Interfacility Emergency Department Transfer for Midface Fractures in the United States

What are the incidence and costs associated with interfacility emergency department transfer patients treated by oral and maxillofacial surgeons?

OBJECTIVE

Interfacility emergency department transfers (IETs) for maxillofacial trauma and infections are prevalent in the United States, with significant implications for health care costs. Limited availability of oral and maxillofacial surgeons (OMS) exacerbates unnecessary transfers and associated expenses. This study aimed to determine the incidence and costs of OMS IET.

STUDY DESIGN

A retrospective cohort study was performed for maxillofacial trauma and infection IET at the University of Illinois Health main hospital via electronic medical record query for terms "infection [or] trauma [and] transfer." Inclusion criteria required presentation from January 1, 2022 to June 30, 2022; emergency department (ED)-ED transfer; and or consultation by OMS. Distance transferred, insurance type, location of treatment, weekend presentation, and associated costs were collected.

RESULTS

One thousand ninety-nine records were identified, including 46 trauma IET and 122 infection IET. Costs ranged from $2,683,918.90 to $7,984,912.89, indicating ∼$1.5 billion annual expenditure across US OMS programs. Three trauma IET required urgent treatment; no infection IETs were "emergent." Trauma IET averaged 20.7 + 17.1 miles and infection IET 22.0 + 17.4 miles for transfer distance. Among trauma IET, 28 were treated in the operating room (OR), 10 had outpatient follow-up, and 8 had ED treatment. Among infection IETs, 57 received ED treatment, 56 received OR treatment, and 9 received antibiotics/no treatment.

CONCLUSIONS

Maxillofacial trauma and infection IET impose significant health care costs. Increased funding for OMS training may mitigate the shortage and improve patient care. Further research is needed for better triaging and reimbursement strategies.

Is Insurance Payor Associated With Hospital Admission of Emergency Department Adult Patients With Odontogenic Infections?

BACKGROUND

Patients who present to the emergency department (ED) with severe odontogenic infections are often hospitalized for surgical drainage and medical management. However, inpatient management of these patients can be financially burdensome. While medical indications for hospital admission are well established, it remains unclear if patient insurance status is associated with admission.

PURPOSE

The purpose of this study was to determine the nationally representative estimates of the incidence of hospital admission for patients with odontogenic infections and the association with insurance payor.

STUDY DESIGN, SETTING, SAMPLE

This retrospective cohort study used the 2018 Nationwide Emergency Department Sample. Patients with odontogenic infections (based on International Classification of Diseases, 10th Revision codes) were included. Patients aged <18 years or who had missing data were excluded.

PREDICTOR VARIABLE

The primary predictor variable was primary payor (private insurance, Medicare, Medicaid, self-pay, and other).

MAIN OUTCOME VARIABLE

The primary outcome variable was hospital admission (yes/no).

COVARIATES

Covariates included sociodemographic, medical, infection, and hospital variables.

ANALYSES

Descriptive, bivariate, and multivariable logistic regression analyses were used to determine national estimates and predictors of admission. Odds ratios and 99% confidence intervals were computed. Discharge weights were accounted for in all analyses to provide nationally representative estimates.

RESULTS

This study included 31,221 weighted ED encounters, of which 10,451 (33.5%) were admitted. In the study cohort, 7,687 (24.6%) had private insurance, 5,046 (16.2%) had Medicare, 10,070 (32.3%) had Medicaid, 7,436 (23.8%) were self-pay, and 982 (3.1%) had other. Bivariate analysis suggested that payor status was significantly associated with hospital admission (P < .01). The multivariable analysis showed that self-pay patients had significantly lower odds of hospital admission compared to those with private insurance (odds ratio, 0.54; 99% confidence interval, 0.42-0.70). Other independent predictors of hospital admission included infection in more than 1 location based on International Classification of Diseases, 10th Revision code, higher Charlson comorbidity index, and alcohol/substance use disorders.

CONCLUSION AND RELEVANCE

Approximately one-third of patients presenting to the ED with odontogenic infections were admitted. Patients with no insurance were less likely to be admitted compared to those with private insurance. This finding may reflect multiple possibilities, including hospital financial incentives.

Is Insurance Payer Associated With Hospital Admission of Emergency Department Patients With Mandible Fractures?

BACKGROUND

There is a lack of consensus on the optimal triage pathway for emergency department (ED) patients with mandibular fractures. It remains unclear if patient insurance payers predict hospital admission given potentially competing logistical and health system incentives.

PURPOSE

To generate nationally representative estimates of the frequency of hospital admission and its association with primary insurance payers for ED patients with mandible fractures.

METHODS

This retrospective cohort study used the 2018 Nationwide Emergency Department Sample, the largest all-payer database in the United States, to identify patients with mandible fractures. The database includes a stratified sample with discharge weights to generate nationally representative estimates. Patients with other facial fractures and/or concomitant injuries that independently warranted admission were excluded.

PREDICTOR

The primary predictor variable was primary payer (public, private, self-pay, and other/no charge).

OUTCOME VARIABLE

The primary outcome variable was hospital admission (yes/no).

COVARIATES

Covariates included patient-, medical/injury-, and hospital-related variables.

ANALYSES

Descriptive statistics, along with bivariate and multivariate logistic regression with Bonferroni correction, were used to produce national estimates and identify predictors of admission. P < .01 was considered significant.

RESULTS

The cohort included 27,238 weighted encounters involving isolated mandible fractures, of which 5,345(20%) were admitted. The payers for admitted patients were 46% public, 25% private, 22% self-pay, and 7% no charge/other. In bivariate analyses, public insurance was associated with a higher likelihood of admission than private insurance (RR 1.24, 95% CI 1.06 to 1.45), though there was no association in the multivariate model (OR 1.03, 95% CI 0.83 to 1.28). In multivariate analysis, higher Charlson Comorbidity Index (OR 1.32, 95% CI 1.18 to 1.48), alcohol-related disorder (OR 3.47, 95% CI 2.74 to 4.39), substance-related disorder (OR 1.43, 95% CI 1.20 to 1.71), and more mandible fractures (OR 3.08, 95% CI 2.65 to 3.59) were associated with admission. Compared to body fractures, subcondylar (OR 3.83, 95% CI 2.39 to 6.14), angle (OR 3.53, 95% CI 2.84 to 6.09), and symphysis (OR 4.14, 95% CI 2.84 to 6.09) fractures had higher odds of admission. Finally, level I (OR 4.11, 95% CI 2.41 to 6.98) and level II (OR 3.16, 95% CI 1.85 to 5.39) trauma centers had higher odds of admission.

CONCLUSIONS

In 2018, 20% of ED patients with isolated mandible fractures were admitted. Several patient and hospital characteristics were predictors of admission. Insurance status was not associated with admission.