Inter-Hospital Transfer Is an Independent Risk Factor for Hospital-Associated Infection

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs.

Trauma - It is a party, but is everyone invited? A single center retrospective analysis of trauma patients at risk for early discharge after transfer

BACKGROUND

Transferred trauma patients frequently are discharged after short stays without undergoing treatments. Strategies to decrease unnecessary transfers are needed.

METHODS

We conducted a retrospective analysis of patients transferred to our level I center from 2019 to 2021. We identified patients discharged within 24 h without interventions and compared demographic, activation, injury, and mechanism of injury characteristics with patients requiring more care. A risk score was developed from these factors.

RESULTS

Of 2424 patients transferred, 463(19%) were discharged within 24 h. In an integer score, age (1 pt), Injury Severity Score (<6 = 5 pts, 7-9 = 2 pts), recreational mechanism (3 pts), no hypertension (1 pt), no diabetes (2 pts), no dementia (3 pts), chest (1 pt), external (4 pts), face (5 pts) and Head/neck trauma (2 pts) were associated with early discharge. The score stratified risk of early discharge from 4.8% (score <7) to 67% (score >15).

CONCLUSION

When prospectively validated the risk score may identify patients who can be managed without transfer.

Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach

BACKGROUND

Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer.

METHODS

This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center.

RESULTS

Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer.

CONCLUSIONS

Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.

Association Between Insurance and the Transfer of Children With Mental Health Emergencies

OBJECTIVES

This study sought to investigate the association between a patient's insurance coverage and a hospital's decision to admit or transfer pediatric patients presenting to the emergency department (ED) with a mental health disorder.

METHODS

This is a cross-sectional study of pediatric mental health ED admission and transfer events using the Healthcare Cost and Utilization Project 2014 Nationwide Emergency Department Sample. Children presenting to an ED with a primary mental health disorder who were either admitted locally or transferred to another hospital were included. Multivariable logistic regression models were used to adjust for confounders.

RESULTS

Nineteem thousand eighty-one acute mental health ED events among children were included in the analyses. The odds of transfer relative to admission were higher for children without insurance (odds ratio, 3.30; 95% confidence interval, 1.73-6.31) compared with patients with private insurance. The odds of transfer were similar for children with Medicaid compared with children with private insurance (odds ratio, 1.23; 95% confidence interval, 0.80-1.88). Transfer rates also varied across mental health diagnostic categories. Patients without insurance had higher odds of transfer compared with those with private insurance when they presented with depressive disorder, bipolar disorder, attention-deficit/conduct disorders, and schizophrenia.

CONCLUSIONS

Children presenting to an ED with a mental health emergency who do not have insurance are more likely to be transferred to another hospital than to be admitted and treated locally compared with those with private insurance. Future studies are needed to determine factors that may protect patients without insurance from disparities in access to care.

The Association of Race, Sex, and Insurance With Transfer From Adult to Pediatric Trauma Centers

OBJECTIVE

Our objective was to investigate whether racial/ethnic-based or payer-based disparities existed in the transfer practices of pediatric trauma patients from adult trauma center (ATC) to pediatric trauma center (PTC) in Pennsylvania.

METHODS

Data on trauma patients aged 14 years or less initially evaluated at level I and II ATC were obtained from the Pennsylvania Trauma Outcome Study (2008-2012) (n = 3446). Generalized estimating equations regression analyses were used to evaluate predictors of subsequent transfer controlling for confounders and clustering. Recent literature has described racial and socioeconomic disparities in outcomes such as mortality after trauma; it is unknown whether these factors also influence the likelihood of subsequent interfacility transfer between ATC and PTC.

RESULTS

Patients identified as nonwhite comprised 36.1% of the study population. Those without insurance comprised 9.9% of the population. There were 2790 patients (77.4%) who were subsequently transferred. Nonwhite race (odds ratio [OR], 4.3), female sex (OR, 1.3), and lack of insurance (OR, 2.3) were associated with interfacility transfer. Additional factors were identified influencing likelihood of transfer (increased odds: younger age, intubated status, cranial, orthopedic, and solid organ injury; decreased odds: operative intervention at the initial trauma center) (P < 0.05 for all).

CONCLUSIONS

Although we assume that a desire for specialized care is the primary reason for transfer of injured children to PTCs, our analysis demonstrates that race, female sex, and lack of insurance are also associated with transfers from ATCs to PTCs for children younger than 15 years in Pennsylvania. Further research is needed to understand the basis of these health care disparities and their impact.

Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study

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.

Clinical Features and Required Aids of Transferred Severe Trauma Patients

Background

It is crucial to identify the pivotal factors for transferring patients with major trauma. We aim to delineate the clinical features and required aids of severe trauma patients and identify the differences between those who were admitted directly to a trauma center and those transferred from other hospitals.

Methods

We retrospectively reviewed all hospitalized trauma patients discharged from the ward in Chi-Mei Medical Center from January 1, 2017 to December 31, 2018. Of 5,846 patients, we identified 1,061 patients with Injury Severity Score >15, of which 92 patients were transferred from two branch hospitals (branch group), 172 patients were transferred from other hospitals (other group), and 797 patients were admitted directly through the emergency department (control group). We compared the clinical variables between control and the other two groups.

Results

The branch group included a high proportion of pediatric patients (control: 1.8%, other: 2.3%, and branch: 6.5%). The branch group demonstrated higher requirements for life-saving interventions and arterial embolization (branch vs. control, life-saving interventions: 26.1% vs. 17.6%, p = 0.046; arterial embolization: 9.8% vs. 3.5%, p = 0.004). However, no statistically significant differences were observed between the control group and other group in terms of requirements of life-saving interventions. The prognoses were similar between the groups.

Conclusions

Our trauma center can provide pediatric trauma care and timely life-saving interventions to help severe trauma patients transferred from other hospitals. The branch hospitals benefit mostly from the aid. Better network connection and information sharing between hospitals might play crucial roles in the management of transferred severe trauma patients.

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.

Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty

OBJECTIVES

We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care-sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients.

METHODS

We performed a cross-sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models.

RESULTS

The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19-1.36) and poor patients (aOR = 1.21, 95% CI = 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest-performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001).

CONCLUSIONS

Sociodemographic risk adjustment of emergency care-sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs.

Interhospital Transfer of Neurosurgical Patients: Implications of Timing on Hospital Course and Clinical Outcomes

BACKGROUND

Interhospital transfer of neurosurgical patients is common; however, little is known about the impact of transfer parameters on clinical outcomes. Lower survival rates have been reported for patients admitted at night and on weekends in other specialties. Whether time or day of admission affects neurosurgical patient outcomes, specifically those transferred from other facilities, is unknown.

OBJECTIVE

To examine the impact of the timing of interhospital transfer on the hospital course and clinical outcomes of neurosurgical patients.

METHODS

All consecutive admissions of patients transferred to our adult neurosurgical service were retrospectively analyzed for a 1-year study period using data from a central transfer database and the electronic health record.

RESULTS

Patients arrived more often at night (70.8%) despite an even distribution of transfer requests. The lack of transfer imaging did not affect length of stay, intervention times, or patient outcomes. Daytime arrivals had shorter total transfer time, but longer intenstive care unit and overall length of stay (8.7 and 11.6 days, respectively), worse modified Rankin Scale scores, lower rates of functional independence, and almost twice the mortality rate. Weekend admissions had significantly worse modified Rankin Scale scores and lower rates of functional independence.

CONCLUSIONS

The timing of transfer arrivals, both by hour or day of the week, is correlated with the time to intervention, hospital course, and overall patient outcomes. Patients admitted during the weekend suffered worse functional outcomes and a trend towards increased mortality. While transfer logistics clearly impact patient outcomes, further work is needed to understand these complex relationships.

Upper Extremity Injuries Seen at a Level 1 Trauma Center: Does Insurance Status Matter?

BACKGROUND

Hand and upper extremity injuries are one of the leading causes of injury in the United States, making up 10% of all emergency department visits. The purpose of this study was to determine if there are any demographic differences between patients presenting primarily to our emergency department for upper extremity injuries versus those transferred from outside hospitals for the same diagnoses.

METHODS

A retrospective review of our hand trauma database was performed between 2011 and 2014. All patients within this period with International Classification of Disease 9 codes consistent with upper extremity injuries were included in this study. Patients were stratified into 2 groups: those who first presented to another hospital and accepted as transfers to our institution (group 1) and those presenting directly to our emergency department (group 2). Demographic data were collected for each group including sex, age, race, insurance status, mechanism, need for emergent surgery, and day and time of presentation. The groups were analyzed using odds ratios with a 95% confidence interval and paired t test for continuous variables.

RESULTS

One hundred thirty-nine patients with isolated upper extremity injuries were accepted for transfer from an outside hospital, and 419 patients presented directly to our institution. The average age of group 1 was 38 (77% M, 23% F) compared with 41 (73% M, 27% F) for group 2. Forty percent of group 1 patients were uninsured compared with 17% for group 2. There was a significant difference between groups (P < 0.05).

CONCLUSIONS

The data suggest that our institution receives a large proportion of uninsured patients transferred for emergent upper extremity care compared with our current patient demographic. Because this is a retrospective study, the precise reason for these discrepancies will remain unknown.

Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury

OBJECTIVE

Among injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation.

METHODS

We analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures.

RESULTS

In 2011, there were a total of 48,160 ED-to-ED injury transfers, half of which (49%) were transferred to non-trauma centers, including 23% with major trauma. A total of 22,011 transfers went to a higher level of care, of which 36% were discharged from the ED without procedures. Relative to torso injuries, discharge without procedures was more likely for patients with soft tissue (OR 6.8, 95%CI 5.6-8.2), head (OR 3.7, 95%CI 3.1-4.6), facial (OR 3.8, 95%CI 3.1-4.7), or hand (OR 3.1, 95%CI 2.6-3.8) injuries. Other factors included Medicaid (OR 1.3, 95%CI 1.2-1.5) or uninsured (OR 1.3, 95%CI 1.2-1.5) status. Treatment at the receiving ED added an additional $2859 on average (95% CI $2750-$2968) per discharged patient to the total charges for injury care, not including the costs of ambulance transport between facilities.

CONCLUSION

Over a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures. Telemedicine consultation with sub-specialists might reduce some of these transfers.

Lower Extremity Bypass Surgery on Patients Transferred from Other Hospitals is Associated with Increased Morbidity and Mortality

BACKGROUND

Despite advances in endovascular surgery, lower extremity arterial bypass remains the gold standard treatment for severe, symptomatic peripheral arterial disease (PAD). Patients who are transferred to other hospitals have generally complex medical problems compared to those patients who are directly admitted from home. The purpose of this study is to identify factors associated with an interfacility transfer in patients with PAD and compare the postoperative outcomes of these patients to those who are directly admitted to the hospital.

METHODS

The 2013 lower extremity revascularization-targeted American College of Surgeons (ACS-National Surgical Quality Improvement Program [NSQIP]) database and generalized 2013 general and vascular surgery ACS-NSQIP Participant Use File were used for this study. Patient, diagnosis, and procedure characteristics of patients undergoing lower extremity bypass surgery were assessed. Multivariate logistic regression analysis was used to determine independent risk factors for transfer to another hospital.

RESULTS

A total of 2,646 patients (65% male, 35% female) were identified in the NSQIP database that underwent lower extremity open revascularization during the year 2013. A total of 287 patients (11%) were transferred from other institutions: acute care hospital inpatient (4%), nursing home/chronic care/intermediate care (3%), outside emergency department (3%), and other (1%). Factors associated with increased risk of interfacility transfer included need for emergency surgery (odds ratio [OR]: 5.51, P < 0.05), infected wounds (OR: 2.77, P < 0.05), and age >85 years (OR: 2.24, P < 0.05). Postoperative outcome associated with transfer was mortality <30 days postop (OR: 1.96) and length of stay >30 days (OR: 2.04; P < 0.05).

CONCLUSIONS

Multiple factors affect an interfacility transfer of patients including advanced age, need for emergency procedure, contaminated wounds. Patients who are transferred from another institution for a lower extremity bypass surgery are at a substantially higher risk for postoperative morbidity and mortality.

Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?

BACKGROUND

Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation.

METHODS

Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only.

RESULTS

For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation.

CONCLUSION

Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Interhospital transfer of pediatric neurosurgical patients

OBJECTIVE The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients. METHODS All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%-30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score. RESULTS Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1-269 days). Median length of hospital stay was 2 days (range 1-269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home. CONCLUSIONS This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

The Association Between Insurance and Transfer of Noninjured Children From Emergency Departments

STUDY OBJECTIVE

Among children requiring hospital admission or transfer, we seek to determine whether insurance is associated with the decision to either admit locally or transfer to another hospital.

METHODS

This cross-sectional study used Healthcare Cost and Utilization Project 2012 Nationwide Emergency Department Sample. Pediatric patients receiving care in emergency departments (EDs) who were either admitted or transferred were included. Clinical Classifications Software was used to categorize patients into noninjury diagnostic cohorts. Multivariable logistic regression models adjusting for potential confounders, including severity of illness and comorbidities, and incorporating nationally representative weights were used to determine the association between insurance and the odds of transfer relative to admission.

RESULTS

A total of 240,620 noninjury pediatric ED events met inclusion criteria. Patient and hospital characteristics, including older age and nonteaching hospitals, were associated with greater odds of transfer relative to admission. Patients who were uninsured or had self-pay had higher odds of transfer (odds ratio [OR] 3.84; 95% confidence interval [CI] 2.08 to 7.09) relative to admission compared with those with private insurance. Uninsured and self-pay patients also had higher odds of transfer across all 13 diagnostic categories, with ORs ranging from 2.96 to 12.00. Patients with Medicaid (OR 1.05; 95% CI 0.90 to 1.22) and other insurances (OR 1.14; 95% CI 0.87 to 1.48) had similar odds of transfer compared with patients with private insurance.

CONCLUSION

Children without insurance and those considered as having self-pay are more likely to be transferred to another hospital than to be admitted for inpatient care within the same receiving hospital compared with children with private insurance. This study reinforces ongoing concerns about disparities in the provision of pediatric ED and inpatient care.

Racial Variation in Treatment of Traumatic Finger/Thumb Amputation: A National Comparative Study of Replantation and Revision Amputation

BACKGROUND

Traumatic finger/thumb amputations are some of the most prevalent traumatic injuries affecting Americans each year. Rates of replantation after traumatic finger/thumb amputation, however, have been declining steadily across U.S. hospitals, which may make these procedures less accessible to minorities and vulnerable populations. The specific aim of this study was to examine racial variation in finger replantation after traumatic finger/thumb amputation.

METHODS

Using a two-level hierarchical model, the authors retrospectively compared replantation rates for African American patients with those of whites, adjusting for patient and hospital characteristics. Patients younger than 65 years with traumatic finger/thumb amputation injuries who sought care at a U.S. trauma center between 2007 and 2012 were included in the study sample.

RESULTS

The authors analyzed 13,129 patients younger than 65 years with traumatic finger/thumb amputation. Replantation rates declined over time from 19 percent to 14 percent (p = 0.004). Adjusting for patient and hospital characteristics, African Americans (OR, 0.81; 95 percent CI, 0.66 to 0.99; p = 0.049) were less likely to undergo replantation procedures than whites, and uninsured patients (OR, 0.73; 95 percent CI, 0.62 to 0.84; p < 0.0001) were less likely than those who were privately insured.

CONCLUSIONS

Despite advancements in microsurgical techniques and the increasing use of reconstructive surgery in other fields, finger/thumb replantation rates are declining in the United States and vulnerable populations are less likely to undergo replantation after amputation injuries. Regionalization of care for these injuries may not only provide a higher quality care but also reduce variations in treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Transfer of acute care surgery patients in a rural state: a concerning trend

BACKGROUND

Regionalized care of complex patients to larger hospitals is an increasingly common practice as the population ages and the physician shortage evolves. The Acute Care Surgery model is new, and there are limited data on the patients being transferred through this system. We hypothesized transfer patients would be older, more complex, and require additional resources.

MATERIALS AND METHODS

Retrospective chart review of Acute Care Surgery patients admitted to a single tertiary facility. Patient demographics, clinical presentation, and outcomes were obtained.

RESULTS

We found that our 161 transferred patients (TPs) were older (61.2 versus 54.7 y [P < 0.001]), had more comorbidities (Charlson Comorbidity Index 4 versus 3.1 [P < 0.001]), and required more resources than 611 local patients (LP; length of stay 8.2 versus 3.4 [P < 0.001], intensive care unit admission 24% versus 6% of patients [P < 0.001]). Admission diagnosis was similar, with pancreaticobiliary (TP 29% versus LP 30%) and small bowel (TP 25% versus LP 23%) complaints most common. Most common intervention was laparoscopic cholecystectomy for both (29% versus 25%). Subspecialty interventions were similar (IR, advanced endoscopy) at TP 10% and LP 8%. TPs were more likely to not require a procedure (31% versus 23%). Insurance provider differed between groups, particularly for Medicare (55% versus 34%) and privately insured (26% versus 45%).

CONCLUSIONS

Although this study confirms transfer patients need the resources for which they were referred to a tertiary center, we unexpectedly found nearly half of transfer patients undergo basic surgical procedures or do not require intervention. This points to a concerning lack of general surgery resources in the community.

Expelled uninsured patients in a less-competitive hospital market in Florida, USA

BACKGROUND

This research evaluates the effect of hospital competition on inward and outward patient transfers for different types of payers including the uninsured. Although it is a less spotlighted issue, an equally important topic is the likelihood of inter-hospital patient transfers of the insured and the uninsured. This study attempts to fill a gap in the research about the relationship between hospital competition and patient transfers.

METHODS

By developing the payer-specific level of hospital competition, this research evaluates the effect of hospital competition on inward and outward patient sharing (or patient transfers) for different types of payers including the uninsured. For patient transfers, instead of focusing on whether a patient is transferred from one hospital to another hospital at the patient level, we measure the numbers of patient transfers between hospitals (both inward and outward) at the hospital level. These dependent variables-the numbers of outward and inward patient transfers by the principal payers-are count variables, and we employ either a Poisson regression model or a negative binomial regression model.

RESULTS

Controlling for hospital characteristics, when the uninsured Hirschman-Herfindahl Index (HHI) increased by 0.01, the uninsured were 593 % more likely to be transferred to another hospital. When a hospital dominates its market, it tends to expel uninsured patients to other hospitals.

CONCLUSION

If patient transfers are medically unnecessary and primarily due to financial incentives, health administrators and policymakers should minimize such events. Since the uninsured who are admitted to a hospital that dominates its hospital market are likely to be much more vulnerable in their access to health care services, the state government of Florida needs to move toward increased health insurance coverage for eligible Floridians.

Care Transfers for Patients With Upper Extremity Trauma: Influence of Health Insurance Type

PURPOSE

To understand the differences in transfer incidence for patients with upper extremity trauma by hospital trauma center designation. We hypothesized that patients with public or no insurance were more likely to be transferred to another facility compared with privately insured patients.

METHODS

Trauma centers are designated by local authorities and verified by the American College of Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of being transferred from one center to another for patients who sustained isolated upper extremity trauma. We used multivariable logistic regression with a clustered variance method to adjust for intrahospital correlation to compare risk-adjusted transfer incidence for patients with upper extremity injuries by trauma center designation.

RESULTS

In 2012, 6,214 patients ages 18-64 with isolated upper extremity trauma presented to 477 hospitals. Overall, transfer incidence was significantly higher among level III trauma centers (26%) compared with level II (11%) or level I (2%) trauma centers. Adjusting for patient and hospital characteristics patients with Medicaid were more likely to be transferred from level III trauma centers to another center compared with privately insured patients.

CONCLUSIONS

Current regulations may not prevent unnecessary patient transfers based on insurance status among level III trauma centers. Policy makers should compensate or provide incentives to hospitals that take care of poorly insured patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/decision III.

Interhospital Transfer of Neurosurgical Patients to a High-Volume Tertiary Care Center: Opportunities for Improvement

BACKGROUND

Neurosurgical indications for patient transfer include absence of local or available neurosurgical coverage, subspecialty or interdisciplinary requirements, and family preference. Transfer of patients to regional centers will increase with further centralization of medical care.

OBJECTIVE

To report the transfer records of a large tertiary care center to identify trends, failures, and opportunities to improve interhospital transfer of neurosurgical patients.

METHODS

All consecutive, prospectively documented requests for interhospital patient transfer to the adult neurosurgical service of Emory University Hospitals were retrospectively identified from a centralized transfer center database for a 1-year study period.

RESULTS

Requests for neurosurgical care constituted 1323 of the 9087 calls (14.6%); 81.1% of these requests were accepted, and a total of 984 patients (74.4%) arrived at our institutions. Patients arrived from 133 unique facilities throughout a catchment area of 66 287 sq miles. Although the median travel time for transfer patients was 36 minutes, the median interval between the request and patient arrival was 4 hours 2 minutes. The most frequent diagnoses were intracranial hemorrhage (31.8%), subarachnoid hemorrhage (31.2%), and intracranial tumor (15.2%). The overall diagnostic error rate was 10.3%. Only 42.5% of patients underwent neurosurgical intervention, and 57 patients admitted to intensive care were immediately transitioned to a lower level of care.

CONCLUSION

Interhospital transfer requires a coordinated effort among hospital administrators, physicians, and staff to make complex decisions that govern this important and costly process. These data suggest common failures and numerous opportunities for improvement in transfer efficiency, diagnostic accuracy, triage, and resource allocation.

Trauma transfers to a rural level 1 center: a retrospective cohort study

BACKGROUND

The regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status.

METHODS

We queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared.

RESULTS

5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06).

CONCLUSIONS

These data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.

The Influence of Insurance Status on the Surgical Treatment of Acute Spinal Fractures

STUDY DESIGN

A retrospective, propensity score, multivariate analysis of the National Trauma Data Bank (NTDB) between 2008 and 2011.

OBJECTIVE

The aim of this study was to determine the relationship between insurance status and rates of surgery for acute spinal fractures with and without spinal cord injury (SCI).

SUMMARY OF BACKGROUND DATA

The decision for surgery in patients with spinal fractures is often based on fracture pattern and stability, associated SCI, and the presence of ligamentous and other associated injuries. It is poorly understood how nonclinical factors, such as insurance status, influence the decision for surgical intervention in patients sustaining spinal trauma.

METHODS

Using NTDB admission years 2008 to 2011, we included patients 18 to 64 years old who sustained a fracture of the cervical or thoracolumbar spine. Patients were excluded if they sustained polytrauma (Injury Severity Score ≥27) or a major injury (Abbreviated Injury Scale severity ≥3) to the head, thorax, or abdomen. Our main outcome measure was surgical versus nonsurgical treatment for spinal injury; our main predictor was insurance status. Hierarchical multivariate regression analysis and propensity scores were used to determine the relationship between insurance status and surgical treatment, controlling for other factors. We calculated adjusted odds ratios (ORs) for rates of surgery.

RESULTS

Our propensity score multivariate analysis demonstrated significantly higher rates of surgery in patients with SCI (OR = 11.76, P < 0.001), insurance (OR = 1.27, P < 0.001), white (OR = 1.21, P = 0.018) versus black race, blunt trauma (OR = 5.63, P < 0.001), shock (OR = 1.62, P < 0.001), higher Glasgow Coma Scale (GCS) score (OR = 1.02, P = 0.002), transfer from lower acuity hospital (OR = 1.51, P < 0.001), and treatment at teaching hospitals (OR = 1.49, P < 0.001). Multivariable subgroup analysis of SCI patients similarly revealed higher surgical rates for insured patients (OR = 1.46, P < 0.001) than those without insurance.

CONCLUSION

Patients with traumatic spine fractures were more likely to receive surgery if they were insured, regardless of the presence of SCI.

Insurance status influences emergent designation in surgical transfers

BACKGROUND

There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs.

MATERIALS AND METHODS

A retrospective cohort study was performed on patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only.

RESULTS

There were 1295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer nonwhite, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% versus 84%, P < 0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (odds ratio [OR], 1.61; 95% confidence interval [CI], 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR, 2.27; CI, 1.08-4.77).

CONCLUSIONS

The finding that uninsured patients were more likely to be designated as EMCs suggests nonclinical variation that may be mitigated by clearer definitions and increased interfacility coordination to identify patients requiring transfer for EMCs.

Achieving regionalization through rural interhospital transfer

Regionalization of emergency medical care aims to provide consistent and efficient high-quality care leading to optimal clinical outcomes by matching patient needs with appropriate resources at a network of hospitals. Regionalized care has been shown to improve outcomes in trauma, myocardial infarction, stroke, cardiac arrest, and acute respiratory distress syndrome. In rural areas, effective regionalization often requires interhospital transfer. The decision to transfer is complex and includes such factors as capabilities of the presenting hospital; capacity at the receiving hospital; and financial, geographic, and patient-preference considerations. Although transfer to a comprehensive center has proven benefits for some conditions, the transfer process is not without risk. These risks include clinical deterioration, limited resource availability during transport, vehicular crashes, time delays for time-sensitive care, poor communication between providers, and neglect of patient preferences. This article reviews the transfer decision, financial implications, risks, and considerations for patients undergoing rural interhospital transfer. We identify several strategies that should be considered for development of the regionalized emergency health care system of the future and identify areas where further research is necessary.

A population-based evaluation of severity and mortality among transferred patients with acute pancreatitis

OBJECTIVES

This study aimed to compare severity of acute pancreatitis (AP) and mortality rates between transferred and nontransferred patients and to determine the factors that influence the decision to transfer.

METHODS

A retrospective analysis coding a statewide administrative database in Maryland was conducted. Severity was defined by presence of organ failure (OF), need for intensive care unit (ICU), mechanical ventilation (MV), or hemodialysis.

RESULTS

There were 71,035 discharges for AP, with 1657 (2.3%) patient transfers. Transferred patients had more multisystem OF (5.6% vs 1.2%), need for ICU (22.8% vs 4.3%), MV (13.1% vs 1.4%), hemodialysis (4.2% vs 2.7%), and higher mortality (6.1% vs 1.1%) compared with nontransferred patients (P < 0.0001). After adjusting for disease severity, mortality was similar between the transferred patients and the nontransferred patients (OR, 1.37; 95% confidence interval, 0.96-1.97). Younger (OR, 0.99), African American (OR, 0.55), and uninsured (OR, 0.46) patients were less likely to be transferred, whereas patients with multisystem OF (OR, 3.5), need for ICU (OR, 2.3), or MV (OR, 2.1) were more likely to be transferred (P < 0.0001).

CONCLUSIONS

Transferred patients with AP have more severe disease and higher overall mortality. Mortality is similar after adjusting for disease severity. Disease severity, insurance status, race, and age all influence the decision to transfer patients with AP.

Insurance status is associated with treatment allocation and outcomes after subarachnoid hemorrhage

OBJECTIVE

Subarachnoid hemorrhage (SAH) is a particularly devastating type of stroke which is responsible for one third of all stroke-related years of potential life lost before age 65. Surgical treatment has been shown to decrease both morbidity and mortality after subarachnoid hemorrhage. We hypothesized that payer status other than private insurance is associated with lower allocation to surgical treatment for patients with SAH and worse outcomes.

DESIGN

We examined the association between insurance type and surgical treatment allocation and outcomes for patients with SAH while adjusting for a wide range of patient and hospital factors. We analyzed the Nationwide Inpatient Sample hospital discharge database using survey procedures to produce weighted estimates representative of the United States population.

PATIENTS

We studied 21047 discharges, representing a weighted estimate of 102595 patients age 18 and above with a discharge diagnosis of SAH between 2003 and 2008.

MEASUREMENTS

Multivariable logistic and generalized linear regression analyses were used to assess for any associations between insurance status and surgery allocation and outcomes.

MAIN RESULTS

Despite the benefits of surgery 66% of SAH patients did not undergo surgical treatment to prevent rebleeding. Mortality was more than twice as likely for patients with no surgical treatment compared to those who received surgery. Medicare patients were significantly less likely to receive surgical treatment.

CONCLUSIONS

Nearly two thirds of patients with SAH don't receive operative care, and Medicare patients were significantly less likely to receive surgical treatment than other patients. Bias against the elderly and those with chronic illness and disability may play a part in these findings. A system of regionalized care for patients presenting with SAH may reduce disparities and improve appropriate allocation to surgical care and deserves prospective study.

Clinical research of mortality in emergency air medical transport

INTRODUCTION

EAMT in Taiwan has experienced increasing demand in the past few years. The objective is to analyze the trend of EAMT in the past six years and mortality rate within three days of patients undergoing interfacility transport in Taiwan.

MATERIAL AND METHOD

We conducted a retrospective review of patients who were airlifted from remote islands to main island between 2006 and 2011. Main outcome measures are EAMT number (EAMT-N), EAMT per thousand population (EAMT frequency, EAMT-F), number of mortality (Mor-N), and mortality rate within three days after EAMT (Mor-R).

RESULTS AND DISCUSSION

Overall mortality rate is 7.54% in 1684 airlifted patients. Acute myocardial infarction (AMI, 26.3%) and traumatic brain injury (TBI, 25.8%) comprise the majority in diagnosis (52.1%). However, Mor-R in these two categories is significantly low in AMI (3.5%) and TBI (5.1%).

CONCLUSION

The present study demonstrates that physician density is not related to EAMT-N but to physician number. As general population ages (10%), the average age of patient who underwent EAMT doubled (21%). This study also leaves room for discussion regarding futile medical care. The results can be used as a reference for increasing utilization of EAMT in current National Health Care Scheme.

The Effectiveness Evaluation of Helicopter Ambulance Transport among Neurotrauma Patients in Korea

Objective

Helicopter ambulance transport (HAT) is a highly resource-intensive facility that is a well-established part of the trauma transport system in many developed countries. Here, we review the benefit of HAT for neurosurgical patients in Korea.

Methods

This retrospective study followed neurotrauma patients who were transferred by HAT to a single emergency trauma center over a period of 2 years. The clinical benefits of HAT were measured according to the necessity of emergency surgical intervention and the differences in the time taken to transport patients by ground ambulance transport (GAT) and HAT.

Results

Ninety-nine patients were transferred to a single university hospital using HAT, of whom 32 were taken to the neurosurgery department. Of these 32 patients, 10 (31.3%) needed neurosurgical intervention, 14 (43.8%) needed non-neurosurgical intervention, 3 (9.4%) required both, and 11 (34.4%) did not require any intervention. The transfer time was faster using HAT than the estimated time needed for GAT, although for a relatively close distance (<50 km) without ground obstacles (mountain or sea) HAT did not improve transfer time. The cost comparison showed that HAT was more expensive than GAT (3,292,000 vs. 84,000 KRW, p<0.001).

Conclusion

In this Korean-based study, we found that HAT has a clinical benefit for neurotrauma cases involving a transfer from a distant site or an isolated area. A more precise triage for using HAT should be considered to prevent overuse of this expensive transport method.

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.

Comprehensive assessment of isolated traumatic subarachnoid hemorrhage

Recent studies have shown that isolated traumatic subarachnoid hemorrhage (tSAH) in the setting of a high Glasgow Coma Scale (GCS) score (13-15) is a relatively less severe finding not likely to require operative neurosurgical intervention. This study sought to provide a more comprehensive assessment of isolated tSAH among patients with any GCS score, and to expand the analysis to examine the potential need for aggressive medical, endovascular, or open surgical interventions in these patients. By undertaking a retrospective review of all patients admitted to our trauma center from 2003-2012, we identified 661 patients with isolated tSAH. Only four patients (0.61%) underwent any sort of aggressive neurosurgical, medical, or endovascular intervention, regardless of GCS score. Most tSAH patients without additional systemic injury were discharged home (68%), including 53% of patients with a GCS score of 3-8. However, older patients were more likely to be discharged to a rehabilitation facility (p<0.01). There were six (1.7%) in-hospital deaths, and five patients of these patients were older than 80 years old. We conclude that isolated tSAH, regardless of admission GCS score, is a less severe intracranial injury that is highly unlikely to require aggressive operative, medical, or endovascular intervention, and is unlikely to be associated with major neurologic morbidity or mortality, except perhaps in elderly patients. Based upon our findings, we argue that impaired consciousness in the setting of isolated tSAH should strongly compel a consideration of non-traumatic factors in the etiology of the altered neurological status.

Insurance status and the transfer of hospitalized patients: an observational study

BACKGROUND

There is little objective evidence to support concerns that patients are transferred between hospitals based on insurance status.

OBJECTIVE

To examine the relationship between patients' insurance coverage and interhospital transfer.

DESIGN

Data analyzed from the 2010 Nationwide Inpatient Sample.

PATIENTS

All patients aged 18 to 64 years discharged alive from U.S. acute care hospitals with 1 of 5 common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, and skin or subcutaneous infection).

MEASUREMENTS

For each diagnosis, the proportion of hospitalized patients who were transferred to another acute care hospital based on insurance coverage (private, Medicare, Medicaid, or uninsured) was compared. Logistic regression was used to estimate the odds of transfer for uninsured patients (reference category, privately insured) while patient- and hospital-level factors were adjusted for. All analyses incorporated sampling and poststratification weights.

RESULTS

Among 315 748 patients discharged from 1051 hospitals with any of the 5 diagnoses, the percentage of patients transferred to another acute care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses, uninsured patients were significantly less likely to be transferred for 3 diagnoses (P 0.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for 4 diagnoses: biliary tract disease (odds ratio, 0.73 [95% CI, 0.55 to 0.96]), chest pain (odds ratio, 0.63 [CI, 0.44 to 0.89]), septicemia (odds ratio, 0.76 [CI, 0.64 to 0.91]), and skin infections (odds ratio, 0.64 [CI, 0.46 to 0.89]). Women were significantly less likely to be transferred than men for all diagnoses.

LIMITATION

This analysis relied on administrative data and lacked clinical detail.

CONCLUSION

Uninsured patients (and women) were significantly less likely to undergo interhospital transfer. Differences in transfer rates may contribute to health care disparities.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Admit or transfer? The role of insurance in high-transfer-rate medical conditions in the emergency department

STUDY OBJECTIVE

We study the association of payer status with odds of transfer compared with admission from the emergency department (ED) for multiple diagnoses with a high percentage of transfers.

METHODS

This was a retrospective study of adult ED encounters using the Healthcare Cost and Utilization Project 2010 Nationwide Emergency Department Sample. We used the Clinical Classification Software to identify disease categories with 5% or more encounters resulting in transfer (27 categories; 3.7 million encounters based on survey weights). We sorted encounters by condition into 12 groups according to expected medical or surgical specialist needs. We used logistic regression to assess the role of payer status on odds of transfer compared with admission and report adjusted odds ratios (ORs).

RESULTS

Among high-transfer conditions in 2010, uninsured patients had double the odds of transfer compared with privately insured patients (OR 2.12; 95% confidence interval [CI] 1.72 to 2.62). Medicaid patients were also more likely to be transferred (OR 1.2; 95% CI 1.04 to 1.38). Uninsured patients had higher odds of transfer in all specialist categories (significant in 9 of 12). The categories with the highest odds of transfer for the uninsured included nephrology (OR 2.44; 95% CI 1.07 to 5.55), psychiatry (OR 2.26; 95% CI 1.65 to 3.25), and hematology-oncology (OR 2.21; 95% CI 1.50 to 3.25); the highest for Medicaid were general surgery (OR 1.61; 95% CI 1.09 to 1.83), hematology-oncology (OR 1.55; 95% CI 1.05 to 2.30), and vascular surgery (OR 1.55; 95% CI 1.02 to 2.28).

CONCLUSION

Insurance status appears to play a role in ED disposition (transfer versus admission) for many high-transfer conditions.

Interhospital transfer and adverse outcomes after general surgery: implications for pay for performance

BACKGROUND

Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes.

STUDY DESIGN

The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission.

RESULTS

Overall, 7% of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95% CI, 1.45-1.52) and mortality (RR = 2.70; 95% CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95% CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95% CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95% CI, 1.00-1.07; mortality: RR = 0.98; 95% CI, 0.88-1.09; length of stay: 1.08 times longer; 95% CI, 1.04-1.11; readmission: RR = 0.97; 95% CI, 0.88-1.08).

CONCLUSIONS

Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers.

Insurance type, not race, predicts mortality after pediatric trauma

BACKGROUND

In adult trauma, mortality varies with race and insurance status. In the elderly, insurance type has little impact on mortality after trauma and the influence of race is reduced. How race and insurance affect pediatric trauma requires further attention. We hypothesized that mortality after pediatric trauma is influenced by insurance type and not race.

METHODS

We reviewed all cases of blunt trauma in children ≤13 y requiring admission, using the National Trauma Data Bank Research Data Sets for 2007 and 2008. Exclusions included an Abbreviated Injury Score of 6 for any body region, dead on arrival, and missing data. Our primary outcome measure was in-hospital mortality.

RESULTS

We identified 831 Asian (1.2%), 10,592 black (15.5%), 45,173 white (66.2%), and 8498 Hispanic (12.5%) children, and 3161 children (4.6%) classified as other race. Mean age was 7.4 ± 4.5 y, 11.9% were uninsured, and overall in-hospital mortality was 1.4%. Multivariable modeling indicated that race was not associated with increased mortality (Asian versus white, adjusted odds ratio [AOR] 1.05, P = 0.88; black versus white, AOR 0.92, P = 0.42; Hispanic versus white, AOR 0.87, P = 0.26; and other race versus white, AOR 1.01, P = 0.96). In contrast, insurance status (any insurance versus no insurance, AOR 0.6, P < 0.01) and insurance type (private insurance versus no insurance, AOR 0.47, P < 0.01; Medicaid versus no insurance, 0.67, P < 0.01) predicted reduced mortality.

CONCLUSIONS

Insurance status and insurance type are important predictors of mortality after pediatric trauma while, in contrast, race is not.

Interfacility helicopter ambulance transport of neurosurgical patients: observations, utilization, and outcomes from a quaternary level care hospital

Background

The clinical benefit of helicopter transport over ground transportation for interfacility transport is unproven. We sought to determine actual practice patterns, utilization, and outcomes of patients undergoing interfacility transport for neurosurgical conditions.

Methodology/Principal Findings

We retrospectively examined all interfacility helicopter transfers to a single trauma center during 2008. We restricted our analysis to those transfers leading either to admission to the neurosurgical service or to formal consultation upon arrival. Major exclusion criteria included transport from the scene, death during transport, and transport to any area of the hospital other than the emergency department. The primary outcome was time interval to invasive intervention. Secondary outcomes were estimated ground transportation times from the referring hospital, admitting disposition, and discharge disposition. Of 526 candidate interfacility helicopter transfers to our emergency department in 2008, we identified 167 meeting study criteria. Seventy-five (45%) of these patients underwent neurosurgical intervention. The median time to neurosurgical intervention ranged from 1.0 to 117.8 hours, varying depending on the diagnosis. For 101 (60%) of the patients, estimated driving time from the referring institution was less than one hour. Four patients (2%) expired in the emergency department, and 34 patients (20%) were admitted to a non-ICU setting. Six patients were discharged home within 24 hours. For those admitted, in-hospital mortality was 28%.

Conclusions/Significance

Many patients undergoing interfacility transfer for neurosurgical evaluation are inappropriately triaged to helicopter transport, as evidenced by actual times to intervention at the accepting institution and estimated ground transportation times from the referring institution. In a time when there is growing interest in health care cost containment, practitioners must exercise discretion in the selection of patients for air ambulance transport—particularly when it may not bear influence on clinical outcome. Neurosurgical evaluation via telemedicine may be one strategy for improving air transport triage.