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Zachrison KS, Hsia RY, Schwamm LH, Yan Z, Samuels-Kalow ME, Reeves MJ, Camargo CA, Onnela JP. Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach. Circ Cardiovasc Qual Outcomes 2023; 16:e009868. [PMID: 37746725 PMCID: PMC10592016 DOI: 10.1161/circoutcomes.122.009868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer. METHODS This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center. RESULTS Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer. CONCLUSIONS Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.
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Affiliation(s)
- Kori S Zachrison
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco (R.Y.H.)
| | - Lee H Schwamm
- Neurology (L.H.S.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Zhiyu Yan
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Margaret E Samuels-Kalow
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.J.R.)
| | - Carlos A Camargo
- Departments of Emergency Medicine (K.S.Z., Z.Y., M.E.S.-K., C.A.C.), Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA (J.-P.O.)
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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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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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Wright MK, Gong W, Hart K, Self WH, Ward MJ. Association of insurance status with potentially avoidable transfers to an academic emergency department: A retrospective observational study. J Am Coll Emerg Physicians Open 2021; 2:e12385. [PMID: 33733247 PMCID: PMC7936794 DOI: 10.1002/emp2.12385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/08/2021] [Accepted: 01/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interfacility transfers between emergency department (EDs) are common and at times unnecessary. We sought to examine the role of health insurance status with potentially avoidable transfers. METHODS We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED-to-ED transfers to a single, quaternary care adult ED in 2018. We defined a potentially avoidable transfer as an ED-to-ED transfer in which the patient did not receive a procedure from a specialist at the receiving hospital and was discharged from the ED or the receiving hospital within 24 hours of arrival. We constructed a multivariable logistic regression model to examine whether insurance status was associated with potentially avoidable transfers among all ED-to-ED transfers adjusting for patient demographics, severity, mode of arrival, clinical condition, and rurality. RESULTS Among 7508 transfers, 1862 (25%) were potentially avoidable and were more likely to be uninsured (20% vs 9%). In the multivariable analysis, among ED-to-ED transfers for adults aged 18-64 years old who were uninsured (vs any insurance) were significantly more likely to be potentially avoidable (adjusted odds ratio [aOR] 2.1 [1.7, 2.4]) and there is a significant interaction with age. Potentially avoidable transfers increased with younger age, male sex, black (vs white), small rural classification (vs urban), and arrival by ground ambulance (vs flight). CONCLUSIONS Potentially avoidable transfers comprised 1 in 4 transfers. Patients who lack insurance were more than twice as likely to be classified as potentially avoidable even after evaluating for confounders and interactions. This effect was most pronounced among younger patients. Further research is needed to explore why uninsured patients are disproportionately more likely to experience potentially avoidable transfers.
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Affiliation(s)
- Megan K. Wright
- Vanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Wu Gong
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Kimberly Hart
- Department of BiostatisticsVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Wesley H. Self
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Michael J. Ward
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- VA Tennessee Valley Healthcare SystemNashvilleTennesseeUSA
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Hand Surgery Transfers to Level 1 Center: Variables Affecting Transfer Method and Diagnostic Accuracy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3279. [PMID: 33425593 PMCID: PMC7787344 DOI: 10.1097/gox.0000000000003279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 10/29/2022]
Abstract
We hypothesize that some costly patient transfers to a level 1 trauma center for hand specialist management may be unnecessary. This analysis evaluates transfer cost effectiveness and whether time of consult, transfer distance, diagnosis at time of transfer, and provider level influence diagnostic accuracy and transport method. Methods Two hundred and sixty-five patients transferred to a suburban level 1 trauma center for hand surgeon evaluation between 2014 and 2019 were evaluated for patient and injury characteristics, time of consult, transfer distance, provider level, transport method, treatment cost, and diagnostic accuracy. Results The average patient age was 36.2 years, and 80.3% were men. 21% of transfers had inaccurate pre-transfer diagnoses, and certain pre-transfer diagnoses correlated with an increased likelihood of inaccuracy, including flexor tenosynovitis and vascular injury. Patients with a language barrier had a greater likelihood of being transferred with an inaccurate diagnosis (P < 0.05). Compared with ground transport, air ambulance was associated with a higher cost of treatment ($225,679 versus $133,887, P < 0.00001). Of all transfers, 14 (5%) were discharged from the emergency department (ED) without a procedure, 9 (3%) were admitted for observation, 73 (27%) had an ED procedure before discharge, and 166 (62%) received operative management. Conclusions Over 30% of transfers to a level 1 trauma center likely could have been managed at the transferring facility at a decreased cost. Certain diagnoses are associated with increased risk for diagnostic error and unnecessarily urgent transport. Providers can use this information to consider transfer patterns and to educate transferring providers.
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Phillips R, Friberg M, Lantz Cronqvist M, Jonson CO, Prytz E. Visual estimates of blood loss by medical laypeople: Effects of blood loss volume, victim gender, and perspective. PLoS One 2020; 15:e0242096. [PMID: 33180812 PMCID: PMC7660581 DOI: 10.1371/journal.pone.0242096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/27/2020] [Indexed: 11/30/2022] Open
Abstract
A severe hemorrhage can result in death within minutes, before professional first responders have time to arrive. Thus, intervention by bystanders, who may lack medical training, may be necessary to save a victim's life in situations with bleeding injuries. Proper intervention requires that bystanders accurately assess the severity of the injury and respond appropriately. As many bystanders lack tools and training, they are limited in terms of the information they can use in their evaluative process. In hemorrhage situations, visible blood loss may serve as a dominant cue to action. Therefore, understanding how medically untrained bystanders (i.e., laypeople) perceive hemorrhage is important. The purpose of the current study was to investigate the ability of laypeople to visually assess blood loss and to examine factors that may impact accuracy and the classification of injury severity. A total of 125 laypeople watched 78 short videos each of individuals experiencing a hemorrhage. Victim gender, volume of blood lost, and camera perspective were systematically manipulated in the videos. The results revealed that laypeople overestimated small volumes of blood loss (from 50 to 200 ml), and underestimated larger volumes (from 400 to 1900 ml). Larger volumes of blood loss were associated with larger estimation errors. Further, blood loss was underestimated more for female victims than male victims and their hemorrhages were less likely to be classified as life-threatening. These results have implications for training and intervention design.
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Affiliation(s)
- Rachel Phillips
- Department of Psychology, Old Dominion University, Norfolk, VA, United States of America
| | - Marc Friberg
- Department of Computer and Information Science, Linköping University, Linköping, Sweden
- Center for Disaster Medicine and Traumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Carl-Oscar Jonson
- Center for Disaster Medicine and Traumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Erik Prytz
- Department of Computer and Information Science, Linköping University, Linköping, Sweden
- Center for Disaster Medicine and Traumatology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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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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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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Trauma Ecosystems: The Impact of Too Many Trauma Centers. CURRENT SURGERY REPORTS 2019. [DOI: 10.1007/s40137-019-0231-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Di Rocco D, Pasquier M, Albrecht E, Carron PN, Dami F. HEMS inter-facility transfer: a case-mix analysis. BMC Emerg Med 2018; 18:13. [PMID: 29769024 PMCID: PMC5956835 DOI: 10.1186/s12873-018-0163-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Helicopter emergency medical services (HEMS) are popular rescue systems despite inconsistent evidence in the scientific literature to support their use for primary interventions, as well as for inter-facility transfer (IFT). There is little research about IFT by HEMS, hence questions remain about the appropriateness of this method of transport. The aim of this study was to describe a case-mix of operational and medical characteristics for IFT activity of a sole HEMS base, and identify indicators of over-triage. METHODS This is a retrospective study on HEMS IFT over 36 months, from January 1st 2013 to December 31st 2015. Medical and operational data from the database of the Emergency Department of Lausanne University Hospital, which provides the emergency physicians for this helicopter base, were reviewed. It included distance and time of flight transport, type of care during flight, and estimated distance of transport if conducted by ground. RESULTS There were 2194 HEMS missions including 979 IFT (44.6%). Most transfers involved adults (> 17 years old; 799 patients, 81.6%). Forty patients (4.1%) were classified as having benefitted from resuscitation or life-saving measures performed in flight, 615 (62.8%) from emergency treatment and 324 (33.1%) from simple clinical examination. The median distance by air between hospitals was 35.4 km. The estimated median distance by road was 47.7 km. The median duration time from origin to destination by air was 12 min. CONCLUSIONS This case-mix of IFTs by HEMS presents a high severity. There are many signs in favour of over-triage. We propose indicators to help choosing whether HEMS is the most appropriate mean of transport to perform the transfer regarding patient condition, geography, and medical competences available aboard ground ambulances; this may reduce over-triage.
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Affiliation(s)
- Damien Di Rocco
- Medical Student, Faculty of Medicine, University of Lausanne, Lausanne, Switzerland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
| | - Eric Albrecht
- Department of Anaesthesia, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre-Nicolas Carron
- Emergency Department, Lausanne University Hospital (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
| | - Fabrice Dami
- Emergency Department, Lausanne University Hospital (CHUV), Bugnon 46, 1011, Lausanne, Switzerland.
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Petkovic D, Wongworawat MD, Anderson SR. Factors Affecting Appropriateness of Interfacility Transfer for Hand Injuries. Hand (N Y) 2018; 13:108-113. [PMID: 29291655 PMCID: PMC5755853 DOI: 10.1177/1558944716675147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Transfers of patients with higher acuity injuries to trauma centers have helped improve care since the enactment of Emergency Medical Treatment and Active Labor Act. However, an unintended consequence is the inappropriate transfer of patients who do not truly require handover of care. METHODS We retrospectively reviewed the records of all patients transferred to our level I trauma center for injuries distal to the ulnohumeral joint between April 1, 2013, and March 31, 2014; 213 patients were included. We examined the records for appropriateness of transfer based on whether the patient required the care of the receiving hospital's attending surgeon (appropriate transfer) or whether junior-level residents treated the patient alone (inappropriate transfer) and calculated odds ratios. We performed logistic regression to identify factors associated with appropriateness of transfer; these factors included specialist evaluation prior to transfer, age, insurance status, race, injury type, sex, shift time, distance traveled, and median income. RESULTS The risk of inappropriate transfers was 68.5% (146/213). Specialist evaluation at the referring hospital was not associated with a lower risk of inappropriate transfers (odds ratio 1.62 [95% CI: 0.48-5.34], P = .383). Only evening shift (15:01 to 23:00) was associated with inappropriate transfers. Amputations and open fractures were associated with appropriate transfers. CONCLUSION Second shift and type of injury (namely, amputations and open fractures) were significant factors to appropriateness of transfer. No significant association was found between specialist evaluation and appropriate transfers. Future studies may focus on finding reasons and aligning incentives to minimize inappropriate transfers and associated systems costs.
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Affiliation(s)
- Djuro Petkovic
- Loma Linda University, CA, USA,Djuro Petkovic, Department of Orthopedic Surgery, Loma Linda University Medical Center, 11406 Loma Linda Drive, Suite 213, Loma Linda, CA 92354, USA.
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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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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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The Ethics of Institutional Transfers: Emergency Hand Transfers in the Context of EMTALA. J Hand Surg Am 2016; 41:e147-9. [PMID: 26794128 DOI: 10.1016/j.jhsa.2015.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 12/02/2015] [Accepted: 12/08/2015] [Indexed: 02/02/2023]
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Lynch KT, Essig RM, Long DM, Wilson A, Con J. Nationwide secondary overtriage in level 3 and level 4 trauma centers: are these transfers necessary? J Surg Res 2016; 204:460-466. [PMID: 27565083 DOI: 10.1016/j.jss.2016.05.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 04/29/2016] [Accepted: 05/18/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Secondary overtriage (SO) refers to the interfacility transfer of trauma patients who are rapidly discharged home without surgical intervention by the receiving institution. SO imposes a financial hardship on patients and strains trauma center resources. Most studies on SO have been conducted from the perspective of the receiving hospital, which is usually a level 1 trauma center. Having previously studied SO from the referring rural hospital's perspective, we sought to identify variables contributing to SO at the national level. METHODS Using data from the 2008-2012 National Trauma Data Bank, we isolated patients transferred to level 1 trauma centers who were: (1) discharged home within 48 h and (2) did not undergo any surgical procedure. This population was subsequently compared with similar patients treated at and discharged directly from level 3 and 4 centers. Multivariate logistic regression analysis was used to isolate variables that independently influenced a patient's risk of undergoing SO. Injury patterns were characterized by use of subspecialty consultants. RESULTS A total of 99,114 patients met inclusion criteria, of which 13.2% were discharged directly from level 3 or 4 trauma centers, and 86.8% of them were transferred to a level 1 trauma center before discharge. The mean Injury Severity Score of the nontransfer and transfer groups was 5.4 ± 4.5 and 7.3 ± 5.7, respectively. Multivariate regression analysis showed that Injury Severity Score > 15, alcoholism, smoking, drug use, and certain injury patterns involving the head, vertebra, and face were associated with being transferred. In this minimally injured population, factors protective against transfers were: age > 65 y, female gender, systolic blood pressure <80, a head computed tomography scan and orthopedic injuries. CONCLUSIONS SO results from the complex interplay of variables including patient demographics, facility characteristics, and injury type. The inability to exclude a potentially devastating neurologic injury seems to drive SO.
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Affiliation(s)
- Kevin T Lynch
- School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Rachael M Essig
- School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Dustin M Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia
| | - Alison Wilson
- Department of Surgery, West Virginia University, Morgantown, West Virginia
| | - Jorge Con
- Department of Surgery, West Virginia University, Morgantown, West Virginia.
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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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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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Losonczy LI, Weygandt PL, Villegas CV, Hall EC, Schneider EB, Cooper LA, Cornwell EE, Haut ER, Efron DT, Haider AH. The severity of disparity: increasing injury intensity accentuates disparate outcomes following trauma. J Health Care Poor Underserved 2015; 25:308-20. [PMID: 24509028 DOI: 10.1353/hpu.2014.0021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Studies have shown disparities in mortality among racial groups and among those with differing insurance coverage. Our goal was to determine if injury severity affects these disparities. METHODS We classified patients from the 2003-2008 National Trauma Data Banks suffering moderate to severe injuries into six groups based on race/ethnicity and insurance, stratifying by injury severity. Logistic regression compared odds of death between races-ethnicities/insurance groups within these strata. We adjusted for age, gender, Injury Severity Score, Glasgow Coma Scale motor component, hypotension, and mechanism of injury. RESULTS Patients meeting inclusion criteria numbered 760,598. Disparities between races-ethnicities/insurance groups increased as injury severity worsened. Odds of death for uninsured Black patients compared with insured Whites increased from 1.82 among moderately injured patients to 3.14 among severely injured, hypotensive patients. A similar pattern was seen among uninsured Hispanic patients. CONCLUSIONS Disparities in trauma mortality suffered by minority and uninsured patients, when compared with non-minority and insured patients, worsen with increasing injury.
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Bible JE, Kadakia RJ, Kay HF, Zhang CE, Casimir GE, Devin CJ. How often are interfacility transfers of spine injury patients truly necessary? Spine J 2014; 14:2877-84. [PMID: 24743061 DOI: 10.1016/j.spinee.2014.01.065] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/13/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Traumatic spine injuries are often transferred to regional tertiary trauma centers from outside hospitals (OSHs) and subsequently discharged from the trauma center's emergency department (ED) suggesting secondary overtriage of such injuries. PURPOSE The aim of the study was to investigate the definitive treatment and disposition of traumatic spine injuries transferred from OSH, particularly those without other trauma injuries or neurologic symptoms. STUDY DESIGN This was a retrospective study. PATIENT SAMPLE Adult patients presenting to a single Level 1 trauma center with spine injuries were included. OUTCOME MEASURES The outcome measures considered in the study were appropriateness of transfer, treatment, and cost. METHODS Four thousand five-hundred consecutive adult patients presenting to a single Level 1 trauma center with spine injuries (isolated or polytrauma) were reviewed. This consisted of 1,427 patients (32%) transferred from an OSH ED. All OSH, emergency medical services, and receiving institution (RI) patient records and imaging were reviewed. RESULTS Patients who were neurologically intact, nonpolytrauma, and without critical medical issues at the OSH (isolated intact spine transfers) comprised 29% of transfers. Helicopters transported 13% of these patients. The most frequent injuries were compression (26%), burst (17%), and transverse process (10%) fractures. Seventy-eight percent were discharged directly from the RI's ED. Similarly, 15% were not given any formal treatment, 13% had surgery, and 72% given orthosis treatment. The average cost for transportation and ED costs for those discharged from the RI ED were $1,863 and $12,895, respectively. Of the isolated intact spine transfers, 42% were considered to be inappropriate to warrant transfer. This was defined as those sent from an OSH with an orthopedic or neurosurgeon on staff and clearly stable injuries with minimal chance of progressing to instability. Isolated intact spine transfers whose OSH spine imaging was not considered unstable was 25% of transfers with a helicopter used to transport 14% of these patients. Eighty-seven percent were discharged from the ED, whereas only 3% went onto surgery. CONCLUSIONS This study is the first to investigate interfacility transfers with spine injuries and found high rate of secondary overtriage of neurologically intact patients with isolated spine injuries. Potential solutions include increasing spine coverage in community EDs, increasing direct communication between the OSH and the spine specialist at the tertiary center, and utilization of teleradiology.
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Affiliation(s)
- Jesse E Bible
- Vanderbilt Orthopaedic Institute, 1215 21st Ave. South, Medical Center East, S Tower, Suite 4200, Nashville, TN 37232, USA.
| | - Rishin J Kadakia
- Vanderbilt Orthopaedic Institute, 1215 21st Ave. South, Medical Center East, S Tower, Suite 4200, Nashville, TN 37232, USA
| | - Harrison F Kay
- Vanderbilt Orthopaedic Institute, 1215 21st Ave. South, Medical Center East, S Tower, Suite 4200, Nashville, TN 37232, USA
| | - Chi E Zhang
- Vanderbilt Orthopaedic Institute, 1215 21st Ave. South, Medical Center East, S Tower, Suite 4200, Nashville, TN 37232, USA
| | - Geoffrey E Casimir
- Vanderbilt Orthopaedic Institute, 1215 21st Ave. South, Medical Center East, S Tower, Suite 4200, Nashville, TN 37232, USA
| | - Clinton J Devin
- Vanderbilt Orthopaedic Institute, 1215 21st Ave. South, Medical Center East, S Tower, Suite 4200, Nashville, TN 37232, USA
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Hanmer J, Lu X, Rosenthal GE, Cram P. Insurance status and the transfer of hospitalized patients: an observational study. Ann Intern Med 2014; 160:81-90. [PMID: 24592493 PMCID: PMC4157678 DOI: 10.7326/m12-1977] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND There is little objective evidence to support concerns that patients are transferred between hospitals based on insurance status. OBJECTIVE To examine the relationship between patients' insurance coverage and interhospital transfer. DESIGN Data analyzed from the 2010 Nationwide Inpatient Sample. PATIENTS All patients aged 18 to 64 years discharged alive from U.S. acute care hospitals with 1 of 5 common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, and skin or subcutaneous infection). MEASUREMENTS For each diagnosis, the proportion of hospitalized patients who were transferred to another acute care hospital based on insurance coverage (private, Medicare, Medicaid, or uninsured) was compared. Logistic regression was used to estimate the odds of transfer for uninsured patients (reference category, privately insured) while patient- and hospital-level factors were adjusted for. All analyses incorporated sampling and poststratification weights. RESULTS Among 315 748 patients discharged from 1051 hospitals with any of the 5 diagnoses, the percentage of patients transferred to another acute care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses, uninsured patients were significantly less likely to be transferred for 3 diagnoses (P 0.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for 4 diagnoses: biliary tract disease (odds ratio, 0.73 [95% CI, 0.55 to 0.96]), chest pain (odds ratio, 0.63 [CI, 0.44 to 0.89]), septicemia (odds ratio, 0.76 [CI, 0.64 to 0.91]), and skin infections (odds ratio, 0.64 [CI, 0.46 to 0.89]). Women were significantly less likely to be transferred than men for all diagnoses. LIMITATION This analysis relied on administrative data and lacked clinical detail. CONCLUSION Uninsured patients (and women) were significantly less likely to undergo interhospital transfer. Differences in transfer rates may contribute to health care disparities. PRIMARY FUNDING SOURCE National Institutes of Health.
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Admit or transfer? The role of insurance in high-transfer-rate medical conditions in the emergency department. Ann Emerg Med 2013; 63:561-571.e8. [PMID: 24342815 DOI: 10.1016/j.annemergmed.2013.11.019] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 10/24/2013] [Accepted: 11/22/2013] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE We study the association of payer status with odds of transfer compared with admission from the emergency department (ED) for multiple diagnoses with a high percentage of transfers. METHODS This was a retrospective study of adult ED encounters using the Healthcare Cost and Utilization Project 2010 Nationwide Emergency Department Sample. We used the Clinical Classification Software to identify disease categories with 5% or more encounters resulting in transfer (27 categories; 3.7 million encounters based on survey weights). We sorted encounters by condition into 12 groups according to expected medical or surgical specialist needs. We used logistic regression to assess the role of payer status on odds of transfer compared with admission and report adjusted odds ratios (ORs). RESULTS Among high-transfer conditions in 2010, uninsured patients had double the odds of transfer compared with privately insured patients (OR 2.12; 95% confidence interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds of transfer in all specialist categories (significant in 9 of 12). The categories with the highest odds of transfer for the uninsured included nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to 3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83), hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR 1.55; 95% CI 1.02 to 2.28). CONCLUSION Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.
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Friebe I, Isaacs J, Mallu S, Kurdin A, Mounasamy V, Dhindsa H. Evaluation of appropriateness of patient transfers for hand and microsurgery to a level I trauma center. Hand (N Y) 2013; 8:417-21. [PMID: 24426959 PMCID: PMC3840759 DOI: 10.1007/s11552-013-9538-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The transfer of patients for hand and microsurgical emergencies to level I trauma centers is a common practice. Many of these transfers do not actually require a hand specialist and could be taken care of at most regional hospitals. In this study, we will evaluate the appropriateness of patient transfers for hand trauma and determine if there is a correlation between inappropriate transfers and undesirable factors, such as insurance status and off-hour's presentation. METHODS A retrospective chart review was performed in all patients transferred to a level I trauma center for hand and microsurgical trauma over a 22-month period. Collected data included indication for transfer, mode of transfer, time and day of the week, patient demographics, insurance status, and whether the transferring facilities had surgical coverage available. A synopsis, including treatment details, of each transfer was created, and a survey was sent to a review committee who rated the appropriateness of the transfers. Statistical analysis was performed to determine whether appropriateness of transfers was influenced by nonmedical variables. RESULTS Over a 22-month period, a total of 95 hand or microsurgical patients were transferred to a single tertiary referral center. Of these, 66 % of the transfers were considered inappropriate by the surveyed physicians. Inappropriate transfers were statistically more likely to be under insured or transferred during nonbusiness hours. CONCLUSION A large percentage of patients are being transferred to tertiary care centers for reasons other than medical necessity, generating a large burden on already strained medical resources.
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Affiliation(s)
- Ilvy Friebe
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, 1200 E. Broad St., West Hospital, 9th Floor, 23298 Richmond, VA USA
| | - Jonathan Isaacs
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, 1200 E. Broad St., West Hospital, 9th Floor, 23298 Richmond, VA USA
| | - Satya Mallu
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, 1200 E. Broad St., West Hospital, 9th Floor, 23298 Richmond, VA USA
| | - Anton Kurdin
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, 1200 E. Broad St., West Hospital, 9th Floor, 23298 Richmond, VA USA
| | - Varatharaj Mounasamy
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, 1200 E. Broad St., West Hospital, 9th Floor, 23298 Richmond, VA USA
| | - Harinder Dhindsa
- Division of Hand Surgery, Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, 1200 E. Broad St., West Hospital, 9th Floor, 23298 Richmond, VA USA
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Mamczak CN, Streubel PN, Gardner MJ, Ricci WM. Unravelling the debate over orthopaedic trauma transfers: The sender's perspective. Injury 2013; 44:1832-7. [PMID: 23648363 DOI: 10.1016/j.injury.2013.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 02/01/2013] [Accepted: 03/31/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The increasing frequency of orthopaedic trauma patient transfers is an issue at the centre of the current orthopaedic "call crisis" that has the potential to inundate resources at tertiary care centres. Appropriateness of transfer has been investigated only from the perspective of receiving surgeons. This study investigates the suitability and reasons for orthopaedic trauma patient transfer from the viewpoint of transferring surgeons. METHODS A questionnaire was e-mailed to a random sampling of 500 active members of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association. Surgeons were split into three groups: senders of trauma patients (senders); orthopaedic traumatologists who receive transfers (traumatologist receivers); and other trauma transfer receivers that are not traumatologists (non-traumatologist receivers). The perceived complexity and appropriateness for transfer of eight virtual case scenarios were determined, along with the specific reasons mitigating transfer. RESULTS 51 Senders, 90 traumatologist receivers, and 98 non-traumatologist receivers completed 239 surveys. There was agreement between groups for case complexity and appropriateness for transfer in five of eight case scenarios (p<0.05). Fracture complexity was cited as the primary reason for transfer by 28% of senders. However, just as common was a lack of resources at the sending hospital; OR equipment (18%), critical care services (18%), and inability to handle the immediacy of the case (7%) were also cited. Likelihood of uninsured status was the least common reason for transfer (1%). CONCLUSIONS In most cases, both senders and receivers of orthopaedic trauma have similar viewpoints regarding fracture complexity and appropriateness of transfer. Sending surgeons cite case complexity and a lack of hospital resources as the primary reasons for patient transfer. Mandating increased call for orthopaedic surgeons at non-trauma centres without a concomitant increase in hospital resources is unlikely to substantially reduce unnecessary patient transfers to higher level facilities.
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Affiliation(s)
- Christiaan N Mamczak
- LCDR, Medical Corps, United States Navy, Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, VA, United States.
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Yiee JH, Chang L, Kaplan A, Kwan L, Chung PJ, Litwin MS. Patterns of care in testicular torsion: influence of hospital transfer on testicular outcomes. J Pediatr Urol 2013; 9:713-20. [PMID: 23896260 PMCID: PMC3999916 DOI: 10.1016/j.jpurol.2013.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 06/06/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate patterns of care for testicular torsion and influence of hospital transfers on testicular outcomes. Hospital transfer may be a source of treatment delay in a condition where delays increase likelihood of orchiectomy. METHODS We used a retrospective cohort of Californian males with ICD-9/CPT-defined torsion from inpatient, emergency department (ED), and ambulatory surgery center (ASC) data. Logistic regression assessed predictors of orchiectomy. RESULTS Predictors of orchiectomy were ages <1 year (OR 19.2, 95% CI 6.3-58.9), 1-9 years (OR 2.7, 95% CI 1.4-5.2), and ≥40 years (OR 6.6, 95% CI 3.1-13.9) (vs. masked age). Treatment at mid-volume (vs. high-volume) facilities was associated with lower odds of orchiectomy (OR 0.5, 95% CI 0.3-0.7). Rural location, non-private insurance, and hospital transfer were associated with orchiectomy on univariate but not multivariate analysis. During 2008-2010, 2794 subjects experienced torsion (average incidence 5.08 per 100,000 males yearly). Encounters occurred in ASCs (55%), inpatient facilities (36%), and EDs (9%). 60% of subjects were privately insured, 2% experienced hospital transfer, and 31% underwent orchiectomy. CONCLUSION Our census found that most cases of testicular torsion were treated in outpatient settings. Hospital transfer was not associated with orchiectomy.
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Affiliation(s)
- Jenny H Yiee
- University of California Los Angeles, Department of Urology, BOX 957383, 924 Westwood Blvd., Ste. 1000, Los Angeles, CA 90095-1738, United States.
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Abstract
Growing orthopedic and nonorthopedic literature illustrates the point that having health insurance does not equal having access to care. The goal of this study was to evaluate the burden placed on patients to gain access to outpatient orthopedic care. For this study, burden was quantified as the distance traveled by the patient to be seen in clinic. This study was a retrospective review of all new patient encounters at an adult orthopedic outpatient clinic in an academic tertiary referral center over 1 calendar year. All patients were stratified into 4 categories: commercial/private insurance, Medic-aid, Medicare, and uninsured/private pay. The average distance traveled by each patient to the center was then calculated based on the patient's billing zip code. Patient visits were further stratified based on whether the patients were seen by 1 of 3 different categories of providers: general orthopedics/adult reconstruction, spine, and sports/upper extremity. The study group comprised 774 (31.1%) Medicaid patients, 653 (26.2%) Medicare patients, 917 (36.8%) commercial/private insurance patients, and 146 (5.9%) uninsured/private pay patients. The average 1-way distance traveled was 36.2 miles for Medicaid patients, 21.3 miles for Medicare patients, 24.1 miles for commercial/private insurance patients, and 25.3 miles for uninsured/private pay patients (P<.00). Subgroup analysis noted a statistical difference in distance traveled for the general orthopedics/adult reconstruction and sports/upper extremity groups. The study's findings suggest that having insurance does not equal access to outpatient orthopedic care at a single institution. The specific burdens that each group faces to gain access to care are unclear.
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Kamath AF, Austin DC, Derman PB, Israelite CL. Transfer of hip arthroplasty patients leads to increased cost and resource utilization in the receiving hospital. J Arthroplasty 2013; 28:1687-92. [PMID: 23932757 DOI: 10.1016/j.arth.2013.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 05/28/2013] [Accepted: 07/06/2013] [Indexed: 02/01/2023] Open
Abstract
Factors other than complexity of care often drive the transfer of orthopedic patients to tertiary centers. We sought to compare the demographics, diagnoses, insurance data, peri-operative outcomes and institutional costs of total hip arthroplasty patients transferred from outside facilities with those of patients derived from our clinics. We analyzed 419 consecutive patients as part of a prospective risk study. Transferred patients were older (P=0.01), less likely to have private insurance (P<0.0001), and more likely to be admitted on weekends (P=0.04). Both dislocation and fracture were more prevalent in transferred patients (P=0.04; P=0.003). Across all key metrics - including length of stay, mortality scoring, peri-operative complications, and direct and total costs - transferred patients more significantly strained the resources of our arthroplasty center.
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Affiliation(s)
- Atul F Kamath
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.
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Short SS, Liou DZ, Singer MB, Bloom MB, Margulies DR, Bukur M, Salim A, Ley EJ. Insurance type, not race, predicts mortality after pediatric trauma. J Surg Res 2013; 184:383-7. [PMID: 23582228 DOI: 10.1016/j.jss.2013.03.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/02/2013] [Accepted: 03/13/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND In adult trauma, mortality varies with race and insurance status. In the elderly, insurance type has little impact on mortality after trauma and the influence of race is reduced. How race and insurance affect pediatric trauma requires further attention. We hypothesized that mortality after pediatric trauma is influenced by insurance type and not race. METHODS We reviewed all cases of blunt trauma in children ≤13 y requiring admission, using the National Trauma Data Bank Research Data Sets for 2007 and 2008. Exclusions included an Abbreviated Injury Score of 6 for any body region, dead on arrival, and missing data. Our primary outcome measure was in-hospital mortality. RESULTS We identified 831 Asian (1.2%), 10,592 black (15.5%), 45,173 white (66.2%), and 8498 Hispanic (12.5%) children, and 3161 children (4.6%) classified as other race. Mean age was 7.4 ± 4.5 y, 11.9% were uninsured, and overall in-hospital mortality was 1.4%. Multivariable modeling indicated that race was not associated with increased mortality (Asian versus white, adjusted odds ratio [AOR] 1.05, P = 0.88; black versus white, AOR 0.92, P = 0.42; Hispanic versus white, AOR 0.87, P = 0.26; and other race versus white, AOR 1.01, P = 0.96). In contrast, insurance status (any insurance versus no insurance, AOR 0.6, P < 0.01) and insurance type (private insurance versus no insurance, AOR 0.47, P < 0.01; Medicaid versus no insurance, 0.67, P < 0.01) predicted reduced mortality. CONCLUSIONS Insurance status and insurance type are important predictors of mortality after pediatric trauma while, in contrast, race is not.
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Affiliation(s)
- Scott S Short
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Radjou AN, Mahajan P, Baliga DK. Where do I go? A trauma victim's plea in an informal trauma system. J Emerg Trauma Shock 2013; 6:164-70. [PMID: 23960371 PMCID: PMC3746436 DOI: 10.4103/0974-2700.115324] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 09/24/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The three pillars of a good trauma system are the prehospital care, definitive care, and rehabilitative services. The prehospital care is a critical component of the efforts to lower trauma mortality. OBJECTIVE To study the prehospital profile of patients who died due to trauma, compute the time taken to reach our facility, find the cause of delay, and make feasible recommendations. MATERIALS AND METHODS A hospital-based study was performed at a trauma center in Puducherry from June 2009 to August 2010. Puducherry is a union territory of India in the geographical terrain of the state of Tamil Nadu. A total of 241deaths due to trauma were included. Apart from the demographic and injury characteristics, a detailed prehospital log was constructed regarding the time of incident, the referral patterns, care given in the prehospital phase, the distance travelled, and the total time taken to reach our center. RESULTS The majority (59%) of patients were referred, with stopovers at two consecutive referral centers (30%), needing at least two vehicles to transport to definitive care (70%), clocking unnecessary distances (67%), and delayed due to non therapeutic intervention (87%). The majority of deaths (66%) were due to head injury. Only 2.96% of referred cases reached us within the first hour. Few of the patients coming directly to us had vehicle change due to local availability and lack of knowledge of predestined definitive care facility. Overall, 94.6% of direct cases arrived within 4 h whereas 93.3% of referred cases required up to 7 h to arrive at definitive care. CONCLUSIONS Seriously injured patients lose valuable prehospital time because there is no direction regarding destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. The lack of direction is compounded in geographical areas that are situated at the border of political jurisdictions.
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Affiliation(s)
- Angeline N Radjou
- Department of Surgery, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | - Preetam Mahajan
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Dillip K Baliga
- Department of Health and Family Welfare, Government of Puducherry, Puducherry, India
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Fifteen-Year Trauma System Performance Analysis Demonstrates Optimal Coverage for Most Severely Injured Patients and Identifies a Vulnerable Population. J Am Coll Surg 2013; 216:687-95; discussion 695-8. [DOI: 10.1016/j.jamcollsurg.2012.12.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/12/2012] [Indexed: 11/17/2022]
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Hartzell TL, Kuo P, Eberlin KR, Winograd JM, Day CS. The overutilization of resources in patients with acute upper extremity trauma and infection. J Hand Surg Am 2013; 38:766-73. [PMID: 23395105 DOI: 10.1016/j.jhsa.2012.12.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 12/12/2012] [Accepted: 12/12/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare patients with acute upper extremity injuries and infections presenting initially to the emergency department with patients transferred from outside institutions, and to evaluate triage guidelines for the appropriate transfer of these patients. METHODS We reviewed the records of 1,172 consecutive patients with acute upper extremity injuries or infections presenting to 2 level 1 trauma centers over 3-month periods. We analyzed demographics, transfer details, injury characteristics, intervention received, follow-up, and complications. Triage guidelines were established by a board of academic upper extremity and emergency physicians and retrospectively applied to patient data. RESULTS Of 1,172 patients, 155 (13%) arrived via transfer from outside facilities. Transferred patients had more complex injuries by our guidelines, but many did not require level 1 emergent care. The receiving emergency department discharged 26% of the transferred patients without upper extremity specialist evaluation, and 24% of the transferred patients received no procedural intervention at any point. Only 10% went to the operating room emergently. Implementing our guidelines for appropriate triage, we found that 53% of transfers did not require emergent transfer to a level 1 facility. These nonemergent transfers spent an average of 15.2 hours from the time of initial evaluation at the outside facility to discharge from the level 1 emergency department, compared with 3.1 hours in patients who arrived primarily. Retrospectively, our triage guidelines had a 2% undertriage rate and a 3% overtriage rate. CONCLUSIONS Over half of the patients transferred with upper extremity injuries and infections for specialized evaluation may be transferred unnecessarily. Guidelines for the care and transfer of patients with acute upper extremity injuries or infections may lead to better use of resources. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic III.
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Bauer AS, Blazar PE, Earp BE, Louie DL, Pallin DJ. Characteristics of emergency department transfers for hand surgery consultation. Hand (N Y) 2013; 8:12-6. [PMID: 24426887 PMCID: PMC3574481 DOI: 10.1007/s11552-012-9466-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The purpose of this study was to establish the characteristics of patients who are transferred from referring emergency departments (EDs) to two receiving institutions for hand-related emergencies. Our primary hypothesis was that many transferred patients would not require emergent specialty intervention. Our secondary hypotheses were that treatment would differ by day of presentation and type of insurance coverage. METHODS We searched ED records for all hand-related cases over 1 year. We reviewed charts for demographics and treatment details. The main outcome measures were whether patients were seen by a hand surgeon or underwent surgery within 24 h of transfer. RESULTS The study group comprised 296 patients. Ninety-two percent saw a specialty resident, and 48 % saw a hand surgeon. Thirty-nine percent of patients were taken to the operating room within 24 h of presentation. Of patients transferred on the weekends, 48 % saw a hand surgeon versus 61 % of those transferred on weekdays. Similarly, 51 % of patients transferred on a weekday were taken to the OR within 24 h, while 38 % of patients transferred on a weekend were taken to the OR in the same time frame. CONCLUSIONS More than half of transfers for hand emergencies did not result in examination by a hand surgeon, and nearly two thirds did not require a visit to the OR within 24 h. Patients transferred on the weekend were less likely to see a hand surgeon than those transferred on weekdays. Alternative methods of consultation might allow avoidance of transfer.
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Affiliation(s)
- Andrea S. Bauer
- />Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114 USA
- />Shriners Hospital for Children Northern California, 2425 Stockton Blvd., Sacramento, CA 95817 USA
| | - Philip E. Blazar
- />Department of Orthopedic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Brandon E. Earp
- />Department of Orthopedic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Dexter L. Louie
- />Department of Orthopedic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel J. Pallin
- />Department of Emergency Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
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Amis B, Friedrich J. Differences in treatment of digital amputation injuries based on community transfer versus tertiary initial presentation. Hand (N Y) 2012; 7:259-62. [PMID: 23997728 PMCID: PMC3418370 DOI: 10.1007/s11552-012-9431-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The purpose of this paper is to compare a group of patients with upper extremity amputation injuries who presented to a tertiary referral center without having been previously seen at another hospital versus a group of patients who was transferred from another facility. We hypothesize that transferred patients will generally undergo more complex treatments, that some transferred patients will be treated in the ER with simple treatments (thereby perhaps not requiring transfer), and that transferred patients will be less likely to have insurance coverage. METHODS All patients who presented to our ER from January 1, 2007 to December 31, 2008 with the classification of hand and finger amputation were included. Data collected included whether or not the patient was transferred from another institution, age, mechanism of injury, partial versus total amputation, location treated, transportation method, general treatment classification, type of insurance, and month of presentation. RESULTS No statistical difference was found between patients who were transferred versus those who were not with respect to age, sex, mechanism, whether the amputation was partial versus complete, or insurance coverage. Statistical differences were noted between the subset of patients who was transferred versus those who were not with respect to treatment location, method of transportation, and treatment. CONCLUSIONS Patients transferred to our institution required significantly more complex treatments and were significantly more likely to be treated in the operating room. A small but significant group of patients was treated in the ER or required relatively simple treatments after transfer. Our hypothesis that a higher percentage of patients transferred to our institution would have less insurance coverage was not supported by the data. Tertiary centers can expect to continue receiving a steady stream of amputation referrals.
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Affiliation(s)
- Benjamin Amis
- Department of Orthopaedics and Sports Medicine, Harborview Medical Center, University of Washington, Box 359798, 325 Ninth Ave., Seattle, WA 98104 USA
| | - Jeffrey Friedrich
- Division of Plastic Surgery, Harborview Medical Center, University of Washington, 8th Floor, East Hospital, Box 359835, 325 Ninth Ave., Seattle, WA 98104 USA
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Haider AH, Saleem T, Leow JJ, Villegas CV, Kisat M, Schneider EB, Haut ER, Stevens KA, Cornwell EE, MacKenzie EJ, Efron DT. Influence of the National Trauma Data Bank on the study of trauma outcomes: is it time to set research best practices to further enhance its impact? J Am Coll Surg 2012; 214:756-68. [PMID: 22321521 PMCID: PMC3334459 DOI: 10.1016/j.jamcollsurg.2011.12.013] [Citation(s) in RCA: 201] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 12/08/2011] [Accepted: 12/08/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND Risk-adjusted analyses are critical in evaluating trauma outcomes. The National Trauma Data Bank (NTDB) is a statistically robust registry that allows such analyses; however, analytical techniques are not yet standardized. In this study, we examined peer-reviewed manuscripts published using NTDB data, with particular attention to characteristics strongly associated with trauma outcomes. Our objective was to determine if there are substantial variations in the methodology and quality of risk-adjusted analyses and therefore, whether development of best practices for risk-adjusted analyses is warranted. STUDY DESIGN A database of all studies using NTDB data published through December 2010 was created by searching PubMed and Embase. Studies with multivariate risk-adjusted analyses were examined for their central question, main outcomes measures, analytical techniques, covariates in adjusted analyses, and handling of missing data. RESULTS Of 286 NTDB publications, 122 performed a multivariable adjusted analysis. These studies focused on clinical outcomes (51 studies), public health policy or injury prevention (30), quality (16), disparities (15), trauma center designation (6), or scoring systems (4). Mortality was the main outcome in 98 of these studies. There were considerable differences in the covariates used for case adjustment. The 3 covariates most frequently controlled for were age (95%), Injury Severity Score (85%), and sex (78%). Up to 43% of studies did not control for the 5 basic covariates necessary to conduct a risk-adjusted analysis of trauma mortality. Less than 10% of studies used clustering to adjust for facility differences or imputation to handle missing data. CONCLUSIONS There is significant variability in how risk-adjusted analyses using data from the NTDB are performed. Best practices are needed to further improve the quality of research from the NTDB.
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Affiliation(s)
- Adil H Haider
- Center for Surgery Trials and Outcomes Research, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21212, USA.
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Kidger J, Gunnell D, Jarvik JG, Overstreet KA, Hollingworth W. The association between bankruptcy and hospital-presenting attempted suicide: a record linkage study. Suicide Life Threat Behav 2011; 41:676-84. [PMID: 22145826 DOI: 10.1111/j.1943-278x.2011.00063.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The associations between admissions to an emergency department following attempted suicide and personal bankruptcy in the preceding and subsequent 2 years were evaluated. Records from a level 1 trauma center (June 1993-December 2002) in Seattle, WA, were linked with case files from the local U.S. District Bankruptcy Court (June 1991 onward). Univariable and multivariable logistic regression models were used to examine the risk of bankruptcy in (i) the 2 years after and (ii) the 2 years before a suicide attempt using a violent method, compared to patients admitted for any other reason. After adjusting for several confounders, patients who had attempted suicide were more likely than other patients to experience bankruptcy in the following 2 years (OR = 2.10, 95% CIs: 1.29, 3.42). A somewhat weaker association was seen with bankruptcy in the preceding 2 years (OR = 1.68, 95% CIs 1.06; 2.67). Attempted suicide is therefore associated with bankruptcy in the preceding and following 2 years. Changes to legislation, improved mental health counselling for those in financial difficulty, and provision of financial advice to those admitted to hospital following a suicide attempt may reduce future cases of serious self-harm and completed suicide.
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Affiliation(s)
- Judi Kidger
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
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Egol KA, Tolisano AM, Spratt KF, Koval KJ. Mortality rates following trauma: The difference is night and day. J Emerg Trauma Shock 2011; 4:178-83. [PMID: 21769202 PMCID: PMC3132355 DOI: 10.4103/0974-2700.82202] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Accepted: 09/17/2010] [Indexed: 11/20/2022] Open
Abstract
Background: Although most medical centers are equipped for 24-h care, some “middle of the night” services may not be as robust as they are during daylight hours. This would have potential impact upon certain outcome measurements in trauma patients. The purpose of this paper was to assess the effect of patient arrival time at hospital emergency departments on in-hospital survival following trauma. Materials and Methods: Data of patients, 18 years of age or older, with no evidence that they were transferred to or from that center were obtained from the National Trauma Data Bank Version 7.0. Patients meeting the above criteria were excluded if there was no valid mortality status, arrival time information, injury severity score, or trauma center designation. The primary analyses investigated the association of arrival time and trauma center level on mortality. Relative risks of mortality versus patient arrival time and trauma level were determined after controlling for age, gender, race, comorbidities, injury, region of the country, and year of admission. Results: In total, 601,388 or 71.7% of the 838,284 eligible patients were retained. The overall in-hospital mortality rate was 4.7%. The 6 p.m. to 6 a.m. time period had a significantly higher adjusted relative risk for in-hospital mortality than the 6 a.m. to 6 p.m. time frame (ARR=1.18, P<;0.0001). This pattern held across trauma center levels, but was the weakest at Level I and the strongest at Level III/IV centers (Level I: ARR=1.10, Level II: ARR=1.14, and combined Level III/IV: ARR=1.32, all P<0.0001). Conclusion: Hospital arrival between midnight and 6 a.m. was associated with a higher mortality rate than other times of the day. This relationship held true across all trauma center levels. This information may warrant a redistribution of hospital resources across all time periods of the day.
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Affiliation(s)
- Kenneth A Egol
- Department of Orthopaedics, The NYU Hospital for Joint Diseases, NY, New York, USA
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Walcott BP, Coumans JV, Mian MK, Nahed BV, Kahle KT. Interfacility helicopter ambulance transport of neurosurgical patients: observations, utilization, and outcomes from a quaternary level care hospital. PLoS One 2011; 6:e26216. [PMID: 22022572 PMCID: PMC3192167 DOI: 10.1371/journal.pone.0026216] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 09/22/2011] [Indexed: 01/28/2023] Open
Abstract
Background The clinical benefit of helicopter transport over ground transportation for interfacility transport is unproven. We sought to determine actual practice patterns, utilization, and outcomes of patients undergoing interfacility transport for neurosurgical conditions. Methodology/Principal Findings We retrospectively examined all interfacility helicopter transfers to a single trauma center during 2008. We restricted our analysis to those transfers leading either to admission to the neurosurgical service or to formal consultation upon arrival. Major exclusion criteria included transport from the scene, death during transport, and transport to any area of the hospital other than the emergency department. The primary outcome was time interval to invasive intervention. Secondary outcomes were estimated ground transportation times from the referring hospital, admitting disposition, and discharge disposition. Of 526 candidate interfacility helicopter transfers to our emergency department in 2008, we identified 167 meeting study criteria. Seventy-five (45%) of these patients underwent neurosurgical intervention. The median time to neurosurgical intervention ranged from 1.0 to 117.8 hours, varying depending on the diagnosis. For 101 (60%) of the patients, estimated driving time from the referring institution was less than one hour. Four patients (2%) expired in the emergency department, and 34 patients (20%) were admitted to a non-ICU setting. Six patients were discharged home within 24 hours. For those admitted, in-hospital mortality was 28%. Conclusions/Significance Many patients undergoing interfacility transfer for neurosurgical evaluation are inappropriately triaged to helicopter transport, as evidenced by actual times to intervention at the accepting institution and estimated ground transportation times from the referring institution. In a time when there is growing interest in health care cost containment, practitioners must exercise discretion in the selection of patients for air ambulance transport—particularly when it may not bear influence on clinical outcome. Neurosurgical evaluation via telemedicine may be one strategy for improving air transport triage.
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Affiliation(s)
- Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States of America.
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Babu MA, Nahed BV, DeMoya MA, Curry WT. Is Trauma Transfer Influenced by Factors Other Than Medical Need? An Examination of Insurance Status and Transfer in Patients With Mild Head Injury. Neurosurgery 2011; 69:659-67; discussion 667. [DOI: 10.1227/neu.0b013e31821bc667] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Oyetunji TA, Crompton JG, Ehanire ID, Stevens KA, Efron DT, Haut ER, Chang DC, Cornwell EE, Crandall ML, Haider AH. Multiple Imputation in Trauma Disparity Research. J Surg Res 2011; 165:e37-41. [DOI: 10.1016/j.jss.2010.09.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Revised: 09/02/2010] [Accepted: 09/20/2010] [Indexed: 10/18/2022]
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Kind AJH, Bartels C, Mell MW, Mullahy J, Smith M. For-profit hospital status and rehospitalizations at different hospitals: an analysis of Medicare data. Ann Intern Med 2010; 153:718-27. [PMID: 21135295 PMCID: PMC3058683 DOI: 10.7326/0003-4819-153-11-201012070-00005] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND About one quarter of rehospitalized Medicare patients are admitted to hospitals different from their original hospital. The extent to which this practice is related to for-profit hospital status and affects payments and mortality is unknown. OBJECTIVE To describe and examine predictors of and payments for rehospitalization at a different hospital among Medicare patients rehospitalized within 30 days at for-profit and nonprofit or public hospitals. DESIGN Cohort study of patients discharged and rehospitalized from January 2005 to November 2006. SETTING Medicare fee-for-service hospitals throughout the United States. PARTICIPANTS A 5% random national sample of Medicare patients with acute care rehospitalizations within 30 days of discharge (n = 74,564). MEASUREMENTS 30-day rehospitalizations at different hospitals and total payments or mortality over the subsequent 30 days. Multivariate logistic and quantile regression models included index hospital for-profit status, discharge counts, geographic region, rural-urban commuting area, and teaching status; patient sociodemographic characteristics, disability status, and comorbid conditions; and a measure of risk adjustment. RESULTS 16 622 patients (22%) in the sample were rehospitalized at a different hospital. Factors associated with increased risk for rehospitalization at a different hospital included index hospitalization at a for-profit, major medical school-affiliated, or low-volume hospital and having a Medicare-defined disability. Compared with patients rehospitalized at the same hospital, patients rehospitalized at different hospitals had higher adjusted 30-day total payments (median additional cost, $1308 per patient; P < 0.001) but no statistically significant differences in 30-day mortality, regardless of index hospital for-profit status. LIMITATION The database lacked detailed clinical information about patients and did not include information about specific provider practice motivations or the role of patient choice in hospitalization venues. CONCLUSION Rehospitalizations at different hospitals are common among Medicare patients, are more likely among those initially hospitalized at a for-profit hospital, and are related to increased overall payments without improved mortality. PRIMARY FUNDING SOURCE University of Wisconsin Hartford Center of Excellence in Geriatrics, National Institutes of Health.
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Affiliation(s)
- Amy J H Kind
- University of Wisconsin School of Medicine and Public Health and William S. Middleton Veterans Affairs Hospital-Geriatric Research Education and Clinical Center, Madison, Wisconsin, USA.
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Fowler RA, Noyahr LA, Thornton JD, Pinto R, Kahn JM, Adhikari NKJ, Dodek PM, Khan NA, Kalb T, Hill A, O'Brien JM, Evans D, Curtis JR. An official American Thoracic Society systematic review: the association between health insurance status and access, care delivery, and outcomes for patients who are critically ill. Am J Respir Crit Care Med 2010; 181:1003-11. [PMID: 20430926 PMCID: PMC3269233 DOI: 10.1164/rccm.200902-0281st] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care. OBJECTIVES To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status. METHODS Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate. MEASUREMENTS AND MAIN RESULTS From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55-0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0-11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46-13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12-7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01-1.33). Patients in managed care systems had 14.3% (95% CI, 11.5-17.2) fewer procedures in intensive care, but were also less likely to receive "potentially ineffective" care. Differences in unmeasured confounding factors may contribute to these findings. CONCLUSIONS Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.
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Cram P, Bayman L, Popescu I, Vaughan-Sarrazin MS, Cai X, Rosenthal GE. Uncompensated care provided by for-profit, not-for-profit, and government owned hospitals. BMC Health Serv Res 2010; 10:90. [PMID: 20374637 PMCID: PMC2907758 DOI: 10.1186/1472-6963-10-90] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 04/07/2010] [Indexed: 01/28/2023] Open
Abstract
Background There is growing concern certain not-for-profit hospitals are not providing enough uncompensated care to justify their tax exempt status. Our objective was to compare the amount of uncompensated care provided by not-for-profit (NFP), for-profit (FP) and government owned hospitals. Methods We used 2005 state inpatient data (SID) for 10 states to identify patients hospitalized for three common conditions: acute myocardial infarction (AMI), coronary artery bypass grafting (CABG), or childbirth. Uncompensated care was measured as the proportion of each hospital's total admissions for each condition that were classified as being uninsured. Hospitals were categorized as NFP, FP, or government owned based upon data obtained from the American Hospital Association. We used bivariate methods to compare the proportion of uninsured patients admitted to NFP, FP and government hospitals for each diagnosis. We then used generalized linear mixed models to compare the percentage of uninsured in each category of hospital after adjusting for the socioeconomic status of the markets each hospital served. Results Our cohort consisted of 188,117 patients (1,054 hospitals) hospitalized for AMI, 82,261 patients (245 hospitals) for CABG, and 1,091,220 patients for childbirth (793 hospitals). The percentage of admissions classified as uninsured was lower in NFP hospitals than in FP or government hospitals for AMI (4.6% NFP; 6.0% FP; 9.5% government; P < .001), CABG (2.6% NFP; 3.3% FP; 7.0% government; P < .001), and childbirth (3.1% NFP; 4.2% FP; 11.8% government; P < .001). In adjusted analyses, the mean percentage of AMI patients classified as uninsured was similar in NFP and FP hospitals (4.4% vs. 4.3%; P = 0.71), and higher for government hospitals (6.0%; P < .001 for NFP vs. government). Likewise, results demonstrated similar proportions of uninsured patients in NFP and FP hospitals and higher levels of uninsured in government hospitals for both CABG and childbirth. Conclusions For the three conditions studied NFP and FP hospitals appear to provide a similar amount of uncompensated care while government hospitals provide significantly more. Concerns about the amount of uncompensated care provided by NFP hospitals appear warranted.
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Affiliation(s)
- Peter Cram
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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Katsaragakis S, Drimousis PG, Kleidi ES, Toutouzas K, Lapidakis E, Papadakis G, Daskalakis K, Larentzakis A, Theodoraki ME, Theodorou D. Interfacility transfers in a non-trauma system setting: an assessment of the Greek reality. Scand J Trauma Resusc Emerg Med 2010; 18:14. [PMID: 20233409 PMCID: PMC2855516 DOI: 10.1186/1757-7241-18-14] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Accepted: 03/16/2010] [Indexed: 01/28/2023] Open
Abstract
Background Quality assessment of any trauma system involves the evaluation of the transferring patterns. This study aims to assess interfacility transfers in the absence of a formal trauma system setting and to estimate the benefits from implementing a more organized structure. Methods The 'Report of the Epidemiology and Management of Trauma in Greece' is a one year project of trauma patient reporting throughout the country. It provided data concerning the patterns of interfacility transfers. We compared the transferred patient group to the non transferred patient group. Information reviewed included patient and injury characteristics, need for an operation, Intensive Care Unit (ICU) admittance and mortality. Analysis employed descriptive statistics and Chi-square test. Interfacility transfers were then assessed according to each health care facility's availability of five requirements; Computed Tomography scanner, ICU, neurosurgeon, orthopedic and vascular surgeon. Results Data on 8,524 patients were analyzed; 86.3% were treated at the same facility, whereas 13.7% were transferred. Transferred patients tended to be younger, male, and more severely injured than non transferred patients. Moreover, they were admitted to ICU more often, had a higher mortality rate but were less operated on compared to non transferred patients. The 34.3% of transfers was from facilities with none of the five requirements, whereas the 12.4% was from those with one requirement. Low level facilities, with up to three requirements transferred 43.2% of their transfer volume to units of equal resources. Conclusion Trauma management in Greece results in a high number of transfers. Patients are frequently transferred between low level facilities. Better coordination could lead to improved outcomes and less cost.
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Affiliation(s)
- Stylianos Katsaragakis
- First Department of Propaedeutic Surgery, Surgical Intensive Care Unit, Hippocration General Hospital, Athens, Greece.
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Melkun ET, Ford C, Brundage SI, Spain DA, Chang J. Demographic and Financial Analysis of EMTALA Hand Patient Transfers. Hand (N Y) 2010; 5:72-6. [PMID: 19603237 PMCID: PMC2820622 DOI: 10.1007/s11552-009-9214-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 06/26/2009] [Indexed: 01/28/2023]
Abstract
In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers to accept hand trauma transfers for higher level of care if capacity exists. However, patient transfer for non-medical reasons, such as ability to pay, is still perceived as a common practice. We hypothesized that EMTALA would cause selective transfer of hand patients who were underinsured or uninsured, thus, effectively burdening a Level I trauma center. A dedicated transfer center documented the demographics and outcomes of all calls for hand trauma transfers from December 2003 to September 2005. This data registry was reviewed for age, gender, race, insurance status, and length of hospital stay. This data was compared with direct admissions to the emergency room for hand emergencies during that same time period. During the 2-year time period, a total of 151 calls for EMTALA transfer were received for hand emergencies. Our institution accepted 92 of these patients for transfer. Reasons for not accepting transfer included lack of bed availability and unavailability of the on-call surgeon due to other emergency operative cases. Compared with hand emergency patients brought directly to our emergency department during the same time period, transferred patients were younger and had a shorter length of stay. Interestingly, they were very similar in terms of sex, race, and insurance status. These data suggest that the primary motivations for EMTALA hand trauma transfers are truly complexity of patient care and specialist availability. Given the often urgent nature of hand trauma surgery and the limited resources available, expansion and development of hand and microsurgery regional centers will be vital to adequately meet demand without overburdening existing centers.
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Affiliation(s)
- Edward T. Melkun
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304 USA
| | - Christian Ford
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304 USA
| | - Susan I. Brundage
- Section of Trauma/Critical Care Surgery, Department of Surgery, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305 USA
| | - David A. Spain
- Section of Trauma/Critical Care Surgery, Department of Surgery, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305 USA
| | - James Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center, 770 Welch Rd., Suite 400, Palo Alto, CA 94304 USA
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Berman L, Rosenthal MS, Moss RL. The paradoxical effect of medical insurance on delivery of surgical care for infants with congenital anomalies. J Pediatr Surg 2010; 45:38-43; discussion 44. [PMID: 20105577 DOI: 10.1016/j.jpedsurg.2009.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 10/06/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Caring for neonates with major congenital anomalies has significant financial implications for the treating institution, which can be positive or negative depending on whether the patient has insurance. We hypothesized that insured affected neonates born in non-children's hospitals would be more likely to be treated on site, whereas uninsured neonates would be more likely to be transferred. PATIENTS AND METHODS We used the Kids' Inpatient Database to study neonates with congenital anomalies who were born in US non-children's hospitals. We performed bivariate analysis using the chi(2) test and adjusted for covariates with multiple logistic regression. RESULTS Uninsured patients were 2.57 (95% confidence interval, 1.83-3.62) times more likely to be transferred compared with patients with private insurance or Medicaid, after adjusting for patient and hospital characteristics. This trend increased over time between 1997 and 2006. CONCLUSIONS The current reimbursement structure in the United States incentivizes non-children's hospitals to retain insured patients with congenital anomalies and transfer uninsured patients with these same anomalies. This places a disproportionate financial burden on children's hospitals while paradoxically causing insured infants to be cared for at hospitals that may not be best equipped to provide complex care.
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Affiliation(s)
- Loren Berman
- Department of Surgery, Yale University School of Medicine, CT 06520-8062, USA
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Rosen H, Saleh F, Lipsitz SR, Meara JG, Rogers SO. Lack of insurance negatively affects trauma mortality in US children. J Pediatr Surg 2009; 44:1952-7. [PMID: 19853754 DOI: 10.1016/j.jpedsurg.2008.12.026] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 12/15/2008] [Accepted: 12/17/2008] [Indexed: 11/17/2022]
Abstract
PURPOSE Uninsured children face health-related disparities in screening, treatment, and outcomes. To ensure payer status would not influence the decision to provide emergency care, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986, which states patients cannot be refused treatment or transferred from one hospital to another when medically unstable. Given findings indicating the widespread nature of disparities based on insurance, we hypothesized that a disparity in patient outcome (death) after trauma among the uninsured may exist, despite the EMTALA. METHODS Data on patients age 17 years or younger (n = 174,921) were collected from the National Trauma Data Bank (2002-2006), containing data from more than 900 trauma centers in the United States. We controlled for race, injury severity score, sex, and injury type to detect differences in mortality among the uninsured and insured. Logistic regression with adjustment for clustering on hospital was used. RESULTS Crude analysis revealed higher mortality for uninsured children and adolescents compared with the commercially or publicly insured (odds ratio [OR] 2.97; 95% confidence interval [CI], 2.64-3.34; P < .001). Controlling for sex, race, age, injury severity, and injury type, and clustering within hospital facility, uninsured children had the highest mortality compared with the commercially insured (OR, 3.32; 95% CI, 2.95-3.74; P < .001], whereas children and adolescents with Medicaid also had higher mortality (OR, 1.19; 95% CI, 1.07-1.33; P = .001). CONCLUSIONS These results demonstrate that uninsured and publicly insured American children and adolescents have higher mortality after sustaining trauma while accounting for a priori confounders. Possible mechanisms for this disparity include treatment delay, receipt of fewer diagnostic tests, and decreased health literacy, among others.
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Affiliation(s)
- Heather Rosen
- Department of Plastic and Oral Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA.
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Parks J, Gentilello LM, Shafi S. Financial triage in transfer of trauma patients: a myth or a reality? Am J Surg 2009; 198:e35-8. [PMID: 19427626 DOI: 10.1016/j.amjsurg.2009.01.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Revised: 01/06/2009] [Accepted: 01/06/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND It has been alleged that smaller hospitals transfer out uninsured trauma patients (wallet biopsy), putting the financial burden on major trauma centers. METHODS We undertook a retrospective analysis of the National Trauma Data Bank to compare patients who received care at major trauma centers after being transferred from another hospital (transfer group, n = 72,900) with patients who received definitive care at a smaller hospital (nontransfer group, n = 6,826). RESULTS Transfer patients were more likely to be uninsured (18% vs 14%; P < .001), but were more severely injured (Injury Severity Score, 11 +/- 10 vs 7 +/- 7; P < .001), or had multiple injuries. After adjustment for these differences, uninsured patients were no more likely to be transferred than insured ones (odds ratio, .95; 95% confidence interval, .88-1.04; P = .3). CONCLUSIONS There was no relationship between lack of insurance and likelihood of transfer to a major trauma center.
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Affiliation(s)
- Jennifer Parks
- Department of Surgery, Division of Burns, Trauma and Surgical Critical Care, University of Texas Southwestern Medical School, Dallas, TX 75390-9158, USA
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Wang NE, Saynina O, Kuntz-Duriseti K, Mahlow P, Wise PH. Variability in pediatric utilization of trauma facilities in California: 1999 to 2005. Ann Emerg Med 2008; 52:607-15. [PMID: 18562043 DOI: 10.1016/j.annemergmed.2008.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 04/11/2008] [Accepted: 05/06/2008] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE We identify geographic, system, and socioeconomic differences between injured children cared for within and outside of state-designated trauma centers. METHODS This was a nonconcurrent observational study of a population-based sample from the California Office of Statewide Health Planning and Development Public Patient Discharge Database 1999 to 2005. Patients were 1 to 14 years of age, with International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes indicative of trauma. Injury Severity Scores were calculated from ICD-9 codes and categorized into severity categories. Outcomes were hospitalization in a trauma or nontrauma center. RESULTS Children with severe injury who resided 0 to 10, 11 to 25, 26 to 50, and more than 50 miles from a trauma center were hospitalized in these centers at rates of 80.0%, 71.2%, 51.4%, and 28.5%, respectively. Children with severe injury who were living in a county with a trauma center were hospitalized in these centers at rates of 78.8%, whereas children living in a county without a trauma center were hospitalized in trauma centers at rates of 39.0%. Children with severe injury and public, private non-health maintenance organization (HMO), and HMO insurance were hospitalized in trauma centers at rates of 77.7%, 68.0%, and 55.4%, respectively. Age, injury severity, insurance type, residence in a county with a trauma center, and proximity to a trauma center were identified as predictors of trauma center utilization by logistic regression. CONCLUSION We demonstrate considerable variation in the utilization pattern of trauma specialty care for children with moderate and severe injuries. Children with HMO and private insurance are cared for less often in trauma centers than those with public insurance, even after adjustment for other variables. Increased distance to a trauma center, as well as lack of trauma center within a county, also decreases trauma center utilization. These results suggest that assessing trauma center utilization patterns in total populations of children may identify opportunities for improved referral policies and practices as part of a larger effort to ensure high-quality trauma care for all children in need.
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Affiliation(s)
- N Ewen Wang
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Ciesla DJ, Sava JA, Street JH, Jordan MH. Secondary overtriage: a consequence of an immature trauma system. J Am Coll Surg 2007; 206:131-7. [PMID: 18155578 DOI: 10.1016/j.jamcollsurg.2007.06.285] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2007] [Revised: 05/31/2007] [Accepted: 06/11/2007] [Indexed: 02/03/2023]
Abstract
BACKGROUND Trauma systems are designed to bring the injured patient to definitive care in the shortest practical time. This depends on prehospital destination criteria (primary triage) and interfacility transfer guidelines (secondary triage). Although primary undertriage is associated with increased costs and worse outcomes for selected injuries, secondary overtriage can overwhelm system resources and delay definitive care. The purpose of this study was to determine the incidence of secondary overtriage in a region without a formal trauma system. STUDY DESIGN Retrospective cohort study of trauma registry data at an American College of Surgeons Committee on Trauma-verified Level I trauma center and regional referral center. Secondary overtriage was defined as patients transferred from another hospital emergency department to our trauma receiving unit who had an injury severity score < 10, did not require an operation, and who were discharged to home within 48 hours of admission. RESULTS Data on 9,064 patients were reviewed; 6,875 (76%) arrived directly from the scene and 2,189 (24%) were transferred. Although the transferred group was more severely injured, the majority (64%) had minor injuries and 824 (39%) met secondary overtriage criteria. The degree of secondary overtriage and injury pattern varied with respect to referring facility. Peak admission day and times for overtriage patients coincided with scene admissions trauma receiving unit closure events. Patient payor mix and facility cost and reimbursement profiles did not differ between scene and transfer overtriage patients. CONCLUSIONS A substantial proportion of transferred trauma patients require only brief diagnostic or observational care. Excessive overtriage calls for development of a regional inclusive trauma system with established primary and secondary triage guidelines to improve access to care and trauma system efficiency.
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Affiliation(s)
- David J Ciesla
- Department of Surgery, Washington Hospital Center, Washington, DC 20005, USA.
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