A prospective evaluation of patients with isolated orthopedic injuries transferred to a level I trauma center

Achieving Health Equity: Combatting the Disparities in American Access to Musculoskeletal Care : Disparities Exist in Every Aspect of Orthopaedic Care in the United States - Access to Outpatient Visits, Discretionary and Unplanned Surgical Care, and Postoperative Outcomes. What Can We Do?

PURPOSE OF REVIEW

Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes.

RECENT FINDINGS

Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations.

Unsupervised clustering analysis of trauma/non-trauma centers using hospital features including surgical care

BACKGROUND

Injuries are a leading cause of death in the United States. Trauma systems aim to ensure all injured patients receive appropriate care. Hospitals that participate in a trauma system, trauma centers (TCs), are designated with different levels according to guidelines that dictate access to medical and research resources but not specific surgical care. This study aimed to identify patterns of injury care that distinguish different TCs and hospitals without trauma designation, non-trauma centers (non-TCs).

STUDY DESIGN

We extracted hospital-level features from the state inpatient hospital discharge data in Washington state, including all TCs and non-TCs, in 2016. We provided summary statistics and tested the differences of each feature across the TC/non-TC levels. We then conducted 3 sets of unsupervised clustering analyses using the Partition Around Medoids method to determine which hospitals had similar features. Set 1 and 2 included hospital surgical care (volume or distribution) features and other features (e.g., the average age of patients, payer mix, etc.). Set 3 explored surgical care without additional features.

RESULTS

The clusters only partially aligned with the TC designations. Set 1 found the volume and variation of surgical care distinguished the hospitals, while in Set 2 orthopedic procedures and other features such as age, social vulnerability indices, and payer types drove the clusters. Set 3 results showed that procedure volume rather than the relative proportions of procedures aligned more, though not completely, with TC designation.

CONCLUSION

Unsupervised machine learning identified surgical care delivery patterns that explained variation beyond level designation. This research provides insights into how systems leaders could optimize the level allocation for TCs/non-TCs in a mature trauma system by better understanding the distribution of care in the system.

Inappropriate Pediatric Orthopaedic Emergency Department Transfers: A Burden on the Health Care System

BACKGROUND

Though the importance of level 1 pediatric trauma has repeatedly been shown to lessen both morbidity and mortality in critically injured children, these same tertiary referral centers also receive numerous transfers of patients with less severe injuries. This not only leads to increased costs and use of limited facility resources but, oftentimes, frustration and unnecessary expense to those families for whom transfer was avoidable. Prior work has demonstrated that half of all inappropriate pediatric interfacility transfers are due to orthopedic injuries. This study aims to evaluate the incidence of inappropriate transfers of pediatric patients with isolated orthopedic injuries to a pediatric level 1 trauma center and identify factors associated with such transfers.

METHODS

All patients transferred to a large metropolitan level 1 pediatric trauma center for isolated orthopedic injuries over a 6-year period were retrospectively evaluated. Medical records were reviewed for demographic and injury data, including age, gender, race, social deprivation index, insurance status, location of transferring institution, timing of transfer, and availability of orthopedic on-call coverage at transferring institution. The transfer was deemed to be appropriate if the patient required a sedated reduction, was admitted to the hospital, or was taken to the operating room within 24 hours of transfer. Regression analysis was reviewed for each of the demographic, patient, and transfer characteristics in an attempt to isolate those associated with inappropriate transfer.

RESULTS

In all, 437 transfers occurred during the study period. Of these, 112 (26%) were deemed inappropriate. 4% of patients transferred for orthopedic injuries did not receive an orthopedic consult following the transfer. Non-white patients were more likely than white patients to be transferred inappropriately (34.01% vs. 21.58%, P=0.009 ). No other demographic characteristic was predictive of inappropriate transfer. There was no difference in the rate of appropriate transfer between patients with private insurance versus government-funded, self-paying, or uninsured patients. The timing of transfer (night vs. day and weekday vs. weekend) did not affect the appropriateness of transfer. Facilities with orthopaedic on-call coverage were more likely to inappropriately transfer patients than those without (26.6% vs. 23.4%, P<0.001 ).

CONCLUSION

A quarter of patients transferred for isolated orthopaedic injuries were inappropriately transferred. Unlike studies published in adult literature, the timing of transfer (overnight and weekend) and the insurance status of the patient did not appear to play a role in the appropriateness of transfer. Inappropriate and unnecessary trauma transfers create a significant burden on tertiary referral centers. Raising awareness of the high incidence of unnecessary transfers coupled with enhanced education of outside emergency medicine providers may result in better stewardship of health care resources, limit delays in patient care, and reduce strain on both the health care delivery system and the families of injured children.

LEVEL OF EVIDENCE

Level III-Therapeutic Study.

It is (not) always on Friday: inter-hospital patient transfers in orthopedic and trauma surgery

BACKGROUND

While inter-hospital transfers for patients who have suffered major trauma have been well investigated, patient flows for other injured patients, or cases with orthopedic complications, are rarely described. This study aims to analyze the affected collective and to show possible reasons, patterns, and pitfalls to optimize the process in future.

MATERIALS AND METHODS

In a prospective cohort study, all consecutive transfers to a Level I trauma center in Germany were documented and assessed. Patients suffering a major trauma were excluded. Data on the primary treating hospital, patient characteristics, and differences between emergency and elective surgery were analyzed.

RESULTS

A total of 227 patients were included; 162 were injured, while 65 had suffered a complication after elective orthopedic surgery or had a complex orthopedic pathology. The most common diagnoses leading to transfer were pathologies of the extremities (n = 62), pathologies of the spine (n = 50), and infections (n = 18). The main reasons stated by the transferring hospitals were a lack of expertise (137 cases) and a lack of capacity (43 cases). There was a significantly higher rate of transfers due to trauma (n = 162) than for orthopedic patients (n = 65), p < 0.0001.

CONCLUSION

There is currently no structured procedure or algorithm for transferring patients in orthopedics and trauma surgery.

The Effect of Joining the ASSH Hand Trauma Center Network on the Volume and Severity of Pediatric Hand Trauma Transfers

Purpose

The purpose of our study was to evaluate how the volume and severity of pediatric hand trauma is affected after enrollment into the American Society for Surgery of the Hand Trauma Center Network.

Methods

We performed a retrospective review using the patient database from our affiliated level-I pediatric trauma center. With this patient database, we compiled all emergent hand trauma transfers from February 2018 to January 2022. We compared the monthly volume, Injury Severity Score, and quarterly payor status between hand trauma transfer patients before and after enrollment into the Hand Trauma Center Network in February 2019.

Results

The average number of monthly transfers increased after joining the Hand Trauma Center Network compared with the years after February 2019. Additionally, the percentage of patients using commercial insurance increased after joining the Hand Trauma Center Network when compared with that before February 2019. Lastly, the percentage of patients using Medicaid decreased after February 2019.

Conclusions

Based on our findings, we believe that new institutions and providers can expect anywhere from a 10% to a 60% increase in hand trauma burden without a significant change in the severity of the trauma cases after joining the network.

Type of study/level of evidence

Prognostic IV.

Interfacility Transfer Patients With Pelvic, Acetabular, and Lower Extremity Fractures Are at Higher Risk for Major Complications and Readmissions

OBJECTIVE

To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home.

METHODS

A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables.

RESULTS

The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32).

CONCLUSIONS

This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

In-Hospital Morbidity and Mortality With Delays in Femoral Shaft Fracture Fixation

OBJECTIVES

To investigate trends in the timing of femur fracture fixation in trauma centers in the United States, identify predictors for delayed treatment, and analyze the association of timing of fixation with in-hospital morbidity and mortality using data from the National Trauma Data Bank.

METHODS

Patients with femoral shaft fractures treated from 2007 to 2015 were identified from the National Trauma Data Bank and grouped by timing of femur fixation: <24, 24-48 hours, and >48 hours after hospital presentation. The primary outcome measure was in-hospital postoperative mortality rate. Secondary outcomes included complication rates, hospital length of stay (LOS), days spent in the intensive care unit LOS (ICU LOS), and days on a ventilator.

RESULTS

Among the 108,825 unilateral femoral shaft fractures identified, 74.2% was fixed within 24 hours, 16.5% between 24 and 48 hours, and 9.4% >48 hours. The mortality rate was 1.6% overall for the group. When fixation was delayed >48 hours, patients were at risk of significantly higher mortality rate [odds ratio (OR) 3.60; 95% confidence interval (CI), 3.13-4.14], longer LOS (OR 2.14; CI 2.06-2.22), longer intensive care unit LOS (OR 3.92; CI 3.66-4.20), more days on a ventilator (OR 5.38; CI 4.89-5.91), and more postoperative complications (OR 2.05; CI 1.94-2.17; P < 0.0001).

CONCLUSIONS

Our study confirms that delayed fixation of femoral shaft fractures is associated with increased patient morbidity and mortality. Patients who underwent fixation >48 hours after presentation were at the greatest risk of increased morbidity and mortality. Although some patients require optimization/resuscitation before fracture fixation, efforts should be made to expedite operative fixation.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Transfers of pediatric patients with isolated injuries to a rural Level 1 Orthopedic Trauma Center in the United States: are they all necessary?

BACKGROUND

Pediatric fractures are difficult to manage and often result in expensive urgent transfers to a pediatric trauma center. Our study seeks to identify patients transferred with isolated acute orthopedic injuries to a Level 1 center in which no procedure occurred and the patient was discharged home. We sought to examine all patients who are transferred to a Level 1 pediatric trauma center for care of isolated orthopedic injuries, and to determine how often no procedure is performed after transfer. Identification of this group ahead of time could potentially lead to less avoidable transfers.

METHODS AND METHODS

A retrospective chart review of all patients with isolated orthopaedic injuries who were transferred to a Level 1 pediatric trauma center in a rural state within the United States over a 5-year period beginning January, 2011 and ending December, 2015. Demographic factors were collected for each patient as well as diagnosis and treatment at the trauma center. Patients were divided into two groups, those who underwent an operation or fracture reduction after admission and those that had no procedure performed. Patient demographics, fracture types and presentation characteristics were examined to attempt to determine factors related to the potentially avoidable transfers.

RESULTS

1303 patients were identified who were transferred with isolated orthopedic fractures. Of these, 1113 (85.6%) patients underwent a procedure for their injuries, including 821 treated with surgical intervention and 292 treated with closed reduction of their fracture. 190 of 1303 (14.6%) of the patients transferred with isolated injuries had neither surgery nor a reduction performed. Identifying characteristics of the non-operative group were that they contained a substantially higher percentage of females, transfers by ambulance, fractures involving only the tibia, fracture types classified as other, and fractures from motor-vehicle accidents.

DISCUSSION

Approximately 14.6% of patients transferred to a pediatric Level 1 trauma center for isolated orthopedic injury underwent no surgery or fracture reductions and were discharged directly home. In particular, isolated tibia fractures were more frequently treated without reduction or surgery. In the future, telemedicine consultation for these specific injury types may limit unnecessary and costly transfers to a Level 1 pediatric trauma hospital.

Socioeconomic Status Impacts Access to Orthopaedic Specialty Care

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Financial, personal, and structural barriers affect access to all aspects of orthopaedic specialty care.

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Disparities in access to care are present across all subspecialties of orthopaedic surgery in the United States.

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Improving timely access to care in orthopaedic surgery is crucial for both health equity and optimizing patient outcomes.

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Options for improving orthopaedic access include increasing Medicaid/Medicare payments to physicians, providing secondary resources to assist patients with limited finances, and reducing language barriers in both clinical care and patient education.

The Curtis Hand Injury Matrix Score: Determining the Need for Specialized Upper Extremity Care

PURPOSE

Given the limited impact of transfer guidelines and the lack of comparative metrics for upper extremity trauma, we introduced the Curtis Hand Injury Matrix (CHIM) score to evaluate upper extremity injury acuity from the specialist perspective. Our goal was to evaluate the CHIM score as an indicator of complexity and specialist need by correlating the score with arrival mode, length of stay (LOS), discharge disposition, and procedure location.

METHODS

We identified all hand and upper extremity emergency room visits at our institution in 2018 and 2019. On initial evaluation, our institution's hand surgery team assigned each patient an alphanumeric score with a number (1-5) and letter (A-H) corresponding to injury severity and pathology, respectively. Patients were divided into 5 groups (1-5) with lower scores indicating greater severity. We compared age, LOS, discharge disposition, procedure location, transfer status, and arrival mode between groups and assessed the relationships between matrix scores and discharge disposition, procedure performed, and LOS.

RESULTS

There were 3,822 patients that accounted for 4,026 upper extremity evaluations. There were significant differences in LOS, discharge dispositions, procedure locations, transfer status, and arrival modes between groups. Patients with more severe scores had higher rates of admission and more operating room procedures. Higher percentages of patients who arrived via helicopter, ambulance, or transfer had more severe scores. Patients with more severe scores were significantly more likely to have a procedure, hospital admission, and longer hospital stay.

CONCLUSIONS

The CHIM score provides a framework to catalog the care and resources required when covering specialized hand and upper extremity calls and accepting transfers. This clinical validation supports considering broader use.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Added Burden of Transfer Status in Patients Undergoing Surgery After Sustaining a Periprosthetic Fracture of the Hip or Knee

Background A significant proportion of patients who sustain periprosthetic fractures are transferred to another institution for definitive care. There is limited understanding of the impact of transfer on outcomes. Methods The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was utilized to identify patients who sustained periprosthetic fractures of the hip or knee requiring surgical intervention. Inclusion criteria were total joint prosthesis of the hip or knee with documented periprosthetic fracture of a single hip or knee along with surgery during hospitalization. Transfer status and discharge location were recorded. A total of 1,194 non-transferred patients were compared to 620 transferred patients. Cohorts were compared utilizing standard parametric and non-parametric tests depending on the characteristics of the data. Results Transferred patients had a higher mean age (75.6 years vs. 72.9 years, p < 0.0001), longer mean length of stay (7.9 days vs. 6.9 days, p = 0.0023), and greater American Society of Anesthesiologists (ASA) grade. Transferred patients were less likely to be discharged home (p = 0.0001) and more likely to be discharged to hospice (p = 0.049) or rehabilitation facilities (p = 0.0001). No significant differences were detected regarding readmissions or complications. In transferred patients, having lower preoperative albumin was a risk factor for readmission within 30 days. Conclusion Transfer centers accepting and treating periprosthetic fractures should be aware that these patients often have a longer length of stay and are less likely to be discharged home. However, the data suggests these patients are well cared for, given the similar complication rates.

Factors associating with surgical site infection following operative management of malleolar fractures at an urban level 1 trauma center

OBJECTIVES

To identify comorbidities and injury characteristics associated with surgical site infection (SSI) following internal fixation of malleolar fractures in an urban level 1 trauma setting.

DESIGN

Retrospective.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Seven-hundred seventy-six consecutive patients with operatively managed malleolar fractures from 2006 to 2016.

INTERVENTION

Open reduction internal fixation.

MAIN OUTCOME MEASUREMENTS

Superficial SSI (erythema and drainage treated with oral antibiotics and wound care) or deep SSI (treated with surgical debridement and antibiotics).

RESULTS

Fifty-six (7.2%) patients developed SSI, with 17 (30%) of these being deep infections. An a-priori power analysis of n = 325 (α=0.05, β=0.2) was tabulated for differences in univariate analysis. Univariate analysis identified categorical associations (P < .05) between SSI and diabetes mellitus, drug abuse, open fracture, and renal disease but not tobacco abuse, body mass index, or neuropathy. Multivariate logistic regression identified categorical associations between diabetes (OR = 2.2, 95% CI: 1.1-4.3), drug abuse (OR = 3.9, 95% CI: 1.2-12.7), open fracture (OR = 4.1, 95% CI: 1.3-12.8), and renal disease (OR = 2.7, 95% CI: 1.4-5.0) and any (superficial or deep) SSI. A separate multivariate logistic regression analysis found categorical associations between deep SSI requiring reoperation and diabetes (OR = 4.4, 95% CI: 1.6-12.2) and open fracture (OR = 4.1, 95% CI: 1.3-12.8). Furthermore, American society of anesthesiologists classification (ASA) Class 4 patients were (OR = 9.2, 95% CI: 2.0-41.79) more likely to experience an SSI than ASA Class 1 patients.

CONCLUSIONS

Factors associated with SSI following malleolar fracture surgery in a single urban level 1 trauma center included diabetes, drug abuse, renal disease, and open fracture. The presence of diabetes or open type fractures were associated with deep SSI requiring reoperation.

LEVEL OF EVIDENCE

Level 3 prognostic: retrospective cohort study.

Trauma Service Utilization Increases Cost But Does Not Add Value for Minimally Injured Patients

OBJECTIVE

Trauma care provides value to the critically injured. Our aim was to assess whether trauma team involvement adds value to the care of minimally injured patients and to define its costs.

METHODS

Minimally injured patients admitted to a trauma center were propensity matched and compared by involvement versus no involvement of the trauma service (TS). Demographics, injury severity, complications, length of emergency department stay, mortality, and hospital costs and charges were studied.

RESULTS

A total of 1253 patients were enrolled, with 308 propensity matched to the following groups: TS (n = 102) and no TS (n = 206). TS demonstrated a 30% increase in total charges and costs with no difference in complications. TS did demonstrate decreased time in the emergency department but had an increased delay to operation. Findings were similar when stratified for only lower extremity injuries.

CONCLUSIONS

TS involvement for minimally injured patients does not increase value. Reducing TS involvement while avoiding trauma undertriage may reduce costs to the healthcare system without affecting outcomes.

The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma

PURPOSE

Underinsured hand trauma patients are more likely to be transferred to quaternary care centers, which burdens these patients and centers. By increasing insurance coverage, care for less severe upper-extremity injuries may be available closer to patients' homes. We evaluated whether the 2014 expansion of Medicaid in Maryland under the Affordable Care Act decreased the number of uninsured upper-extremity trauma patients and the volume of unnecessary emergency trauma visits at our hand center.

METHODS

We identified all upper-extremity trauma patients between 2010 and 2017 at our hand trauma referral center. Injury severity was classified based on the need for subspecialty care. Bivariate relations between insurance status and demographic covariates, including injury type and distance, both before and after Medicaid expansion were evaluated. We used patient-level and multinomial logistic regression models to evaluate changes in payer and transfer appropriateness.

RESULTS

We studied 12,009 acute upper-extremity trauma patients. With Medicaid expansion, the percentage of trauma patients with Medicaid coverage increased from 15% to 24%, with a decrease in uninsured from 31% to 24%. After Medicaid expansion, non-transfer patient appropriateness decreased and appropriateness of transfers remained consistent across all payers. The average distance patients traveled for care remained similar before and after expansion.

CONCLUSIONS

Medicaid expansion significantly decreased the proportion of uninsured upper-extremity trauma patients. We identified no significant changes in the distances these patients traveled for specialized care. In addition, the appropriateness of transferred patients did not change significantly after expansion, whereas appropriateness of nontransferred patients actually declined after Medicaid expansion.

CLINICAL RELEVANCE

This study indicates no notable change in adherence to transfer guidelines after expansion, and a possible increase in use of emergency services by newly insured patients.

Pediatric Emergency Room Transfers: Are They Warranted?

BACKGROUND

Emergency room transfers to a higher level of care are a vital component of modern health care, as optimal care of patients requires providing access to specialized personnel and facilities. However, literature has shown that orthopaedic transfers to a higher level of care facility are frequently unnecessary. The purpose of this study was to assess the appropriateness of pediatric orthopaedic transfers to a tertiary care center and the factors surrounding these transfers.

METHODS

All pediatric orthopaedic transfers to the pediatric emergency department (ED) were evaluated over a 4-year period. A retrospective chart review was performed to assess the factors surrounding the transfer including patient demographics, time of transfer, day of transfer, insurance status, outcome of transfer, and diagnosis. Three independent variables were utilized to assess the appropriateness of the transfer: the need for an operative procedure, the need for conscious sedation, and the need for a closed reduction in the ED.

RESULTS

A total of 218 pediatric orthopaedic emergency room transfers were evaluated, of which 86% of them involved an acute fracture. Twenty-seven percent (59/218) of the transfers occurred on the weekend, with over half (61%) of these transfers being initiated between 6 PM and 6 AM. Approximately half (47%) of the transfers involved patients with Medicaid. Fifty-five percent (120/218) of cases required a procedure in the operating room and 22% (49/218) had a closed reduction performed in the ED. Conscious sedation was provided in the ED for 22% (48/218) of patients. Twenty-two percent (47/218) of transfers did not require a trip to the operating room, conscious sedation, nor a closed reduction procedure in the ED.

CONCLUSION

The vast majority of pediatric orthopaedic transfers are warranted as they required operative intervention, a closed reduction maneuver, or conscious sedation in the ED.

LEVEL OF EVIDENCE

Level III-Therapeutic.

Appropriateness of Pediatric Orthopaedic Transfers to a Level 1 Hospital

OBJECTIVE

To compare a cohort of transferred pediatric orthopaedic patients with orthopaedic patients who primarily presented to a Level 1 pediatric emergency department to identify risk factors for transfer.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center in New York.

PATIENTS

The cohort consisted of patients younger than 18 years who presented to 1 Level 1 pediatric trauma center between January 1, 2013, and December 31, 2013, with an orthopaedic fracture diagnosis code (ICD-9 805.0-839.9). The control group included the patients who presented to that hospital primarily, and the study group included patients who were transferred to that same hospital from another institution.

INTERVENTION

Demographic and injury-related data [age, sex, mechanism of injury, location of injury, injury severity score, and insurance status] were collected.

MAIN OUTCOME MEASUREMENTS

Regression analysis was performed to assess for predictors of transfer to a Level 1 hospital. Subgroup analysis examined whether transfers were appropriate, based on the type of injury.

RESULTS

There were 1064 patients in the nontransfer group and 67 patients in the transfer group. Transferred patients were more likely to have surgery within 24 hours (39.42% vs. 2.63%) and were more likely to have no insurance or Medicaid (50.75% vs. 33.24%). Injury severity score and insurance status were independent predictors for transfer.

CONCLUSIONS

This study indicates that injury severity is the primary predictor in deciding to transfer a pediatric patient; however, insurance status may play a role in that decision.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Survey of the Statewide Impact of Payer Source on Referral of Small Burns to Burn Centers

It is generally agreed that patients with large burns will be referred to organized burn centers, however, the referral of patients with smaller burns is less certain. A two-part survey was conducted to identify referral patterns for burn patients that meet American Burn Association referral criteria, and any effect insurance type might have on the referral patterns. The emergency departments of our state hospital association's member hospitals were contacted seeking a referral for a fictitious patient with a third-degree scald of the dominant hand. The referral sites were contacted twice, first stating that the patient had commercial insurance, next stating that the patient had Medicaid. Data collected included wait time for an appointment or reasons for denial of an appointment. Of 218 hospitals, 46 were excluded because they did not offer emergency care, and eight because they were listed as burn centers on the American Burn Association website. Of the remaining 164, 119 (73%) would refer to a burn center, 21 (13%) to a plastic surgeon, 10 (6%) to a hand surgeon, 7 (4%) to a wound center, 7 (4%) to another nonburn physician resource. There was no difference in wait time to the first available appointment with regards to insurance type (6.56 ± 4.68 vs 6.53 ± 5.05 days). Our state's referral pattern gives us insight into the regional referral pattern. This information will be used to guide a focused education and communication program to provide better service for the burn victims of our state.

"What Do People Do If They Don't Have Insurance?": ED-to-ED Referrals

OBJECTIVE

Up to 20% of patients seen in public emergency departments (EDs) have already been seen for the same complaint at another ED, but little is known about the origin or impact of these duplicate ED visits. The goals of this investigation were to explore 1) whether patients making a repeat ED visit are self-referred or indirectly referred from the other ED and 2) gather the perspective of affected patients on the health, social, and financial consequences of these duplicate ED visits.

METHODS

This mixed-methods study conducted over a 10-week period during 2016 in a large public hospital ED in Texas prospectively surveyed patients seen in another ED for the same chief complaint. Selected patients presenting with fractures were then enrolled for semistructured qualitative interviews, which were audiotaped, transcribed, and independently coded by two team members until thematic saturation was reached.

RESULTS

A total of 143 patients were identified as being recently seen at another local ED for the same chief complaint prior to presenting to the public hospital; 94% were uninsured and 61% presented with fractures. A total of 27% required admission at the public ED and 95% of those discharged required further outpatient follow-up. Fifty-one percent of patients completed a survey and qualitative interviews were conducted with 23 fracture patients. Fifty-three percent of patients reported that staff at the first hospital told them to go the public hospital ED, and 23% reported referral from a follow-up physician associated with the first hospital. Seventy-three percent reported receiving the same tests at both EDs. Interview themes identified multiple health care visits for the same injury, concern about complications, disrespectful treatment at the first ED, delayed care, problems accessing needed follow-up care without insurance, loss of work, and financial strain.

CONCLUSIONS

The majority of patients presenting to a public hospital ED after treatment for the same complaint in another local ED were indirectly referred to the public ED without transferring paperwork or records, incurring duplicate testing and patient anxiety.

Factors Affecting Appropriateness of Interfacility Transfer for Hand Injuries

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.

Patients Transferred for Upper Extremity Amputation: Participation of Regional Trauma Centers

PURPOSE

Level-I trauma centers are required to provide hand and microsurgery capability at all times. We examined transfers to our center to better understand distant patient referrals and, indirectly, study referrals in our region.

METHODS

Records were reviewed from 2010 to 2015 to evaluate patients transferred to our level-I institution for upper extremity amputation. Patients were referred from 6 states to our institution over this period. We measured the straight-line distance from each patient's transferring facility to our facility and compared this distance with the straight-line distances from the zip code of the transferring facility to the zip code of each level-I trauma center.

RESULTS

We had data for 250 transferred patients (91% male, 9% female). For 110 patients (44%), our hospital was the nearest level-I trauma center; however, for the remaining 140 patients (56%), other level-I trauma facilities were located closer to the referring hospital. Among these 140 patients, the mean distance of the referring facility to the nearest level-I trauma center (30 miles; SD, 27) was significantly different from the mean distance of the referring facility to our facility (71 miles; SD, 60). A median of 4 (range, 1-10) level-I trauma centers were bypassed before patients arrived at our center. Medicaid and "self-pay" patients were more likely to be transferred to our facility.

CONCLUSIONS

Fifty-six percent of patients transferred to our hospital for upper extremity amputation had a level-I trauma center closer to their injury. Patients with upper extremity amputation are referred to our regional center despite the proximity of closer level-I trauma centers. This suggests that regional microsurgery expertise does not correlate with level-I trauma designation, and establishment of designated microsurgery centers and formal referral guidelines may be beneficial for management of these difficult injuries.

CLINICAL RELEVANCE

We believe that this study further supports the need for formal designation of regional centers of expertise for microsurgical hand trauma.

Impact of Safety Net Hospitals in the Care of the Hand-Injured Patient: A National Perspective

A clear disparity in the pattern and provision of surgical care exists, particularly for patients with vulnerable socioeconomic backgrounds. For hand-injured patients in particular, this discrepancy has been frequently shown in their receiving appropriate care. With the advent of the Affordable Care Act and with Medicaid expansion on the horizon, more patients will be requiring access to care. Safety net programs have been shown to provide equivalent levels of care for patients compared with non-safety net providers, and the survival of these hospitals for the disadvantaged is essential to providing quality care for this growing patient population. In this article, the authors review the factors that affect the barriers to care, the importance of safety net hospitals, the epidemiology of the hand-injured patient, and how the Affordable Care Act will impact these safety net programs.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center

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.

Understanding an inclusive trauma system through characterization of admissions at level IV centers

BACKGROUND

Level IV trauma centers are an integral part of inclusive trauma systems, although sparse data exists for these facilities.

METHODS

An observational study was conducted using a Midwestern state's inpatient data files to characterize level IV center patients. Injury and severity levels, injury mechanism and/or intent, and distances to nearest tertiary centers were determined.

RESULTS

During the study year, 3,346 injured patients were admitted at level IV centers. The median distance to nearest tertiary center was 43 miles. Median patient age was 81 years, and primary injury mechanism was falls. Overall, 22% of patients had an isolated hip fracture. Of moderately injured patients, 64% had an isolated hip fracture, 8% nonisolated hip fractures, and 9% rib fractures without hip fracture. Overall, 30% of patients had a high severity of injury.

CONCLUSIONS

A large number of patients were admitted to level IV trauma centers. Patients admitted tended to be elderly and have orthopedic fall injuries. Study results provide important implications for provider education, prevention efforts, need for orthopedic surgical capabilities, and necessity of capturing these data in registries.

Healthcare reimbursement models and orthopaedic trauma: will there be change in patient management? A survey of orthopaedic surgeons

OBJECTIVES

Healthcare reimbursement models are changing. Fee-for-service may be replaced by pay-for-performance or capitated care. The purpose of this study was to examine the potential changes in orthopaedic trauma surgery patient management based on potential shifts in policy surrounding readmission and reimbursement.

METHODS

An e-mail survey consisting of 3 case-based scenarios was delivered to 375 orthopaedic surgeons. Five options for management of each case were provided. Each of the 3 cases was presented in 3 different healthcare settings: scenario A, our current healthcare setting; scenario B, in which 90-day reoperation or readmission would not be reimbursed; and scenario C, in which a capitated healthcare structure paid a fixed amount per patient.

RESULTS

The response rate was 40.3% with 151 surgeons completing the survey. A 71.1% of the respondents were in private practice settings, whereas 28.3% were in academic centers. In each case, there was significant increase in the respondents' choice to transfer patients to tertiary care centers under both the capitated and penalization systems as compared with the current fee-for-service model.

CONCLUSIONS

This survey is the first of its kind to demonstrate through case-based scenarios that a healthcare system with readmission penalties and capitated reimbursement models may lead to a significant increase in transfer of complex orthopaedic trauma patients to tertiary care centers. Physicians should be encouraged to continue evidence-based medicine instead of making decisions due to finances, and other avenues of healthcare savings should be explored to decrease patient transfer rates with healthcare changes.

Reasons for transfer to a level 1 trauma center and barriers to timely definitive fracture fixation

OBJECTIVE

Our purpose was to compare patients transferred from another hospital to our trauma center with those arriving directly, to identify barriers to care for similar fractures. We hypothesized that the most frequent reason for delayed definitive fixation would be interhospital transfer and that patients would be transferred primarily for 2 reasons: complex patients with more severe injuries and less complex patients without insurance.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 1549 skeletally mature patients with 1655 fractures: 379 acetabulum, 301 pelvic ring, 876 femur, and 99 spine.

INTERVENTION

All patients were treated surgically, with early fixation defined as <24 hours after injury.

MAIN OUTCOME MEASUREMENTS

Demographic and injury characteristics were recorded. Reasons for and timing of transfer were determined.

RESULTS

A total of 814 patients (53%) were transferred from another hospital, including 66% of acetabular and 62% of pelvic ring fractures. Transferred patients were older (39.1 vs. 36.6 years, P = 0.002), had more commercial insurance (21% vs. 17%, P = 0.10), and were less often uninsured (27% vs. 31%, P = 0.11). However, the mean Injury Severity Score of uninsured transferred patients was lower than that of the other transferred patients (22.9 vs. 25.8, P < 0.0001). Transfer was not related to weekday or time of injury. A total of 973 patients (63%) had early definitive fixation. Delayed fixation was often for surgeon preference (57%). Transferred patients were more likely to have delayed fixation (43% vs. 31% of nontransferred, P < 0.0001).

CONCLUSIONS

Internal barriers to definitive fracture care were noted, the most frequent of which is surgeon preference. Treatment delays due to transfer accounted for 12% of all delays. Many transferred patients appeared appropriate based on injury complexity. However, over one-fourth of those transferred had low Injury Severity Score and a significantly higher incidence of no insurance. Communication and transparency about these issues may serve to expedite care and to enhance financial stability of larger trauma centers.

LEVEL OF EVIDENCE

Prognostic level II.

The characteristics of referring facilities and transferred hand surgery patients: factors associated with emergency patient transfers

BACKGROUND

As emergency departments (EDs) become increasingly overwhelmed and specialist coverage in some EDs decreases, patients may be transferred to tertiary or quaternary facilities for specialized care to decrease patient load at transferring facilities. Our objective was to determine whether facilities that transferred patients for hand surgery had hand surgery coverage and to evaluate any nonmedical factors that might have been associated with transfer.

METHODS

A retrospective review was conducted for 1167 visits of hand and wrist patients seen in the EDs of two urban level-I trauma centers. The hand surgery capacity of referring facilities was determined by phone calls to the EDs. Univariate and multivariable analyses were conducted to identify nonmedical factors that could potentially affect the decision to transfer.

RESULTS

A total of 155 (13.3%) of 1167 patients arrived from other facilities for specialized hand care. These patients were significantly more likely to be male (p = 0.02), have noncommercial insurance (p = 0.04), require an interpreter (p = 0.01), and arrive between 6:00 p.m. and midnight (p = 0.03). In a multivariable analysis, sex and insurance status were significantly associated with transfer (p &lt; 0.05). The subset of ninety-five patients who were transferred from other EDs was significantly more likely to be male (p &lt; 0.01) and arrive on weekends (p &lt; 0.01) or between 6:00 p.m. and midnight (p &lt; 0.01). Of these patients, seventy-seven (81%) were transferred from an ED that reported partial or full hand surgery coverage. However, only eight (10.4%) received a hand surgery evaluation prior to transfer.

CONCLUSIONS

The low percentage of patients receiving hand surgery evaluations prior to transfer suggests that referring hospitals are not using their own hand surgeon resources. Nonmedical factors, including noncommercial insurance and off-hour time of initial arrival, may be associated with the decision to transfer patients.

CLINICAL RELEVANCE

Identifying nonmedical factors associated with patient transfers and referrals can enlighten efforts to improve the quality and appropriate use of transfers for specialty care.

Evaluation of appropriateness of patient transfers for hand and microsurgery to a level I trauma center

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.

Unravelling the debate over orthopaedic trauma transfers: The sender's perspective

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.

Transfer of hip arthroplasty patients leads to increased cost and resource utilization in the receiving hospital

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.

Prospective Non-randomized Studies in Orthopaedics and Traumatology: Systematic Assessment of its Methodological Quality

In surgical interventions, randomization and blinding may be difficult to implement. In this situation, non-randomized prospective studies (EPNR) can generate the best evidence. The objective of this study is to evaluate, by means of the scale proposed by Downs & Black, the quality of EPNR published in our country and to assess the interobserver reproducibility of this scale. EPNR published in Acta Ortopedica Brasileira and Revista Brasileira de Ortopedia until 2011 and prior to 2006 were included. Two of us independently applied the Downs & Black scale. The studies were stratified by period of publication, journal and type of intervention. The scores obtained were considered to assess the reliability of the scale and groups comparison. 59 studies were considered, seven excluded during the assessments. There were no differences between the scores, except for the type of intervention, which showed better methodological quality for studies involving clinical interventions (p < 0.001). The correlation coefficient for the Downs & Black score was 0.79 (95% CI 0.65 to 0.88), demonstrating good reliability. EPNR present methodological quality similar when stratified by the periodic publication and publication period. Studies with clinical interventions have better methodological quality. The Downs & Black scale shows good interobserver reproducibility.

The overutilization of resources in patients with acute upper extremity trauma and infection

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.

Characteristics of emergency department transfers for hand surgery consultation

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.

The influence of insurance status on access to and utilization of a tertiary hand surgery referral center

BACKGROUND

The purpose of this study was to systematically examine the impact of insurance status on access to and utilization of elective specialty hand surgical care. We hypothesized that patients with Medicaid insurance or those without insurance would have greater difficulty accessing care both in obtaining local surgical care and in reaching a tertiary center for appointments.

METHODS

This retrospective cohort study included all new patients with orthopaedic hand problems (n = 3988) at a tertiary center in a twelve-month period. Patient insurance status was categorized and clinical complexity was quantified on an ordinal scale. The relationships of insurance status, clinical complexity, and distance traveled to appointments were quantified by means of statistical analysis. An assessment of barriers to accessing care stratified with regard to insurance status was completed through a survey of primary care physicians and an analysis of both patient arrival rates and operative rates at our tertiary center.

RESULTS

Increasing clinical complexity significantly correlated (p < 0.001) with increasing driving distance to the appointment. Patients with Medicaid insurance were significantly less likely (p < 0.001) to present with problems of simple clinical complexity than patients with Medicare and those with private insurance. Primary care physicians reported that 62% of local surgeons accepted patients with Medicaid insurance and 100% of local surgeons accepted patients with private insurance. Forty-four percent of these primary care physicians reported that, if patients who were underinsured (i.e., patients with Medicaid insurance or no insurance) had been refused by community surgeons, they were unable to drive to our tertiary center because of limited personal resources. Patients with Medicaid insurance (26%) were significantly more likely (p < 0.001) to fail to arrive for appointments than patients with private insurance (11%), with no-show rates increasing with the greater distance required to reach the tertiary center.

CONCLUSIONS

Economically disadvantaged patients face barriers to accessing specialty surgical care. Among patients with Medicaid coverage or no insurance, local surgical care is less likely to be offered and yet personal resources may limit a patient's ability to reach distant centers for non-emergency care.

Does insurance status affect continuity of care for ambulatory patients with operative fractures?

BACKGROUND

We compared insurance status among three groups of ambulatory patients with an operatively treated fracture of the distal part of the radius or of the ankle, in order to determine if insurance status affected continuity of care. The patients were categorized as having received initial care at our institution, having received initial care elsewhere with an identifiable reason for transfer to a tertiary care center, or having received initial care elsewhere with no identifiable reason for transfer.

METHODS

We conducted a retrospective review of 697 patients with an operatively treated distal radial fracture or ankle fracture who had received their definitive treatment at a level-I trauma center. Demographic data, the mechanism of injury, the insurance type, and the location of the initial care were recorded.

RESULTS

The proportion of uninsured or underinsured patients in the group that had had their initial treatment at our trauma center was similar to that in the group that had had a specific reason to seek definitive care with us (64% and 63%, p < 0.832). However, the proportion of uninsured or underinsured patients was significantly larger in the group that had not received initial care from us and had no specific reason to receive definitive care from us (82% vs. 63%, p < 0.001). With other variables held constant, the odds of being underinsured or uninsured were 2.53 times greater for the patients initially treated elsewhere who had no specific reason to receive definitive treatment from us.

CONCLUSIONS

These results suggest that nonmedical reasons play a role in determining where ambulatory patients with fractures requiring operative treatment are able to receive definitive care. Patients without specific medical or nonmedical reasons to receive definitive care at our center were significantly more likely to be uninsured or underinsured.

Trauma Team Activation can be Tailored by Prehospital Criteria

A two phase prospective study was carried out at a regional Level I trauma center over 1 year. Phase I involved collecting observational data to determine which trauma criteria could potentially be used to identify patients that could be evaluated by a lower level trauma activation (category-3). A category-3 involved a smaller response team with priority access to imaging. Phase II involved implementing this third tier activation system and prospectively evaluating the outcomes related to resources and patient care. A total of 3104 patients were evaluated with 2076 patients in phase I and 1037 in phase II. Three commonly identified activation criteria out of the 36 studied were not associated with admission. These criteria were pedestrian struck by vehicle, high speed vehicular crash, and Glasgow Coma Score 12-14. These criteria were then used as triggers for a category-3 activation in phase II. Comparisons of patients with these three identified criteria between phase I and II demonstrated that significantly fewer patients were admitted, charges were reduced, emergency department times were similar, and less man-power hours were needed in phase II. The utilization of a third tiered activation system resulted in a decrease utilization of many resources without sacrificing patient care.

Pedestrians struck by motor vehicles further worsen race- and insurance-based disparities in trauma outcomes: the case for inner-city pedestrian injury prevention programs

BACKGROUND

Pedestrian trauma is the most lethal blunt trauma mechanism, and the rate of mortality in African Americans and Hispanics is twice that compared with whites. Whether insurance status and differential survival contribute to this disparity is unknown.

METHODS

This study is a review of vehicle-struck pedestrians in the National Trauma Data Bank, v7.0. Patients <16 years and > or =65 years, as well as patients with Injury Severity Score (ISS) <9, were excluded. Patients were categorized as white, African American, or Hispanic, and as privately insured, government insured, or uninsured. With white and privately insured patients as reference, logistic regression was used to evaluate mortality by race and insurance status after adjusting for patient and injury characteristics.

RESULTS

In all, 26,404 patients met inclusion criteria. On logistic regression, African Americans had 22% greater odds of mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.06-1.41) and Hispanics had 33% greater odds of mortality (OR, 1.33; 95% CI, 1.14-1.54) compared with whites. Uninsured patients had 77% greater odds of mortality (OR, 1.77; 95% CI, 1.52-2.06) compared with privately insured patients.

CONCLUSION

African American and Hispanic race, as well as uninsured status, increase the risk of mortality after pedestrian crashes. Given the greater incidence of pedestrian crashes in minorities, this compounded burden of injury mandates pedestrian trauma prevention efforts in inner cities to decrease health disparities.

Appropriateness of patient transfer with associated orthopaedic injuries to a Level I trauma center

OBJECTIVE

To prospectively evaluate the appropriateness, indications, risk factors, and epidemiology of patients with orthopaedic injuries transferred to a Level I trauma center.

DESIGN

Prospective data were supplemented through chart review on all patients transferred to a Level I trauma center with orthopaedic injuries (n = 546) from January 1, 2007, to December 31, 2007. The accepting orthopaedic trauma surgeon evaluated the appropriateness of transfer by visual analog scale.

SETTING

A Level I trauma center.

PARTICIPANTS

Patients transferred to the trauma center requiring orthopaedic trauma service involvement.

MAIN OUTCOME MEASUREMENTS

Demographics and visual analog scale appropriateness scores were collected on each patient.

RESULTS

The authors considered 16.5% of the cohort inappropriate transfers, 49.3% appropriate, and the remaining 34.2% were designated as intermediate. The transfers came from an emergency department physician in 81% of cases, an orthopaedic surgeon in 14% of cases, and 5% by general surgeon or internist. One hundred forty-eight cases transferred primarily as a result of orthopaedic injuries had an available orthopaedic surgeon on-call at the original institution. Sixty percent were transferred as a result of orthopaedic injury complexity, but only 39% of the 148 were evaluated by an actual orthopaedic surgeon before transfer. Lack of orthopaedic coverage at the referring hospital accounted for 27% of transfers.

CONCLUSIONS

A total of 16.5% of transfers were deemed completely inappropriate by the accepting orthopaedic traumatologist. Most transfers, both appropriate and inappropriate, were attributed to either complete lack of orthopaedic coverage or a lack of expertise at the referring center.

Inappropriate transfer of patients with orthopaedic injuries to a Level I trauma center: a prospective study

OBJECTIVE

The objective of this study was to analyze the appropriateness of transfer of patients with orthopaedic injuries to a Level I trauma center from surrounding Level II to IV centers.

DESIGN

A prospective study was conducted over a 5-month period by collecting data on all orthopaedic patients being transferred to our facility. All transfer diagnoses were designated as appropriate or inappropriate. Patient demographics were calculated.

SETTING

The transfer of patients occurred from 23 Level II to IV hospitals to a Level I trauma center. These hospitals service 1 to 1.5 million people a year. PATIENTS/PARTICIPANTS MAIN OUTCOME MEASUREMENTS: All patients transferred with orthopaedic injuries were recorded. Patient variables such as transfer diagnosis, age, gender, insurance status, time of arrival, day of transfer, transferring and accepting physicians, previous imaging studies, and patient disposition were recorded. Outcome measurements included chi tests to determine variation in demographics based on insurance and appropriateness of transfer. Multivariate regression analysis was also performed to determine influence of individual patient variables on the main outcome variable: appropriateness of transfer.

RESULTS

Two hundred sixteen patients were transferred of which we considered 52% inappropriate. Sixty-eight percent of transfers occurred between 6:00 pm and 5:59 am and 60% of all transfers were over the weekend. Also, 69% of inappropriate transfers were discharged directly from the emergency department. Insurance was an independent factor affecting appropriateness of transfer. A larger percentage of inappropriate patients transferred were uninsured. The inappropriate patient who was transferred had more likelihood of being uninsured than insured. Moreover, there was a significantly higher percentage of inappropriate uninsured patients transferred after hours and over the weekend as compared with insured patients. More than 97% of inappropriate transfers were accepted by the emergency department physician without communication with the on-call orthopaedist at our facility.

CONCLUSIONS

There is a trend among community hospitals to transfer uninsured patients with benign orthopaedic injuries inappropriately to a Level I trauma center. This effect is magnified on weekends and at night. Strict regulation of the Emergency Labor Act and better communication between Level II to IV hospitals and Level I orthopaedic surgeons can decrease the inappropriate transfer of patients and reduce the burden on our healthcare system.

Prior treatment of fracture patients in a tertiary pediatric emergency department: informal referrals from other emergency departments

BACKGROUND

The purposes of this study were to determine the following: (1) the percentage of fracture patients at a tertiary pediatric emergency department (ED) who previously sought treatment for the injury elsewhere and (2) how often such patients were sent from another ED.

METHODS

A prospective survey was conducted in the ED of a tertiary pediatric medical center in a large metropolitan area. Patients who presented with suspected extremity fractures and previously sought treatment elsewhere were asked where they had sought treatment and whether staff at another ED had told them to come to the tertiary ED. Demographic, clinical, insurance, and transfer information were also collected.

RESULTS

Ninety-two patients who had sought previous care for the injury elsewhere participated in the survey, with 82 (89%) ultimately being diagnosed with fractures. This represents 33% (82/246) of the patients with extremity fractures treated by the participating ED physicians during the study. Seventy-nine percent (73/92) of the subjects had previously sought treatment at another ED. For those who did not also visit a regular physician, 69% (37/54) were told to come to the tertiary ED by staff at the initial ED. No differences were observed based on race or insurance status because the study subjects were predominantly minority (91%, including 80% Hispanic) and lacking private insurance (84%).

CONCLUSIONS

Seeking follow-up care in a tertiary ED, often on the advice of staff from another ED, is a common practice for this largely minority and poorly insured population. Because patients did not present to our ED until an average of 3 days after injury and many had been discharged to a primary care physician, it is likely that many of the patients did not require emergency care. This practice inefficiently uses limited emergency care resources.

LEVEL OF EVIDENCE

Level II prospective survey.

The influence of insurance status on the transfer of femoral fracture patients to a level-I trauma center

BACKGROUND

The aim of the present study was to evaluate transfer patterns and insurance status for patients with a femoral fracture who were definitively managed within a six-hospital health-care system. We hypothesized that insurance status significantly influenced transfer of these patients to the level-I trauma center and that the level-I center provided definitive care for a disproportionate percentage of uninsured femoral fracture patients.

METHODS

The present retrospective cohort study was performed within a six-hospital health-care system. The system comprises a single American College of Surgeons-designated level-I trauma center and five nondesignated community hospitals. We identified 243 patients with 251 femoral shaft fractures that had been definitively treated with intramedullary nail fixation within the system. From the health-care system billing database and trauma registries, we obtained diagnosis and procedure codes, insurance status, and trauma center transfer data. Differences in the proportions of uninsured and insured patients were calculated.

RESULTS

One hundred and seventy-two (71%) of the 243 patients who were definitively managed within our health-care system initially had been taken to the regional level-I center, and thirty-eight patients (16%) had been transferred to the trauma center. Of the thirty-eight patients who had been transferred, eighteen (47%) had met appropriate transfer criteria. Of the twenty patients with an isolated femoral fracture who had been transferred from hospitals with regular orthopaedic coverage, four (20%) had met appropriate transfer criteria. Twenty-two (58%) of the thirty-eight patients who had been transferred were uninsured, and all thirty-three patients who had not been transferred were insured (p = 0.0008); this observation remained when controlling for injury severity and available orthopaedic coverage (p < 0.0001). The proportion of insured patients definitively managed at the trauma center (52%) differed significantly from the proportion of insured patients definitively managed at the community hospitals (100%) (p < 0.0001).

CONCLUSIONS

The majority (71%) of the patients with a femoral fracture who had been managed definitively within our health-care system, regardless of injury severity, had been taken directly to the trauma center. This finding suggests over-triage, which errs on the side of patient well-being. Because there was a significant difference in insurance status between patients who had been transferred to the level-I center and those who had not been transferred as well as between patients who had been definitively managed at the level-I center and those who had been managed in community hospitals, it can be assumed that insurance status as well as injury severity and orthopaedic surgeon availability influence the decision to transfer femoral fracture patients to a level-I trauma center.