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

The goal of this study was to determine whether injured patients are being transferred from referring facilities inappropriately based primarily on financial status. If this were true, it would create an unnecessary financial burden on regional trauma centers. Therefore, changes in our trauma transfer protocols might be necessary to reduce this burden and provide better care. However, contrary to our hypothesis, TTP had a higher proportion in more favorable insurance categories, namely Medicare and Managed Care, and decreased proportion in the uninsured or self-pay population. Collectively these data suggest payor status is not a major determinant in the decision to transfer injured patients in upstate New York. This begs the following questions: “why does payor status show these discrepancies between these patient populations and what are the determinants for transfer?” There are several key factors that could address this discrepancy. First of all, the age distribution of TTP gravitates more towards the extremes of age than the PTP group, including a larger elder adult population that are covered by Medicare. Second, TTP has a decreased proportion of penetrating trauma, a population generally accepted to be underinsured [17]. Finally, more TTP were discharged by subspecialty services compared with PTP.

Analysis of our data suggests age is an important factor affecting transfer. It is well known that populations at extremes of age are much more likely to suffer morbidity from traumatic injuries and benefit from early transfer to designated trauma centers [24–29]. Pediatric trauma patients have been shown to have higher in-hospital mortality, length of stay, and cost of care in adult hospitals than pediatric-centered hospitals [25]. Additionally, increased age (65 years old) is also a risk factor for the development of multiple organ failure morbidity from traumatic brain injury and overall morbidity and mortality [29–31]. The increased proportion of elder individuals in the TTP population also helps explain the larger number of Medicare beneficiaries in that population.

Surgery subspecialist availability can be problematic even at level 1 and 2 centers, let alone more regional referring institutions. For example, hand and microvascular call is inconsistent at level 1 and 2 trauma centers and one study in Cook County found that neurosurgical services had decreased across the board except at academic medical centers, as of 2008 [32, 33]. Given the significantly increased proportion of subspecialty surgical discharges, it appears at least one impetus for transfer was decreased subspecialty availability at referring hospitals and subsequent need for transfer for injuries requiring subspecialist surgical care.

There are several limitations to this study, as well as directions that can be further explored within our database. For one, most of the papers that cited a difference in payor status examined surgery subspecialties, especially neurosurgery and orthopedics [12–14, 34]. Consequently, subgroup analysis can be performed within these populations to see if there are different trends within the subspecialist service transfers compared with all transfers as a whole, and the primary trauma population. This analysis would be challenging because even if ISS or payor status were lower, it would be difficult to determine whether a transfer is based on subspecialist availability. There are other factors which could be analyzed such as ICU length of stay, mortality, ethnicity, and disposition from the hospital to name a few. Also, our data could be compared with the statewide database to compare the transferred patients with trauma patients who were not transferred. Finally, we are a level 1 trauma center in the middle of a primarily rural environment, and so our findings may not generalize well to a more urban population.

Our data suggest the general population of trauma transfer patients is insured, has similar injury acuity to our primary trauma patient population, and consists of extremes of age. Based on this observation, it seems likely the primary motivation for transfer is the need for subspecialty surgical care and not unfavorable insurance status. In the context of the Affordable Care Act, we are likely to see several changes in the landscape of medicine. First of all, the uninsured population will decrease, as more people are able to get access to insurance, primarily from increased Medicaid beneficiaries and decreased self-pay individuals because nonelderly Medicaid enrollment is estimated to increase by one-third [35] . This has already been described in New York State, with the expansion of Medicaid specifically, within the past decade before the Affordable Care Act (ACA) and resultant increase of Medicaid patients within subspecialty clinics after Medicaid expansion [36]. In addition, the implementation of mandatory health insurance has been tried in other states. Universal health insurance is associated with a global decrease in hospital LOS an associated increase in home health services and no change in mortality [37]. Therefore, we might expect the TTP and PTP populations to both experience an increase in reimbursement and decreased associated cost. This will not fully offset the losses incurred by tertiary care facilities. A large proportion of the cost of trauma care is due to the high standby costs associated with continuous coverage at Level 1 trauma centers and the significant costs of trauma program administration and performance improvement activities. These costs are not reimbursed by third party payors regardless of how much trauma is received. The ACA should, however, help mitigate the financial burden that tertiary trauma centers incur by allowing some reimbursement of patients where there was none [38]. Nevertheless, our results indicate that the perception that trauma transfers increase fiscal burden is unsubstantiated.