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Lin S, Shermeyer A, Nikpay S, Hsia RY, Ward MJ. Initial treatment of uninsured patients with ST-elevation myocardial infarction by facility percutaneous coronary intervention capabilities. Acad Emerg Med 2024; 31:119-128. [PMID: 37921055 PMCID: PMC11025473 DOI: 10.1111/acem.14831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Timely reperfusion is necessary to reduce morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI). Initial care by facilities with percutaneous coronary intervention (PCI) capabilities reduces time to reperfusion. We sought to examine whether insurance status was associated with initial care at emergency departments (EDs) with PCI capabilities among adult patients with STEMI. METHODS We conducted a retrospective cross-sectional study using Department of Healthcare Access and Information, a nonpublic statewide database reporting ED visits and hospitalizations in California. We included adults initially arriving at EDs with STEMI by diagnostic code (International Classification of Diseases Ninth Revision or 10th Revision) from 2011 to 2019. Multivariable logistic regression modeling included initial care by PCI capable facility as the primary outcome and insurance status (none vs. any) as the primary exposure. Covariates included patient, facility, and temporal factors and we conducted multiple robustness checks. RESULTS We analyzed 135,358 eligible visits with STEMI included. In our multivariable model, the odds of uninsured patients being initially treated at a PCI-capable facility were significantly lower than those of insured patients (adjusted odds ratio 0.62, 95% CI 0.54-0.72, p < 0.001) and was unchanged in sensitivity analyses. CONCLUSIONS Uninsured patients with STEMI had significantly lower odds of first receiving care at facilities with PCI capabilities. Our results suggest potential disparities in accessing high-quality and time-sensitive treatment for uninsured patients with STEMI.
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Affiliation(s)
- Sara Lin
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Andrew Shermeyer
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Sayeh Nikpay
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California at San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, California, USA
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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Ward MJ, Nikpay S, Shermeyer A, Nallamothu BK, Rokos I, Self WH, Hsia RY. Interfacility Transfer of Uninsured vs Insured Patients With ST-Segment Elevation Myocardial Infarction in California. JAMA Netw Open 2023; 6:e2317831. [PMID: 37294567 PMCID: PMC10257096 DOI: 10.1001/jamanetworkopen.2023.17831] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/26/2023] [Indexed: 06/10/2023] Open
Abstract
Importance Insurance status has been associated with whether patients with ST-segment elevation myocardial infarction (STEMI) presenting to emergency departments are transferred to other facilities, but whether the facility's percutaneous coronary intervention capabilities mediate this association is unknown. Objective To examine whether uninsured patients with STEMI were more likely than patients with insurance to experience interfacility transfer. Design, Setting, and Participants This observational cohort study compared patients with STEMI with and without insurance who presented to California emergency departments between January 1, 2010, and December 31, 2019, using the Patient Discharge Database and Emergency Department Discharge Database from the California Department of Health Care Access and Information. Statistical analyses were completed in April 2023. Exposures Primary exposures were lack of insurance and facility percutaneous coronary intervention capabilities. Main Outcomes and Measures The primary outcome was transfer status from the presenting emergency department of a percutaneous coronary intervention-capable hospital, defined as a facility performing 36 percutaneous coronary interventions per year. Multivariable logistic regression models with multiple robustness checks were performed to determine the association of insurance status with the odds of transfer. Results This study included 135 358 patients with STEMI, of whom 32 841 patients (24.2%) were transferred (mean [SD] age, 64 [14] years; 10 100 women [30.8%]; 2542 Asian individuals [7.7%]; 2053 Black individuals [6.3%]; 8285 Hispanic individuals [25.2%]; 18 650 White individuals [56.8%]). After adjusting for time trends, patient factors, and transferring hospital characteristics (including percutaneous coronary intervention capabilities), patients who were uninsured had lower odds of experiencing interfacility transfer than those with insurance (adjusted odds ratio, 0.93; 95% CI, 0.88-0.98; P = .01). Conclusions and Relevance After accounting for a facility's percutaneous coronary intervention capabilities, lack of insurance was associated with lower odds of emergency department transfer for patients with STEMI. These findings warrant further investigation to understand the characteristics of facilities and outcomes for uninsured patients with STEMI.
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Affiliation(s)
- Michael J. Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Sayeh Nikpay
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Andrew Shermeyer
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Brahmajee K. Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Ivan Rokos
- Department of Emergency Medicine, UCLA-Olive View, Los Angeles, California
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco
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Asti L, Chisolm DJ, Xiang H, Deans KJ, Cooper JN. Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients. J Surg Res 2023; 283:161-171. [PMID: 36410232 DOI: 10.1016/j.jss.2022.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/01/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers. METHODS Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles. RESULTS Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage. CONCLUSIONS In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.
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Affiliation(s)
- Lindsey Asti
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Deena J Chisolm
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Division of Health Services Management & Policy, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210
| | - Henry Xiang
- Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Center for Pediatric Trauma Research and Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Surgery, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Childrens Drive, Columbus, Ohio 43205; Department of Pediatrics, College of Medicine, The Ohio State University, 370 West 9th Avenue, Columbus, Ohio 43210; Division of Epidemiology, College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, Ohio 43210.
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Zogg CK, Schuster KM, Maung AA, Davis KA. The extent to which geography explains one of trauma's troubling trends: Insurance-based differences in appropriate interfacility transfer. J Trauma Acute Care Surg 2022; 93:686-694. [PMID: 35293375 PMCID: PMC9470786 DOI: 10.1097/ta.0000000000003605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A growing body of literature suggests the persistence of a counterproductive triage pattern wherein uninsured adults with major injuries presenting to nontrauma centers (NTCs) are more likely than insured adults to be transferred. Geographic differences are frequently blamed. The objective of this study was to explore geography's influence on variations in insurance transfer patterns, asking whether differences in distance and travel time by road from NTCs to the nearest level 1 or 2 trauma center alter the effect. As a secondary objective, differences in neighborhood socioeconomic disadvantage were also assessed. METHODS Adults (16-64 years) with major injuries (Injury Severity Score, >15) presenting to NTC emergency departments (EDs) were abstracted from 2007 to 2014 state inpatient/ED claims. Differences in the risk-adjusted odds of admission versus transfer were compared using mixed-effect hierarchical logistic regression and spatial analysis. RESULTS A total of 48,283 adults presenting to 492 NTC EDs were included. Among them, risk-adjusted admission differences based on insurance status exist (e.g., private vs. uninsured odds ratio [95% confidence interval], 1.60 [1.45-1.76]). Spatial analysis revealed significant geographic variation ( p < 0.001). However, in contrast to expectations, the largest insurance-based discrepancies were seen in less disadvantaged NTCs located closer to larger trauma centers. Stratified analyses comparing the closest versus furthest distance, shortest versus longest travel time, and least versus most deprived populations agreed, as did sensitivity analyses restricting uninsured transfer patients to those who remained uninsured versus subsequently became insured. CONCLUSION Adults with major injuries presenting to NTCs were less likely to be transferred if insured. The trend persisted after accounting for differences in access to care, revealing that, while significant geographic variation in the phenomenon exists, geography alone does not explain the issue. Taken together, the findings suggest that additional and potentially subjective elements to insurance-based triage disparities at NTCs are likely to exist. LEVEL OF EVIDENCE Prognostic/Epidemiological, Level III.
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Affiliation(s)
- Cheryl K. Zogg
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Adrian A. Maung
- Department of Surgery, Yale School of Medicine, New Haven, CT
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5
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Evans CS, Hart K, Self WH, Nikpay S, Thompson CM, Ward MJ. Burn related injuries: a nationwide analysis of adult inter-facility transfers over a six-year period in the United States. BMC Emerg Med 2022; 22:147. [PMID: 35974305 PMCID: PMC9380358 DOI: 10.1186/s12873-022-00705-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background US emergency department (ED) visits for burns and factors associated with inter-facility transfer are unknown and described in this manuscript. Methods We conducted a retrospective analysis of burn-related injuries from 2009–2014 using the Nationwide Emergency Department Sample (NEDS), the largest sample of all-payer datasets. We included all ED visits by adults with a burn related ICD-9 code and used a weighted multivariable logistic regression model to predict transfer adjusting for covariates. Results Between 2009–2014, 3,047,701 (0.4%) ED visits were for burn related injuries. A total of 108,583 (3.6%) burn visits resulted in inter-facility transfers occurred during the study period, representing approximately 18,097 inter-facility transfers per year. Burns with greater than 10% total body surface area (TBSA) resulted in a 10-fold increase in the probability of transfer, compared to burn visits with less than 10% TBSA burns. In the multivariable model, male sex (adjusted odds ratio [aOR] 2.4, 95% CI 2.3–2.6) was associated with increased odds of transfer. Older adults were more likely to be transferred compared to all other age groups. Odds of transfer were increased for Medicare and self-pay patients (vs. private pay) but there was a significant interaction of sex and payer and the effect of insurance varied by sex. Conclusions In a national sample of ED visits, burn visits were more than twice as likely to have an inter-facility transfer compared to the general ED patient population. Substantial sex differences exist in U.S. EDs that impact the location of care for patients with burn injuries and warrants further investigation. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00705-6.
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Affiliation(s)
- Christopher S Evans
- Information Services, ECU Health, Greenville, NC, USA.,Department of Emergency Medicine, East Carolina University, Greenville, NC, USA
| | - Kimberly Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sayeh Nikpay
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | | | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. .,VA Tennessee Valley Healthcare System, 1313 21st Ave South; Oxford House 312, Nashville, TN, 37232, USA.
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Minetos PD, Karamian BA, Kothari P, Jeyamohan H, Canseco JA, Patel PD, Thaete L, Singh A, Campbell D, Kaye ID, Woods BI, Kurd MF, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department. Am J Med Qual 2022; 37:207-213. [PMID: 34787591 DOI: 10.1097/jmq.0000000000000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.
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Affiliation(s)
- Paul D Minetos
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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7
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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: 13] [Impact Index Per Article: 3.3] [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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Crowley BM, Griffin RL, Andrew Smedley W, Moore D, McCarthy S, Hendershot K, Kerby JD, Jansen JO. Secondary Overtriage of Trauma Patients: Analysis of Clinical and Geographic Patterns. J Surg Res 2020; 254:286-293. [PMID: 32485430 DOI: 10.1016/j.jss.2020.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/24/2020] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The purpose of a trauma system is to match patients' needs with hospitals' ability to care for them, recognizing that the highest levels of care cannot be provided in all locations. This means that some patients will need to be transferred from a local facility to a higher level of care. Unnecessary transfers are expensive and inconvenient to patients and families. The aim of this study is to analyze the pattern of secondary transfers in a regional trauma system. METHODS This is a retrospective analysis. We included patients aged 16 y and older who were transferred to University of Alabama at Birmingham Hospital between 2014 and 2018. We conducted bivariate and multivariate logistic regression analysis to identify clinical and organizational predictors of requiring a critical intervention, early discharge, intensive care unit admission, and mortality. Rather than treating each injury as isolated, we analyzed injury patterns. RESULTS A total of3824 patients met the inclusion criteria. Of them, 664 patients (17.4%) required a critical intervention, 635 (16.6%) were discharged within 24 h, 1356 (35.5%) were admitted to the intensive care unit, and 172 (4.0%) patients died. Univariate and multivariate analyses revealed many positive associations, with regard to injury pattern, originating center, and insurance status. CONCLUSIONS There are patterns in the data, and further study is required to understand drivers of secondary overtriage, and how we might be able to address this problem. Reducing the number of unnecessary transfers is a difficult task, which will require engagement at all levels of the trauma system.
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Affiliation(s)
- Brandon M Crowley
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama; School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Russell L Griffin
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama; Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - W Andrew Smedley
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama; School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Dylana Moore
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama; School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sean McCarthy
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama; School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kimberly Hendershot
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey D Kerby
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama.
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9
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Characterization of Age-Related Injury Patterns and Surgical Treatment of Pediatric Facial Fractures. J Craniofac Surg 2019; 30:2189-2193. [DOI: 10.1097/scs.0000000000005789] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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10
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Kappy NS, Hazelton JP, Capano-Wehrle L, Gibbs R, Dalton MK, Ross SE. Financial Impact of Minor Injury Transfers on a Level 1 Trauma Center. J Surg Res 2019; 233:403-407. [DOI: 10.1016/j.jss.2018.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 07/13/2018] [Accepted: 08/18/2018] [Indexed: 10/28/2022]
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Insurance Status Biases Trauma-system Utilization and Appropriate Interfacility Transfer. Ann Surg 2018; 268:681-689. [DOI: 10.1097/sla.0000000000002954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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12
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Missios S, Bekelis K. Access disparities to Magnet hospitals for patients undergoing neurosurgical operations. J Clin Neurosci 2017; 44:47-52. [PMID: 28684152 PMCID: PMC5582027 DOI: 10.1016/j.jocn.2017.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Centers of excellence focusing on quality improvement have demonstrated superior outcomes for a variety of surgical interventions. We investigated the presence of access disparities to hospitals recognized by the Magnet Recognition Program of the American Nurses Credentialing Center (ANCC) for patients undergoing neurosurgical operations. METHODS We performed a cohort study of all neurosurgery patients who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of African-American race and lack of insurance with Magnet status hospitalization for neurosurgical procedures. A mixed effects propensity adjusted multivariable regression analysis was used to control for confounding. RESULTS During the study period, 190,535 neurosurgical patients met the inclusion criteria. Using a multivariable logistic regression, we demonstrate that African-Americans had lower admission rates to Magnet institutions (OR 0.62; 95% CI, 0.58-0.67). This persisted in a mixed effects logistic regression model (OR 0.77; 95% CI, 0.70-0.83) to adjust for clustering at the patient county level, and a propensity score adjusted logistic regression model (OR 0.75; 95% CI, 0.69-0.82). Additionally, lack of insurance was associated with lower admission rates to Magnet institutions (OR 0.71; 95% CI, 0.68-0.73), in a multivariable logistic regression model. This persisted in a mixed effects logistic regression model (OR 0.72; 95% CI, 0.69-0.74), and a propensity score adjusted logistic regression model (OR 0.72; 95% CI, 0.69-0.75). CONCLUSIONS Using a comprehensive all-payer cohort of neurosurgery patients in New York State we identified an association of African-American race and lack of insurance with lower rates of admission to Magnet hospitals.
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Affiliation(s)
- Symeon Missios
- Center for Neuro and Spine, Akron General Hospital-Cleveland Clinic, Akron, OH, United States
| | - Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States; The Dartmouth Institute for Health Policy and Clinical Practice, NH, Lebanon; Geisel School of Medicine at Dartmouth, Hanover, NH, United States.
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13
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Ward MJ, Kripalani S, Zhu Y, Storrow AB, Wang TJ, Speroff T, Munoz D, Dittus RS, Harrell FE, Self WH. Role of Health Insurance Status in Interfacility Transfers of Patients With ST-Elevation Myocardial Infarction. Am J Cardiol 2016; 118:332-7. [PMID: 27282834 PMCID: PMC4949088 DOI: 10.1016/j.amjcard.2016.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/05/2016] [Accepted: 05/05/2016] [Indexed: 11/20/2022]
Abstract
Lack of health insurance is associated with interfacility transfer from emergency departments for several nonemergent conditions, but its association with transfers for ST-elevation myocardial infarction (STEMI), which requires timely definitive care for optimal outcomes, is unknown. Our objective was to determine whether insurance status is a predictor of interfacility transfer for emergency department visits with STEMI. We analyzed data from the 2006 to 2011 Nationwide Emergency Department Sample examining all emergency department visits for patients age 18 years and older with a diagnosis of STEMI and a disposition of interfacility transfer or hospitalization at the same institution. For emergency department visits with STEMI, our multivariate logistic regression model included emergency department disposition status (interfacility transfer vs hospitalization at the same institution) as the primary outcome, and insurance status (none vs any [including Medicare, Medicaid, and private insurance]) as the primary exposure. We found that among 1,377,827 emergency department STEMI visits, including 249,294 (18.1%) transfers, patients without health insurance (adjusted odds ratio 1.6, 95% CI 1.5 to 1.7) were more likely to be transferred than those with insurance. Lack of health insurance status was also an independent risk factor for transfer compared with each subcategory of health insurance, including Medicare, Medicaid, and private insurance. In conclusion, among patients presenting to United States emergency departments with STEMI, lack of insurance was an independent predictor of interfacility transfer. In conclusion, because interfacility transfer is associated with longer delays to definitive STEMI therapy than treatment at the same facility, lack of health insurance may lead to important health disparities among patients with STEMI.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Yuwei Zhu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thomas J Wang
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Theodore Speroff
- Geriatric Research, Education, and Clinical Center, Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Daniel Munoz
- Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Robert S Dittus
- Geriatric Research, Education, and Clinical Center, Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, Tennessee; Department of Medicine, Institute for Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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