS Data on trauma patients aged 14 years or less initially evaluated at level I and II ATC were obtained from the Pennsylvania Trauma Outcome Study (2008-2012) (n = 3446). Generalized estimating equations regression analyses were used to evaluate predictors of subsequent transfer controlling for confounders and clustering. Recent literature has described racial and socioeconomic disparities in outcomes such as mortality after trauma; it is unknown whether these factors also influence the likelihood of subsequent interfacility transfer between ATC and PTC. RESULTS Patients identified as nonwhite comprised 36.1% of the study population. Those without insurance comprised 9.9% of the population. There were 2790 patients (77.4%) who were subsequently transferred. Nonwhite race (odds ratio [OR], 4.3), female sex (OR, 1.3), and lack of insurance (OR, 2.3) were associated with interfacility transfer. Additional factors were identified influencing likelihood of transfer (increased odds: younger age, intubated status, cranial, orthopedic, and solid organ injury; decreased odds: operative intervention at the initial trauma center) (P < 0.05 for all). CONCLUSIONS Although we assume that a desire for specialized care is the primary reason for transfer of injured children to PTCs, our analysis demonstrates that race, female sex, and lack of insurance are also associated with transfers from ATCs to PTCs for children younger than 15 years in Pennsylvania. Further research is needed to understand the basis of these health care disparities and their impact.
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Affiliation(s)
| | | | | | | | - Brett W Engbrecht
- Division of Pediatric Surgery, Peyton Manning Children's Hospital, Indianapolis, IN
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15
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Teng CY, Davis BS, Rosengart MR, Carley KM, Kahn JM. Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions. JAMA Netw Open 2021; 4:e2123389. [PMID: 34468755 PMCID: PMC8411299 DOI: 10.1001/jamanetworkopen.2021.23389] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/27/2021] [Indexed: 12/30/2022] Open
Abstract
Importance Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood. Objective To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes. Design, Setting, and Participants This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021. Exposures Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality). Main Outcomes and Measures The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes. Results Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: β = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = -0.50 [95% CI, -1.13 to 0.12]; P = .27). Conclusions and Relevance In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.
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Affiliation(s)
- Cindy Y. Teng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Billie S. Davis
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathleen M. Carley
- Department of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
- Department of Public Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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16
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Pontell M, Mount D, Steinberg JP, Mackay D, Golinko M, Drolet BC. Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon. Craniomaxillofac Trauma Reconstr 2021; 14:201-208. [PMID: 34471476 PMCID: PMC8385630 DOI: 10.1177/1943387520962276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
STUDY DESIGN Secondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit. OBJECTIVE The aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma. METHODS A 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant. RESULTS The survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected. CONCLUSION Most facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.
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Affiliation(s)
- Matthew Pontell
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Delora Mount
- Division of Plastic Surgery, University of Wisconsin Hospital, Madison, WI, USA
| | - Jordan P. Steinberg
- Department of Plastic and Reconstructive Surgery, Pediatric Plastic and Craniofacial Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Donald Mackay
- Division of Plastic Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Michael Golinko
- Division of Pediatric Plastic Surgery, Division of Cleft and Craniofacial Surgery, Monroe Carrell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
| | - Brian C. Drolet
- Department of Plastic Surgery, Department of Medical Bioinformatics, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Grossman Verner HM, Figueroa BA, Salgado Crespo M, Lorenzo M, Amos JD. Trauma center funding: time for an update. Trauma Surg Acute Care Open 2021; 6:e000596. [PMID: 34423132 PMCID: PMC8340286 DOI: 10.1136/tsaco-2020-000596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 06/21/2021] [Indexed: 01/04/2023] Open
Abstract
Background Uncompensated care (UC) is healthcare provided with no payment from the patient or an insurance provider. UC directly contributes to escalating healthcare costs in the USA and potentially impacts patient care. In Texas, there has been a steady increase in the number of trauma centers and UC volumes without an increase in trauma funding of UC. The method of calculating UC trauma funds in Texas is imprecise as it is driven by Medicaid volumes and not actual trauma care costs. Methods Five years of annual trauma UC disbursement reports from the Texas Department of State Health Services were used to determine changes in UC economic considerations for level I, II, and III trauma centers in the largest urban trauma service areas (TSAs). Data for UC costs, compensation, and TSA demographics were used to assess variations. Statistical significance was determined using a Kruskal-Wallis test with Dunn's pairwise comparison post-hoc analysis and logistic regression. Results TSA-E (Dallas-Fort Worth area) has 33% of the level I trauma centers in Texas (n=6) and yet serves only 27% of the total state population across 14 metropolitan and 5 non-metropolitan counties. Since 2015, TSA-E has shown higher UC costs (p<0.02) and lower reimbursement (p<0.01) than the second largest urban hub, TSA-Q (Houston area). TSA-E level I trauma centers trended towards decreased UC reimbursements. Discussion The unregulated expansion of trauma centers in Texas has led to an unprecedented increase in hospitals participating in trauma care. The unbalanced allocation of UC funding could lead to further economic instability, compromise resource allocation, and negatively impact patient care in an already fragile healthcare environment. Level of evidence Level IV; Retrospective economic analysis and evaluation.
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Affiliation(s)
| | - Brian A Figueroa
- Clinical Research Institute, Methodist Health System, Dallas, Texas, USA
| | - Marcos Salgado Crespo
- Associates in Surgical Acute Care, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Manuel Lorenzo
- Associates in Surgical Acute Care, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Joseph D Amos
- Associates in Surgical Acute Care, Methodist Dallas Medical Center, Dallas, Texas, USA
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18
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Shannon EM, Schnipper JL, Mueller SK. Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study. J Gen Intern Med 2020; 35:2939-2946. [PMID: 32700216 PMCID: PMC7572909 DOI: 10.1007/s11606-020-06046-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 07/07/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized. OBJECTIVE To evaluate the association between race/ethnicity and IHT. DESIGN Cross-sectional analysis of 2016 National Inpatient Sample data. PATIENTS Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed. MAIN MEASURES We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis. KEY RESULTS Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78-0.89) and Hispanic (OR 0.81, 95% CI 0.75-0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79-0.98). Disparities in IHT by race/ethnicity varied by region and medical diagnosis. CONCLUSIONS Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.
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Affiliation(s)
- Evan Michael Shannon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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19
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Hauser BM, Gupta S, Xu E, Wu K, Bernstock JD, Chua M, Khawaja AM, Smith TR, Dunn IF, Bergmark RW, Bi WL. Impact of insurance on hospital course and readmission after resection of benign meningioma. J Neurooncol 2020; 149:131-140. [PMID: 32654076 DOI: 10.1007/s11060-020-03581-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/02/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Surgical outcomes and healthcare utilization have been shown to vary based on patient insurance status. We analyzed whether patients' insurance affects case urgency for and readmission after craniotomy for meningioma resection, using benign meningioma as a model system to minimize confounding from the disease-related characteristics of other neurosurgical pathologies. METHODS We analyzed 90-day readmission for patients who underwent resection of a benign meningioma in the Nationwide Readmission Database from 2014-2015. RESULTS A total of 9783 meningioma patients with private insurance (46%), Medicare (39%), Medicaid (10%), self-pay (2%), or another scheme (3%) were analyzed. 72% of all cases were elective; with 78% of cases in privately insured patients being elective compared to 71% of Medicare (p > 0.05), 59% of Medicaid patients (OR 2.3, p < 0.001), and 49% of self-pay patients (OR 3.4, p < 0.001). Medicare (OR 1.5, p = 0.002) and Medicaid (OR 1.4, p = 0.035) were both associated with higher likelihood of 90-day readmission compared to private insurance. In comparison, 30-day analyses did not unveil this discrepancy between Medicaid and privately insured, highlighting the merit for longer-term outcomes analyses in value-based care. Patients readmitted within 30 days versus those with later readmissions possessed different characteristics. CONCLUSIONS Compared to patients with private insurance coverage, Medicaid and self-pay patients were significantly more likely to undergo non-elective resection of benign meningioma. Medicaid and Medicare insurance were associated with a higher likelihood of 90-day readmission; only Medicare was significant at 30 days. Both 30 and 90-day outcomes merit consideration given differences in readmitted populations.
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Affiliation(s)
| | - Saksham Gupta
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.,Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Edward Xu
- Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Kyle Wu
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Joshua D Bernstock
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Melissa Chua
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA
| | - Ayaz M Khawaja
- Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Timothy R Smith
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.,Computational Neurosurgical Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Regan W Bergmark
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.,Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Wenya Linda Bi
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, Boston, MA, 02115, USA.
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20
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Xu TQ, Wiegmann AL, Jarazcewski TJ, Ritz EM, Santos CAQ, Dorafshar AH. Patient Race and Insurance Status Do Not Impact the Treatment of Simple Mandibular Fractures. Craniomaxillofac Trauma Reconstr 2020; 13:15-22. [PMID: 32642027 PMCID: PMC7311844 DOI: 10.1177/1943387520905399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Health-care disparities have been reported throughout medical literature for decades. While blatant explicit bias is not prevalent, a substantial body of research has been published suggesting that systemic biases related to sex, race, income, and insurance status likely exist. To our knowledge, no study has assessed the impact of patient race and insurance status on clinical decision-making in facial fracture repair in the United States. Thus, the objective of this project was to assess if race and insurance status impacted whether patients obtained open or closed treatment of simple mandibular fractures. METHODS Patients who had either open or closed treatment of mandibular fractures were extracted from the 2012 and 2013 National Inpatient Sample and analyzed. Patients who had a length of stay longer than 3 days or died during their inpatient stay were excluded. These exclusion criteria were used to control for patients with polytrauma as well as complicated fractures. Univariate analysis was undertaken to elucidate different variable associations with the type of reduction performed. All covariates were then entered into a multivariable logistic regression model to test the variables simultaneously. RESULTS Patients with simple condylar, alveolar border, and closed mandibular fractures were more likely to undergo closed reduction (CR) on univariate analysis, as were patients with female gender and a fall mechanism (P value < .05). African Americans, Hispanics, and patients without insurance were more likely to undergo open reduction on univariate analysis (P value < .05). Multivariate analysis demonstrated that patients with simple condylar, subcondylar, alveolar border, or closed mandibular fractures were more likely to undergo a CR, as were patients with female gender and a firearm or fall mechanism (P < .05). However, neither race nor insurance status demonstrated a statistically significant association with closed or open reduction. CONCLUSION Anatomic location and mechanism of injury were the variables found to be significantly associated with patients undergoing open reduction versus CR of simple mandibular fractures-not race or insurance status.
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Affiliation(s)
- Thomas Q. Xu
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Aaron L. Wiegmann
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Taylor J. Jarazcewski
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Ethan M. Ritz
- Bioinformatics and Biostatistics Core at Rush University, Rush University Medical Center, Chicago, IL, USA
| | - Carlos A. Q. Santos
- Bioinformatics and Biostatistics Core at Rush University, Rush University Medical Center, Chicago, IL, USA
| | - Amir H. Dorafshar
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
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21
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Parikh PP, Parikh P, Mamer L, McCarthy MC, Sakran JV. Association of System-Level Factors With Secondary Overtriage in Trauma Patients. JAMA Surg 2019; 154:19-25. [PMID: 30325989 DOI: 10.1001/jamasurg.2018.3209] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance Studies show that secondary overtriage (SO) contributes significantly to the economic burden of injured patients; thus, the association of SO with use of the trauma system has been examined. However, the association of the underlying trauma system design with such overtriage has yet to be evaluated. Objectives To evaluate whether the distribution of trauma centers in a statewide trauma system is associated with SO and to identify clinical and demographic factors that may lead to SO. Design, Setting, and Participants A retrospective cohort study was performed using 2008-2012 data from the Ohio Trauma and Emergency Medical Services registries. All patients taken to level III or nontrauma centers from the scene of the injury with an Injury Severity Score less than 15 and discharged alive were included. Among these patients, those with SO were identified as those who were subsequently transferred to a level I or II trauma center, had no surgical intervention, and were discharged alive within 48 hours of admission. The SO group was analyzed descriptively. Multiple logistic regression was used to identify system-level factors associated with SO. Statistical analysis was performed from August 1, 2017, to January 31, 2018. Main Outcomes and Measures The primary outcome was the occurrence of SO. Results Of 34 494 trauma patients able to be matched in the 2 registries, 7881 (22.9%) met the inclusion criteria, of whom 965 (12.2%) had SO. The median age in the SO group was 40 years (interquartile range, 26-55 years), with 299 women and 666 men. After adjusting for age, sex, comorbidities, injury type, and insurance status, the study found that system-level factors (number of level I or II trauma centers in the region [>1]) were significantly associated with SO (adjusted odds ratio, 1.98; 95% CI, 1.64-2.38; P < .001; area under the curve, 0.89). The reasons for choice of destination by emergency medical services (specifically, choosing the closest facility: adjusted odds ratio, 1.65; 95% CI, 1.37-1.98; P < .001) and use of a field trauma triage protocol (adjusted odds ratio, 2.21; 95% CI, 1.70-2.87; P < .001), significantly increased the likelihood of SO. Conclusions and Relevance This study's findings suggest that the distribution of major trauma centers in the region is significantly associated with SO. Subsequent investigation to identify the optimal number and distribution of trauma centers may therefore be critical. Specific outreach and collaboration of level III trauma centers and nontrauma centers with level I and II trauma centers, along with the use of telemedicine, may provide further guidance to level III trauma centers and nontrauma centers on when to transfer injured patients.
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Affiliation(s)
- Priti P Parikh
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Pratik Parikh
- Department of Surgery, Wright State University, Dayton, Ohio.,Department of Biomedical, Industrial, and Human Factors Engineering, Wright State University, Dayton, Ohio
| | - Logan Mamer
- Department of Biomedical, Industrial, and Human Factors Engineering, Wright State University, Dayton, Ohio
| | - Mary C McCarthy
- Department of Surgery, Wright State University, Dayton, Ohio
| | - Joseph V Sakran
- Department of Surgery, Johns Hopkins University, Baltimore, Maryland
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Chen H, Scarborough J, Zens T, Brummeyer B, Agarwal S, Haines KL. Race and Insurance Status as Predictors of Bicycle Trauma Outcome in Adults. J Surg Res 2019; 245:198-204. [PMID: 31421362 DOI: 10.1016/j.jss.2019.07.064] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 07/10/2019] [Accepted: 07/19/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Race and insurance status have been shown to predict outcomes in pediatric bicycle traumas. It is unknown how these factors influence outcomes in adult bicycle traumas. This study aims to evaluate the association, if any, between race and insurance status with mortality in adults. METHODS This retrospective cohort study used the National Trauma Data Bank Research Data Set for the years 2013-2015. Multivariate logistic regression models were used to determine the independent association between patient race and insurance status on helmet use and on outcomes after hospitalization for bicycle-related injury. These models adjusted for demographic factors and comorbid variables. When examining the association between race and insurance status with outcomes after hospitalization, injury characteristics were also included. RESULTS A study population of 45,063 met the inclusion and exclusion criteria. Multivariate regression demonstrated that black adults and Hispanic adults were significantly less likely to be helmeted at the time of injury than white adults [adjusted odds ratio of helmet use for blacks 0.25 (95% CI 0.22-0.28) and for Hispanics 0.33 (95% CI 0.30-0.36) versus whites]. Helmet usage was also independently associated with insurance status, with Medicare-insured patients [AOR 0.51 (95% CI 0.47-0.56) versus private-insured patients], Medicaid-insured patients [AOR 0.18 (95% CI 0.17-0.20)], and uninsured patients [AOR 0.29 (95% CI 0.27-0.32)] being significantly less likely to be wearing a helmet at the time of injury compared with private-insured patients. Although patient race was not independently associated with hospital mortality among adult bicyclists, we found that uninsured patients had significantly higher odds of mortality [AOR 2.02 (AOR 1.31-3.12)] compared with private-insured patients. CONCLUSIONS Minorities and underinsured patients are significantly less likely to be helmeted at the time of bicycle-related trauma when compared with white patients and those with private insurance. Public health efforts to improve the utilization of helmets during bicycling should target these subpopulations.
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Affiliation(s)
- HuaFu Chen
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John Scarborough
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Tiffany Zens
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Brandon Brummeyer
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Suresh Agarwal
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Krista L Haines
- Division of Trauma, Acute, and Critical Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Abstract
BACKGROUND Emergency room transfers to a higher level of care are a vital component of modern health care, as optimal care of patients requires providing access to specialized personnel and facilities. However, literature has shown that orthopaedic transfers to a higher level of care facility are frequently unnecessary. The purpose of this study was to assess the appropriateness of pediatric orthopaedic transfers to a tertiary care center and the factors surrounding these transfers. METHODS All pediatric orthopaedic transfers to the pediatric emergency department (ED) were evaluated over a 4-year period. A retrospective chart review was performed to assess the factors surrounding the transfer including patient demographics, time of transfer, day of transfer, insurance status, outcome of transfer, and diagnosis. Three independent variables were utilized to assess the appropriateness of the transfer: the need for an operative procedure, the need for conscious sedation, and the need for a closed reduction in the ED. RESULTS A total of 218 pediatric orthopaedic emergency room transfers were evaluated, of which 86% of them involved an acute fracture. Twenty-seven percent (59/218) of the transfers occurred on the weekend, with over half (61%) of these transfers being initiated between 6 PM and 6 AM. Approximately half (47%) of the transfers involved patients with Medicaid. Fifty-five percent (120/218) of cases required a procedure in the operating room and 22% (49/218) had a closed reduction performed in the ED. Conscious sedation was provided in the ED for 22% (48/218) of patients. Twenty-two percent (47/218) of transfers did not require a trip to the operating room, conscious sedation, nor a closed reduction procedure in the ED. CONCLUSION The vast majority of pediatric orthopaedic transfers are warranted as they required operative intervention, a closed reduction maneuver, or conscious sedation in the ED. LEVEL OF EVIDENCE Level III-Therapeutic.
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Factors Associated With the Interhospital Transfer of Emergency General Surgery Patients. J Surg Res 2019; 240:191-200. [PMID: 30978599 DOI: 10.1016/j.jss.2018.11.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 10/22/2018] [Accepted: 11/26/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Transferred emergency general surgery (EGS) patients constitute a highly vulnerable, acutely ill population. Guidelines to facilitate timely, appropriate EGS transfers are lacking. We determined patient- and hospital-level factors associated with interhospital EGS transfers, a critical first step to identifying which patients may require transfer. METHODS Adult EGS patients (defined by American Association for the Surgery of Trauma International Classification of Diseases, Ninth Revision diagnosis codes) were identified within the 2008-2013 Nationwide Inpatient Sample (n = 17,175,450). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multivariate proportional cause-specific hazards model with a competing risk analysis to assess the effect of risk factors for transfer. RESULTS 1.8% of encounters resulted in a transfer (n = 318,286). Transferred patients were on average 62 y old and most commonly had Medicare (52.9% [n = 168,363]), private (26.7% [n = 84,991]), or Medicaid insurance (10.8% [n = 34,279]). 67.7% were white. The most common EGS diagnoses among transferred patients were related to hepatic-pancreatic-biliary (n = 90,989 [28.6%]) and upper gastrointestinal tract (n = 60,088 [18.9%]) conditions. Most transferred patients (n = 269,976 [84.8%]) did not have a procedure before transfer. Transfer was more likely if patients were in small (hazard ratio 2.52, 95% confidence interval 2.28-2.79) or medium (1.32, 1.21-1.44) versus large facilities, government (1.19, 1.11-1.28) versus private facilities, and rural (4.58, 3.98-5.27) or urban nonteaching (1.89, 1.70-2.10) versus urban teaching facilities. Patient-level factors were not strong predictors of transfer. CONCLUSIONS We identified that hospital-level characteristics more strongly predicted the need for transfer than patient-related factors. Consideration of these factors by providers as care is delivered in the context of the resources and capabilities of local institutions may facilitate transfer decision-making.
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Kappy NS, Hazelton JP, Capano-Wehrle L, Gibbs R, Dalton MK, Ross SE. Financial Impact of Minor Injury Transfers on a Level 1 Trauma Center. J Surg Res 2019; 233:403-407. [DOI: 10.1016/j.jss.2018.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 07/13/2018] [Accepted: 08/18/2018] [Indexed: 10/28/2022]
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Insurance Status Biases Trauma-system Utilization and Appropriate Interfacility Transfer. Ann Surg 2018; 268:681-689. [DOI: 10.1097/sla.0000000000002954] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
OBJECTIVE To compare a cohort of transferred pediatric orthopaedic patients with orthopaedic patients who primarily presented to a Level 1 pediatric emergency department to identify risk factors for transfer. DESIGN Retrospective cohort study. SETTING Level 1 trauma center in New York. PATIENTS The cohort consisted of patients younger than 18 years who presented to 1 Level 1 pediatric trauma center between January 1, 2013, and December 31, 2013, with an orthopaedic fracture diagnosis code (ICD-9 805.0-839.9). The control group included the patients who presented to that hospital primarily, and the study group included patients who were transferred to that same hospital from another institution. INTERVENTION Demographic and injury-related data [age, sex, mechanism of injury, location of injury, injury severity score, and insurance status] were collected. MAIN OUTCOME MEASUREMENTS Regression analysis was performed to assess for predictors of transfer to a Level 1 hospital. Subgroup analysis examined whether transfers were appropriate, based on the type of injury. RESULTS There were 1064 patients in the nontransfer group and 67 patients in the transfer group. Transferred patients were more likely to have surgery within 24 hours (39.42% vs. 2.63%) and were more likely to have no insurance or Medicaid (50.75% vs. 33.24%). Injury severity score and insurance status were independent predictors for transfer. CONCLUSIONS This study indicates that injury severity is the primary predictor in deciding to transfer a pediatric patient; however, insurance status may play a role in that decision. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Jones RE, Gee KM, Burkhalter LS, Beres AL. Correlation of payor status and pediatric transfer for acute appendicitis. J Surg Res 2018; 229:216-222. [PMID: 29936993 DOI: 10.1016/j.jss.2018.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/15/2018] [Accepted: 04/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tertiary referral centers provide specialty and critical care for patients presenting to hospitals that lack these resources. There is a notion among tertiary centers that outside hospitals are more likely to transfer uninsured or underinsured patients. We examined funding status of patients transferred to our tertiary pediatric hospital for surgical management of appendicitis, hypothesizing that transferred patients were more likely to have unfavorable coverage. MATERIALS AND METHODS The electronic medical record was queried for all cases of laparoscopic appendectomy at our hospital between 2011 and 2015. Insurance was grouped into three categories: commercial, Medicaid/Children's Health Insurance Plan, or none. Transferred patients were compared to patients who presented directly. RESULTS A total of 5758 patients underwent laparoscopic appendectomy during the study period, of which 1683 (29.2%) were transfer patients. Transfer patients were more likely to be older, with a median age of 10.5 y versus 9.8 y in nontransferred patients (P ≤ 0.0001), and were more likely to be identified as non-Hispanic (50.0% versus 36.5%; P ≤ 0.0001). Insurance coverage was similar between groups. However, subgroup analysis of the hospitals that most frequently used our transfer services revealed a trend to transfer a higher proportion of Medicaid/Children's Health Insurance Plan patients. CONCLUSIONS Overall, pediatric patients transferred for laparoscopic appendectomy had similar insurance coverage to patients admitted directly, but subgroup analysis shows that not all centers follow this trend. Transfer patients were more frequently older and non-Hispanic. This builds upon the existing literature regarding the correlation of funding and transfer practices and highlights the need for additional research in this area.
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Affiliation(s)
- Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
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Abstract
OBJECTIVES Patient transfers between hospitals are becoming more common in the United States. Disease-specific studies have reported varying outcomes associated with transfer status. However, even as national quality improvement efforts and regulations are being actively adopted, forcing hospitals to become financially accountable for the quality of care provided, surprisingly little is known about transfer patients or their outcomes at a population level. This population-wide study provides timely analyses of the characteristics of this particularly vulnerable and sizable inpatient population. We identified and compared characteristics and outcomes of transfer and nontransfer patients. METHODS With the use of the 2009 Nationwide Inpatient Sample, a nationally representative sample of U.S. hospitalizations, we examined patient characteristics, in-hospital adverse events, and discharge disposition for transfer versus nontransfer patients in this observational study. RESULTS We identified 1,397,712 transfer patients and 31,692,211 nontransfer patients. Age, sex, race, and payer were significantly associated with odds of transfer (P < 0.05). Transfer patients had higher risk-adjusted inpatient mortality (4.6 versus 2.1, P < 0.01), longer length of stay (13.3 versus 4.5, P < 0.01), and fewer routine disposition discharges (53.6 versus 68.7, P < 0.01). In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients (P < 0.05). CONCLUSIONS Our results suggest that transfer patients have inferior outcomes compared with nontransfer patients. Although they are clinically complex patients and assessing accountability as between the transferring and receiving hospitals is methodologically difficult, transfer patients must nonetheless be included in quality benchmark data to assess the potential impact this population has on hospital outcome profiles. With hospital accountability and value-based payments constituting an integral part of health care reform, documenting the quality of care delivered to transfer patients is essential before accurate quality assessment improvement efforts can begin in this patient population.
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Appropriateness of patients transferred with orthopedic injuries: experience of a level I trauma center. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:551-554. [DOI: 10.1007/s00590-018-2134-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/17/2018] [Indexed: 12/23/2022]
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Medford-Davis LN, Holena DN, Karp D, Kallan MJ, Delgado MK. Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury. Am J Emerg Med 2017; 36:797-803. [PMID: 29055613 DOI: 10.1016/j.ajem.2017.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/07/2017] [Accepted: 10/09/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Among injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation. METHODS We analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures. RESULTS In 2011, there were a total of 48,160 ED-to-ED injury transfers, half of which (49%) were transferred to non-trauma centers, including 23% with major trauma. A total of 22,011 transfers went to a higher level of care, of which 36% were discharged from the ED without procedures. Relative to torso injuries, discharge without procedures was more likely for patients with soft tissue (OR 6.8, 95%CI 5.6-8.2), head (OR 3.7, 95%CI 3.1-4.6), facial (OR 3.8, 95%CI 3.1-4.7), or hand (OR 3.1, 95%CI 2.6-3.8) injuries. Other factors included Medicaid (OR 1.3, 95%CI 1.2-1.5) or uninsured (OR 1.3, 95%CI 1.2-1.5) status. Treatment at the receiving ED added an additional $2859 on average (95% CI $2750-$2968) per discharged patient to the total charges for injury care, not including the costs of ambulance transport between facilities. CONCLUSION Over a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures. Telemedicine consultation with sub-specialists might reduce some of these transfers.
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Affiliation(s)
- Laura N Medford-Davis
- Department of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, United States.
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
| | - David Karp
- University of Pennsylvania Wharton Geographic Information Systems Lab, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - Michael J Kallan
- University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - M Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 933 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
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Huang Y, Kissee JL, Dayal P, Wang NE, Sigal IS, Marcin JP. Association Between Insurance and Transfer of Injured Children From Emergency Departments. Pediatrics 2017; 140:peds.2016-3640. [PMID: 28928288 DOI: 10.1542/peds.2016-3640] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine if injured children presenting to nondesignated trauma centers are more or less likely to be transferred relative to being admitted based on insurance status. METHODS We conducted a cross-sectional study by using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Pediatric trauma patients receiving care in emergency departments (EDs) at nontrauma centers who were either admitted locally or transferred to another hospital were included. We performed logistic regression analysis adjusting for injury severity and other confounders and incorporated nationally representative weights to determine the association between insurance and transfer or admission. RESULTS Nine thousand four hundred and sixty-one ED pediatric trauma events at 386 nontrauma centers met inclusion criteria. EDs that treated a higher proportion of patients with Medicaid had higher odds of transfer relative to admission (odds ratio [OR]: 1.2 per 10% increase in Medicaid; 95% confidence interval [CI]: 1.1-1.4), resulting in overall higher odds of transfer among patients with Medicaid compared with patients with private insurance (OR: 1.3; 95% CI: 1.0-1.5). A patient's insurance status was not associated with different odds of transfer relative to admission within individual EDs after adjusting for the ED's proportion of patients with Medicaid (Medicaid OR: 1.0; 95% CI: 0.8-1.1). CONCLUSIONS Injured pediatric patients presenting to nondesignated trauma centers are slightly more likely to be transferred than admitted when the ED treats a higher proportion of Medicaid patients. In this study, ongoing concerns about inequities in the delivery of care among hospitals treating high proportions of children with Medicaid are reinforced.
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Affiliation(s)
- Yunru Huang
- Department of Pediatrics, University of California, Davis, Sacramento, California; and
| | - Jamie L Kissee
- Department of Pediatrics, University of California, Davis, Sacramento, California; and
| | - Parul Dayal
- Department of Pediatrics, University of California, Davis, Sacramento, California; and
| | - Nancy Ewen Wang
- Division of Emergency Medicine, Department of Surgery, Stanford University, Stanford, California
| | - Ilana S Sigal
- Department of Pediatrics, University of California, Davis, Sacramento, California; and
| | - James P Marcin
- Department of Pediatrics, University of California, Davis, Sacramento, California; and
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Peng J, Wheeler K, Groner JI, Haley KJ, Xiang H. Undertriage of Pediatric Major Trauma Patients in the United States. Clin Pediatr (Phila) 2017; 56:845-853. [PMID: 28516800 PMCID: PMC6518411 DOI: 10.1177/0009922817709553] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although trauma undertriage has been widely discussed in the literature, undertriage in the pediatric trauma population remains understudied. Using the 2009-2013 Nationwide Emergency Department Sample, we assessed the national undertriage rate in pediatric major trauma patients (age ≤16 years and injury severity score [ISS] >15), and identified factors associated with pediatric trauma undertriage. Nationally, 21.7% of pediatric major trauma patients were undertriaged. Children living in rural areas were more likely to be undertriaged ( P = .02), as were those without insurance ( P = .00). Children with life-threatening injuries were less likely to be undertriaged ( P < .0001), as were those with chronic conditions ( P < .0001). Improving access to specialized pediatric trauma care through innovative service delivery models may reduce undertriage and improve outcomes for pediatric major trauma patients.
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Affiliation(s)
- Jin Peng
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Ohio State University, College of Public Health, Columbus, OH, USA
| | - Krista Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Ohio State University, College of Medicine, Columbus, OH, USA,Department of Pediatric Surgery, Trauma Program, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kathryn J. Haley
- Department of Pediatric Surgery, Trauma Program, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA,The Ohio State University, College of Public Health, Columbus, OH, USA,The Ohio State University, College of Medicine, Columbus, OH, USA
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Zhou Q, Rosengart MR, Billiar TR, Peitzman AB, Sperry JL, Brown JB. Factors Associated With Nontransfer in Trauma Patients Meeting American College of Surgeons' Criteria for Transfer at Nontertiary Centers. JAMA Surg 2017; 152:369-376. [PMID: 28052158 DOI: 10.1001/jamasurg.2016.4976] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Secondary triage from nontertiary centers is vital to trauma system success. It remains unclear what factors are associated with nontransfer among patients who should be considered for transfer to facilities providing higher-level care. Objective To identify factors associated with nontransfer among patients meeting American College of Surgeons (ACS) guideline criteria for transfer from nontertiary centers. Design, Setting, and Participants A retrospective cohort study was performed using multilevel logistic regression to ascertain factors associated with nontransfer from nontertiary centers, including demographics, injury characteristics, and center resources. With information obtained from the National Trauma Data Bank (January 1, 2007, to December 31, 2012), relative proportion of variance in outcome across centers was determined for patient-level and center-level attributes. In all, 96 528 patients taken to nontertiary centers (levels III, IV, V, and nontrauma centers) that met ACS guideline transfer criteria were eligible for inclusion. Data analysis was performed from March 17, 2016, to May 20, 2016. Main Outcomes and Measures The primary outcome was nontransfer from a nontertiary center. Results Among 96 528 patients meeting ACS guideline criteria for transfer taken initially to nontertiary centers, 55 611 (57.6%) were male and the median age was 52 years (interquartile range, 28-77 years). Only 19 396 patients (20.1%) underwent transfer. Patient-level factors associated with nontransfer included age older than 65 years (adjusted odds ratio [AOR], 1.70; 95% CI, 1.46-1.98; P < .001), severe chest injury (AOR, 1.63; 95% CI, 1.42-1.89; P < .001), and commercial insurance (vs self-pay: AOR, 1.39; 95% CI, 1.15-1.67; P < .001). Center-level factors associated with nontransfer included larger bed size (>600 vs <200 beds: AOR, 9.22; 95% CI, 7.70-11.05; P < .001), nontrauma center (vs level III centers: AOR, 2.71; 95% CI, 2.44-3.01; P < .001), university affiliation (vs community: AOR, 9.68; 95% CI, 8.03-11.66; P < .001), more trauma surgeons (per surgeon: AOR, 1.08; 95% CI, 1.06-1.09; P < .001), and more neurosurgeons (per surgeon: AOR, 1.25; 95% CI, 1.23-1.28; P < .001). For-profit status was associated with nontransfer at nontrauma centers (AOR, 1.55; 95% CI, 1.39-1.74; P < .001), but not at level III, IV, and V trauma centers. Overall, patient-level factors accounted for 36% and center-level factors accounted for 58% of the variation in transfer practices. Patient-level factors accounted for more variation at level III, IV, and V trauma centers (44%), but less variation at nontrauma centers (13%). Conclusions and Relevance Only 1 in 5 patients meeting ACS transfer criteria underwent transfer. Factors associated with nontransfer may be useful for trauma system stakeholders to target education and outreach to guide development of more inclusive trauma systems. Further study is necessary to critically evaluate whether these ACS criteria identify patients who require transfer.
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Affiliation(s)
- Quanhong Zhou
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Department of Anesthesiology, Shanghai Sixth People's Hospital, Shanghai, China
| | - Matthew R Rosengart
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Timothy R Billiar
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew B Peitzman
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason L Sperry
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua B Brown
- Division of General Surgery and Trauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Unnecessary Emergency Transfers for Evaluation by a Plastic Surgeon: A Burden to Patients and the Health Care System. Plast Reconstr Surg 2017; 137:1927-1933. [PMID: 27219245 DOI: 10.1097/prs.0000000000002147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Plastic surgeons are frequently consulted for hand and facial injuries, and patients are often transferred to trauma centers for evaluation of these problems. The authors sought to identify the frequency and impact of "unnecessary" transfers for emergency evaluation by a plastic surgeon at a Level I trauma center. METHODS The authors reviewed more than 32,000 consecutive emergency department encounters at their institution between April of 2009 and April of 2013 and found 1181 patients transferred for evaluation by plastic surgery. Using a retrospective chart review, necessity of transfer was determined based on the intervention performed at the authors' institution and the availability of resources at the transferring site. RESULTS Of all the patients referred for "emergency" evaluation, 860 (74.1 percent) were unnecessary. Transfers for hand-related issues were more likely to be coded as unnecessary compared with referrals for facial trauma and infection (76 percent versus 66 percent; p < 0.001). The average time from referral to discharge from the emergency department was 412 minutes. The expense for these unnecessary transfers exceeded $4.6 million. CONCLUSIONS This is the first intervention-based study evaluating the impact of unnecessary transfer for evaluation of hand and facial emergencies. Using a framework based on objective outcomes, the authors found that fewer than one-third of patients required emergent transfer for evaluation by a plastic surgeon, and almost half did not receive an intervention following transfer. Based on patient time and financial expenses for these unnecessary evaluations, improvements could be made in both quality and cost of care by limiting inappropriate emergency department referrals.
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Interhospital transfers of the critically ill: Time spent at referring institutions influences survival. J Crit Care 2016; 39:1-5. [PMID: 28082138 DOI: 10.1016/j.jcrc.2016.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 12/08/2016] [Accepted: 12/14/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine if the length of stay at a referring institution intensive care unit (ICU) before transfer to a tertiary/quaternary care facility is a risk factor for mortality. DESIGN We performed a retrospective chart review of patients transferred to our ICU from referring institution ICUs over a 3-year period. Logistical regression analysis was performed to determine which factors were independently associated with increased mortality. The primary outcomes were ICU and hospital mortality. MAIN RESULTS A total of 1248 patients were included in our study. Length of stay at the referring institution was an independent risk factor for both ICU and hospital mortality (P<.0001), with increasing lengths of stay correlating with increased mortality. Each additional day at the referring institution was associated with a 1.04 increase in likelihood of ICU mortality (95% confidence interval, 1.02-1.06; P =0.001) and a 1.029 (95% confidence interval, 1.01-1.05; P .005) increase in likelihood of hospital mortality. CONCLUSIONS Length of stay at the referring institution before transfer is a risk factor for worse outcomes, with longer stays associated with increased likelihood of mortality. Further studies delineating which factors most affect length of stay at referring institutions, though a difficult task, should be pursued.
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Gornitzky AL, Milby AH, Gunderson MA, Chang B, Carrigan RB. Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center. Orthopedics 2016; 39:e333-9. [PMID: 26913765 DOI: 10.3928/01477447-20160222-06] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/01/2015] [Indexed: 02/03/2023]
Abstract
Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.
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Hamilton EC, Miller CC, Cotton BA, Cox C, Kao LS, Austin MT. The association of insurance status on the probability of transfer for pediatric trauma patients. J Pediatr Surg 2016; 51:2048-2052. [PMID: 27686481 DOI: 10.1016/j.jpedsurg.2016.09.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/12/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to evaluate the association of insurance status on the probability of transfer of pediatric trauma patients to level I/II centers after initial evaluation at lower level centers. METHODS A retrospective review of all pediatric trauma patients (age<16years) registered in the 2007-2012 National Trauma Data Bank was performed. Multiple regression techniques controlling for clustering at the hospital level were used to determine the impact of insurance status on the probability of transfer to level I/II trauma centers. RESULTS Of 38,205 patients, 33% of patients (12,432) were transferred from lower level centers to level I/II trauma centers. Adjusting for demographics and injury characteristics, children with no insurance had a higher likelihood of transfer than children with private insurance. Children with public or unknown insurance status were no more likely to be transferred than privately insured children. There were no variable interactions with insurance status. CONCLUSIONS Among pediatric trauma patients, lack of insurance is an independent predictor for transfer to a major trauma center. While burns, severely injured, and younger patients remain the most likely to be transferred, these findings suggest a triage bias influenced by insurance status. Additional policies may be needed to avoid unnecessary transfer of uninsured pediatric trauma patients. LEVEL OF EVIDENCE Case-control study, level III.
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Affiliation(s)
- Emma C Hamilton
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Charles C Miller
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan A Cotton
- Department of Surgery and Center for Translational Injury Research, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Charles Cox
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Department of Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Mary T Austin
- Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX; Children's Memorial Hermann Hospital, Houston, TX; Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Department of Pediatric Patient Care, Children's Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Bell N, Repáraz L, Fry WR, Smith RS, Luis A. Variation in type and frequency of diagnostic imaging during trauma care across multiple time points by patient insurance type. BMC Med Imaging 2016; 16:61. [PMID: 27809859 PMCID: PMC5094090 DOI: 10.1186/s12880-016-0146-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 06/13/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Research has shown that uninsured patients receive fewer radiographic studies during trauma care, but less is known as to whether differences in care are present among other insurance groups or across different time points during hospitalization. Our objective was to examine the number of radiographic studies administered to a cohort of trauma patients over the entire hospital stay as well as during the first 24-hours of care. METHODS Patient data were obtained from an American College of Surgeons (ACS) verified Level I Trauma Center between January 1, 2011 and December 31, 2012. We used negative binomial regression to construct relative risk (RR) ratios for type and frequency of radiographic imaging received among persons with Medicare, Medicaid, no insurance, or government insurance plans in reference to those with commercial indemnity plans. The analysis was adjusted for patient age, sex, race/ethnicity, injury severity score, injury mechanism, comorbidities, complications, hospital length of stay, and Intensive Care Unit (ICU) admission. RESULTS A total of 3621 records from surviving patients age > =18 years were assessed. After adjustment for potential confounders, the expected number of radiographic studies decreased by 15 % among Medicare recipients (RR 0.85, 95 % CI 0.78-0.93), 11 % among Medicaid recipients (0.89, 0.81-0.99), 10 % among the uninsured (0.90, 0.85-0.96) and 19 % among government insurance groups (0.81, 0.72-0.90), compared with the reference group. This disparity was observed during the first 24-hours of care among patients with Medicare (0.78, 0.71-0.86) and government insurance plans (0.83, 0.74-0.94). Overall, there were no differences in the number of radiographic studies among the uninsured or among Medicaid patients during the first 24-hours of care compared with the reference group, but differences were observed among the uninsured in a sub-analysis of severely injured patients (ISS > 15). CONCLUSIONS Both uninsured and insured patients treated at a not-for-profit verified Level I Trauma Center receive fewer radiographic studies than patients with commercial indemnity plans, even after adjusting for clinical and demographic confounders. There is less disparity in care during the first 24-hours, which suggests that patient pathology is the determining factor for radiographic evaluation during the acute care phase. Results from this study offer initial evidence of disparity in diagnostic imaging across multiple insurance groups over different periods of trauma care.
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Affiliation(s)
- Nathaniel Bell
- College of Nursing, University of South Carolina, 1601 Greene Street, Columbia, SC 29208 USA
| | - Laura Repáraz
- College of Nursing, University of South Carolina, 1601 Greene Street, Columbia, SC 29208 USA
| | - William R. Fry
- Department of Surgery, Good Samaritan Medical Center, Lafayette, CO USA
| | - R. Stephen Smith
- Professor of Surgery, Trauma Medical Director, University of Florida, Gainesville, FL USA
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Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue. J Orthop Trauma 2016; 30:306-11. [PMID: 26741643 DOI: 10.1097/bot.0000000000000524] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay. DESIGN Prospective consecutive series. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0. INTERVENTION Femur, pelvis, or spine fractures treated surgically. MAIN OUTCOME MEASUREMENTS Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded. RESULTS Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days). CONCLUSIONS Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue. J Orthop Trauma 2016. [DOI: 10.1097/00005131-201606000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Access to post-discharge inpatient care after lower limb trauma. J Surg Res 2016; 203:140-4. [PMID: 27338544 DOI: 10.1016/j.jss.2016.02.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 02/06/2016] [Accepted: 02/26/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Most hospitals in the United States are required to provide emergency care to all patients, regardless of insurance status. However, uninsured patients might be unable to access non-acute services, such as post-discharge inpatient care (PDIC). This could result in prolonged acute hospitalization. We tested the hypothesis that insurance status would be independently associated with both PDIC and length of stay (LOS). METHODS An observational study was undertaken using the California State Inpatient Database (2007-2011), which captures 98% of patients admitted to hospital in California. All patients with a diagnosis of orthopedic lower limb trauma were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes 820-828. Multivariable logistic and generalized linear regression models were used to adjust odds of PDIC and LOS for patient and hospital characteristics. RESULTS There were 278,573 patients with orthopedic lower limb injuries, 160,828 (57.7%) of which received PDIC. Uninsured patients had lower odds of PDIC (adjusted odds ratio 0.20, 95% confidence interval 0.17-0.24) and significantly longer hospital LOS (predicted mean difference 1.06 [95% confidence interval 0.78-1.34] d) than those with private insurance. CONCLUSIONS Lack of health insurance is associated with reduced access to PDIC and prolonged hospital LOS. This potential barrier to hospital discharge could reduce the number of trauma beds available for acutely injured patients.
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Englum BR, Hui X, Zogg CK, Chaudhary MA, Villegas C, Bolorunduro OB, Stevens KA, Haut ER, Cornwell EE, Efron DT, Haider AH. Association Between Insurance Status and Hospital Length of Stay Following Trauma. Am Surg 2016; 82:281-288. [PMID: 27099067 PMCID: PMC5142530 DOI: 10.1177/000313481608200324] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Previous research has demonstrated that nonclinical factors are associated with differences in clinical care, with uninsured patients receiving decreased resource use. Studies on trauma populations have also shown unclear relationships between insurance status and hospital length of stay (LOS), a commonly used metric for evaluating quality of care. The objective of this study is to define the relationship between insurance status and LOS after trauma using the largest available national trauma dataset and controlling for significant confounders. Data from 2007 to 2010 National Trauma Data Bank were used to compare differences in LOS among three insurance groups: privately insured, publically insured, and uninsured trauma patients. Multivariable regression models adjusted for potential confounding due to baseline differences in injury severity and demographic and clinical factors. A total of 884,493 patients met the inclusion criteria. After adjusting for the influence of covariates, uninsured patients had significantly shorter hospital stays (0.3 days) relative to privately insured patients. Publicly insured patients had longer risk-adjusted LOS (0.9 days). Stratified differences in discharge disposition and injury severity significantly altered the relationship between insurance status and LOS. In conclusion, this study elucidates the association between insurance status and hospital LOS, demonstrating that a patient's ability to pay could alter LOS in acute trauma patients. Additional research is needed to examine causes and outcomes from these differences to increase efficiency in the health care system, decrease costs, and shrink disparities in health outcomes.
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Affiliation(s)
- Brian R Englum
- Duke University School of Medicine, Durham, North California, USA
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Missios S, Bekelis K. Nonmedical factors and the transfer of spine trauma patients initially evaluated at Level III and IV trauma centers. Spine J 2015; 15:2028-35. [PMID: 25998327 DOI: 10.1016/j.spinee.2015.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/08/2015] [Accepted: 05/13/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The influence of nonmedical factors on the disposition of spine trauma patients, initially seen in less specialized institutions, remains an issue of debate. PURPOSE To investigate the association of lack of insurance and African-American race with the probability of being transferred to a Level I or II trauma center, after being evaluated in the emergency department (ED) of Level III or IV trauma centers for spine trauma. STUDY DESIGN/SETTING This was a retrospective cohort study. PATIENT SAMPLE A total of 14,133 patients who were registered in National Trauma Data Bank (NTDB) from 2009 to 2011 and initially evaluated in the ED of Level III or IV trauma centers for spine trauma were included. OUTCOME MEASURES The outcome measures were rates of transfer to a higher level of care trauma center. METHODS We performed a retrospective cohort study involving spine trauma patients, who were registered in the NTDB between 2009 and 2011. Regression techniques, controlling for clustering at the hospital level, were used to investigate the association of insurance status and race with the possibility of transfer. RESULTS Overall, 4,142 patients (29.31%) were transferred to a higher level of care institution, and 9,738 (70.69%) were admitted to a Level III or IV trauma center. Multivariable logistic regression analysis demonstrated an association of uninsured patients with increased possibility of transfer (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.22-1.61). This persisted after using a mixed effects model to control for clustering at the hospital level (OR, 1.65; 95% CI, 1.37-1.96). African-American race was not associated with the decision to transfer, when using a mixed effects model (OR, 1.15; 95% CI, 0.89-1.48). However, African-Americans with Glasgow Coma Scale greater than 8 (OR, 1.40; 95% CI, 1.13-1.74) or Injury Severity Score less than 15 (OR, 1.54; 95% CI, 1.21-1.96) were associated with a higher likelihood of transfer. CONCLUSIONS In summary, lack of insurance was associated with increased possibility of transfer to higher level of care institutions, after evaluation in a Level III or IV trauma center ED for spine trauma. The same was true for African-Americans with milder injuries.
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Affiliation(s)
- Symeon Missios
- Department of Surgery, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756, USA
| | - Kimon Bekelis
- Department of Neurosurgery, Louisiana State University Health Sciences Center, 1541 Kings Hwy, Shreveport, LA 71103, USA.
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Kummerow Broman K, Phillips S, Hayes RM, Ehrenfeld JM, Holzman MD, Sharp K, Kripalani S, Poulose BK. Insurance status influences emergent designation in surgical transfers. J Surg Res 2015; 200:579-85. [PMID: 26346526 DOI: 10.1016/j.jss.2015.08.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 06/12/2015] [Accepted: 08/14/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs. MATERIALS AND METHODS A retrospective cohort study was performed on patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only. RESULTS There were 1295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer nonwhite, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% versus 84%, P < 0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (odds ratio [OR], 1.61; 95% confidence interval [CI], 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR, 2.27; CI, 1.08-4.77). CONCLUSIONS The finding that uninsured patients were more likely to be designated as EMCs suggests nonclinical variation that may be mitigated by clearer definitions and increased interfacility coordination to identify patients requiring transfer for EMCs.
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Affiliation(s)
- Kristy Kummerow Broman
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, Tennessee.
| | - Sharon Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel M Hayes
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M Ehrenfeld
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael D Holzman
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenneth Sharp
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Benjamin K Poulose
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
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The Association of Insurance Status and Race With Transfers of Patients With Traumatic Brain Injury Initially Evaluated at Level III and IV Trauma Centers. Ann Surg 2015; 262:9-15. [PMID: 26020113 DOI: 10.1097/sla.0000000000001239] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the association of lack of insurance and African American race with the probability of transfer to level I/II trauma centers after evaluation in the emergency department of level III/IV trauma centers for traumatic brain injury (TBI). BACKGROUND The influence of nonmedical factors on the disposition of TBI patients initially seen in less specialized institutions is debated. METHODS We conducted a retrospective cohort study involving TBI patients who were registered in the National Trauma Data Bank between 2009 and 2011. Regression methods were used to investigate the association of insurance status and race with the disposition of TBI patients evaluated in less specialized trauma centers. RESULTS During the study period, there were 26,031 TBI patients who were registered in the National Trauma Data Bank and met inclusion criteria. Of these, 10,572 (35.9%) were transferred to a higher level of care institution. Multivariable logistic regression after coarsened exact matching demonstrated an association of uninsured patients with an increased possibility of transfer (odds ratio [OR] = 1.22; 95% confidence interval [CI], 1.05-1.42). On the contrary, there was no association of African Americans with transfers (OR = 1.27; 95% CI, 0.99-1.62). Those with Glasgow Coma Scale score above 8 (OR = 1.22; 95% CI, 1.08-1.39) or Injury Severity Score below 16 (OR = 1.33; 95% CI, 1.13-1.56) had a higher possibility of transfer. CONCLUSIONS In TBI patients, lack of insurance was associated with an increased possibility of transfer to higher level of care institutions after evaluation in a level III or IV trauma center emergency department. Regardless of insurance status, this transfer pattern was also observed for African Americans, but only for those with milder injuries.
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Feazel L, Schlichting AB, Bell GR, Shane DM, Ahmed A, Faine B, Nugent A, Mohr NM. Achieving regionalization through rural interhospital transfer. Am J Emerg Med 2015; 33:1288-96. [PMID: 26087707 DOI: 10.1016/j.ajem.2015.05.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 05/19/2015] [Indexed: 01/19/2023] Open
Abstract
Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.
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Affiliation(s)
- Leah Feazel
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Adam B Schlichting
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Gregory R Bell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Dan M Shane
- Department of Health Management and Policy, College of Public Health, Iowa City, IA, USA
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Brett Faine
- Department of Pharmacy, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Andrew Nugent
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Con J, Long D, Sasala E, Khan U, Knight J, Schaefer G, Wilson A. Secondary overtriage in a statewide rural trauma system. J Surg Res 2015; 198:462-7. [PMID: 25959835 DOI: 10.1016/j.jss.2015.03.077] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 03/10/2015] [Accepted: 03/25/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rural hospitals have variable degrees of involvement within the nationwide trauma system because of differences in resources and operational goals. "Secondary overtriage" refers to the patient who is discharged home shortly after being transferred from another hospital. An analysis of these occurrences is useful to determine the efficiency of the trauma system as a whole. MATERIALS AND METHODS Data were extracted from a statewide trauma registry from 2007-2012 to include those who were (1) discharged home within 48 h of arrival and (2) did not undergo a surgical procedure. We then identified those who arrived as a transfer before being discharged (secondary overtriage) from those who arrived from the scene. Factors associated with transfers were analyzed using a logistic regression. Injuries were classified based on the need of a specific consultant. Time of arrival to the emergency department was analyzed using 8-h blocks, with the 7 AM-3 PM block as reference. RESULTS A total of 19,319 patients fit our inclusion criteria of which 1897 (9.8%) arrived as transfers. Descriptive analysis showed a number of differences between transfers and nontransfers because of our large sample size. Thus, we examined variables that had more clinical significance using logistic regression controlling for age, injury severity score, the type of injury, blood products given, the time of arrival to initial emergency room, and whether a computed tomography scan was obtained initially. Factors associated with being transferred were injury severity score >15, transfusion of packed-red-blood-cells, graveyard-shift arrivals, and neurosurgical, spine, and facial injuries. Patients having a computed tomography scan were less likely to be transferred. CONCLUSIONS Secondary overtriage may result from the hospital's limited resources. Some of these limitations are the availability of surgical specialists, blood products, and overall coverage during the "graveyard-shift." However, some of these transfers may be appropriate even though patients are ultimately discharged shortly after transfer.
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Affiliation(s)
- Jorge Con
- Department of Surgery, West Virginia University, Morgantown, West Virginia.
| | - Dustin Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Emily Sasala
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Uzer Khan
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Jennifer Knight
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Greg Schaefer
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Alison Wilson
- Department of Surgery, West Virginia University, Morgantown, West Virginia
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Abstract
BACKGROUND Trauma centers often receive transfers from lower-level trauma centers or nontrauma hospitals. The aim of this study was to analyze the incidence and pattern of secondary overtriage to our Level I trauma center. METHODS We performed a 2-year retrospective analysis of all trauma patients transferred to our Level I trauma center and discharged within 24 hours of admission. Reason for referral, referring specialty, mode of transport, and intervention details were collected. Outcomes measures were incidence of secondary overtriage as well as requirement of major or minor procedure. Major procedure was defined as surgical intervention in the operating room. Minor procedures were defined as procedures performed in the emergency department. RESULTS A total of 1,846 patients were transferred to our Level I trauma center, of whom 440 (24%) were discharged within 24 hours of admission. The mean (SD) age was 35 (21) years, 72% were male, and mean (SD) Injury Severity Score (ISS) 4 (4). The most common reasons for referral were extremity fractures (31%), followed by head injury (23%) and soft tissue injuries (13%).Of the 440 patients discharged within 24 hours, 380 (86%) required only observation (268 of 380) or minor procedure (112 of 380). Minor procedures were entirely consisted of fracture management (n = 47, 42%) and wound care (n = 65, 58%). The mean (SD) interfacility transfer distance was 45 (46) miles. Mean (SD) hospital charges per transfer were $12,549 ($5,863). CONCLUSION A significant number of patients transferred to our trauma center were discharged within 24 hours; most of them required observation and/or minor procedures. Appropriately increasing primary hospital resources, in addition to interhospital outreach in the form of education or telemedicine, should be considered to decrease the number of avoidable transfers. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Mohan D, Barnato AE, Rosengart MR, Angus DC, Wallace DJ, Kahn JM. Triage patterns for medicare patients presenting to nontrauma hospitals with moderate or severe injuries. Ann Surg 2015; 261:383-9. [PMID: 24670846 PMCID: PMC4176560 DOI: 10.1097/sla.0000000000000603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To understand hospital-level variation in triage practices for patients with moderate-to-severe injuries presenting initially to nontrauma centers. BACKGROUND Many patients with moderate-to-severe traumatic injuries receive care at nontrauma hospitals, despite evidence of a survival benefit from treatment at trauma centers. METHODS We used claims from the Centers for Medicare and Medicaid Services to identify patients with moderate-to-severe injuries who presented initially to nontrauma centers. We determined whether or not they were transferred to a level I or II trauma center within 24 hours of presentation, and used multivariate regression to assess the influence of hospital-level factors on triage practices, after adjusting for differences in case mix. RESULTS Transfer of patients with moderate-to-severe injuries to trauma centers occurred infrequently, with significant variation among hospitals (median 2%; interquartile range 1%-6%). Greater resource availability at nontrauma centers was associated with lower rates of successful triage, including the presence of neurosurgeons (relative reduction in transfer rate: 76%, P < 0.01), more than 20 intensive care unit beds (relative reduction 30%, P < 0.01) and a high resident-to-bed ratio (relative reduction 23%, P < 0.01). However, patients were more likely to survive if they presented to hospitals with higher triage rates (odds of death for patients cared for at hospitals with the highest tercile of triage rates, compared with lowest tercile: 0.92; 95% confidence interval: 0.85-0.99, P = 0.02). CONCLUSIONS Injured Medicare beneficiaries presenting to nontrauma centers experience high rates of undertriage, determined in part by increasing availability of resources. Care at hospitals with low rates of successful triage is associated with worse outcomes.
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Affiliation(s)
- Deepika Mohan
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amber E. Barnato
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Matthew R. Rosengart
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Derek C. Angus
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - David J. Wallace
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeremy M. Kahn
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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