Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non–Trauma Center Emergency Departments: Disparities by Insurance Status | Emergency Medicine | JAMA Surgery | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address 35.170.64.36. Please contact the publisher to request reinstatement.
1.
Centers for Disease Control and Prevention.  Web-based Injury Statistics Query and Reporting System.http://www.cdc.gov/injury/wisqars/index.html. Accessed November 20, 2009.
2.
Finkelstein  EA, Corso  PS, Miller  TR.  The Incidence and Economic Burden of Injuries in the United States. New York, NY: Oxford University Press; 2006.
3.
MacKenzie  EJ, Rivara  FP, Jurkovich  GJ,  et al.  A national evaluation of the effect of trauma-center care on mortality.  N Engl J Med. 2006;354(4):366-378.PubMedGoogle ScholarCrossref
4.
Newgard  CD, McConnell  KJ, Hedges  JR, Mullins  RJ.  The benefit of higher level of care transfer of injured patients from nontertiary hospital emergency departments.  J Trauma. 2007;63(5):965-971.PubMedGoogle ScholarCrossref
5.
Garwe  T, Cowan  LD, Neas  B, Cathey  T, Danford  BC, Greenawalt  P.  Survival benefit of transfer to tertiary trauma centers for major trauma patients initially presenting to nontertiary trauma centers.  Acad Emerg Med. 2010;17(11):1223-1232.PubMedGoogle ScholarCrossref
6.
Mann  NC, Mullins  RJ, MacKenzie  EJ, Jurkovich  GJ, Mock  CN.  Systematic review of published evidence regarding trauma system effectiveness.  J Trauma. 1999;47(3)(suppl):S25-S33.PubMedGoogle ScholarCrossref
7.
Nathens  AB, Jurkovich  GJ, Cummings  P, Rivara  FP, Maier  RV.  The effect of organized systems of trauma care on motor vehicle crash mortality.  JAMA. 2000;283(15):1990-1994.PubMedGoogle ScholarCrossref
8.
Nathens  AB, Jurkovich  GJ, MacKenzie  EJ, Rivara  FP.  A resource-based assessment of trauma care in the United States.  J Trauma. 2004;56(1):173-178.PubMedGoogle ScholarCrossref
9.
Hsia  RY, Wang  E, Torres  H, Saynina  O, Wise  PH.  Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006.  J Trauma. 2010;68(1):217-224.PubMedGoogle Scholar
10.
Ciesla  DJ, Pracht  EE, Cha  JY, Langland-Orban  B.  Geographic distribution of severely injured patients: implications for trauma system development.  J Trauma Acute Care Surg. 2012;73(3):618-624.PubMedGoogle ScholarCrossref
11.
Newgard  CD, Zive  D, Holmes  JF,  et al; WESTRN investigators.  A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults.  J Am Coll Surg. 2011;213(6):709-721.PubMedGoogle ScholarCrossref
12.
Branas  CC, MacKenzie  EJ, Williams  JC,  et al.  Access to trauma centers in the United States.  JAMA. 2005;293(21):2626-2633.PubMedGoogle ScholarCrossref
13.
Nathens  AB, Maier  RV, Copass  MK, Jurkovich  GJ.  Payer status: the unspoken triage criterion.  J Trauma. 2001;50(5):776-783.PubMedGoogle ScholarCrossref
14.
Newgard  CD, McConnell  KJ, Hedges  JR.  Variability of trauma transfer practices among non–tertiary care hospital emergency departments.  Acad Emerg Med. 2006;13(7):746-754.PubMedGoogle Scholar
15.
Parks  J, Gentilello  LM, Shafi  S.  Financial triage in transfer of trauma patients: a myth or a reality?  Am J Surg. 2009;198(3):e35-e38. doi:10.1016/j.amjsurg.2009.01.012.PubMedGoogle ScholarCrossref
16.
MacKenzie  EJ, Hoyt  DB, Sacra  JC,  et al.  National inventory of hospital trauma centers.  JAMA. 2003;289(12):1515-1522.PubMedGoogle ScholarCrossref
17.
Owens  PL, Barrett  ML, Gibson  TB, Andrews  RM, Weinick  RM, Mutter  RL.  Emergency department care in the United States: a profile of national data sources.  Ann Emerg Med. 2010;56(2):150-165.PubMedGoogle ScholarCrossref
18.
Lossius  HM, Kristiansen  T, Ringdal  KG, Rehn  M.  Inter-hospital transfer: the crux of the trauma system, a curse for trauma registries.  Scand J Trauma Resusc Emerg Med. 2010;18:15. doi:10.1186/1757-7241-18-15.PubMedGoogle ScholarCrossref
19.
 Healthcare Cost and Utilization Project. Nationwide Emergency Department Sample (NEDS): database documentation–description of data elements. http://www.hcup-us.ahrq.gov/db/nation/neds/nedsdde.jsp. Accessed March 26, 2013.
20.
Hsia  RY, Wang  E, Torres  H, Saynina  O, Wise  PH.  Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006.  J Trauma. 2010;68(1):217-224.PubMedGoogle ScholarCrossref
21.
Hsia  RY, Wang  E, Saynina  O, Wise  P, Pérez-Stable  EJ, Auerbach  A.  Factors associated with trauma center use for elderly patients with trauma: a statewide analysis, 1999-2008.  Arch Surg. 2011;146(5):585-592.PubMedGoogle ScholarCrossref
22.
Osler  T, Baker  SP, Long  W.  A modification of the Injury Severity Score that both improves accuracy and simplifies scoring.  J Trauma. 1997;43(6):922-926.PubMedGoogle ScholarCrossref
23.
Maier  RV.  Trauma: the paradigm for medical care in the 21st century.  J Trauma. 2003;54(5):803-813.PubMedGoogle ScholarCrossref
24.
Schiff  RL, Ansell  DA, Schlosser  JE, Idris  AH, Morrison  A, Whitman  S.  Transfers to a public hospital: a prospective study of 467 patients.  N Engl J Med. 1986;314(9):552-557.PubMedGoogle ScholarCrossref
25.
Olson  CM, Jastremski  MS, Vilogi  JP, Madden  CM, Beney  KM.  Stabilization of patients prior to interhospital transfer.  Am J Emerg Med. 1987;5(1):33-39.PubMedGoogle ScholarCrossref
26.
Kellermann  AL, Hackman  BB.  Emergency department patient “dumping”: an analysis of interhospital transfers to the Regional Medical Center at Memphis, Tennessee.  Am J Public Health. 1988;78(10):1287-1292.PubMedGoogle ScholarCrossref
27.
Centers for Medicare and Medicaid Services.  Emergency Medical Treatment & Labor Act (EMTALA).http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/emtala.Accessed December 19, 2013.
28.
Phibbs  CS, Bronstein  JM, Buxton  E, Phibbs  RH.  The effects of patient volume and level of care at the hospital of birth on neonatal mortality.  JAMA. 1996;276(13):1054-1059.PubMedGoogle ScholarCrossref
29.
Phibbs  CS, Baker  LC, Caughey  AB, Danielsen  B, Schmitt  SK, Phibbs  RH.  Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.  N Engl J Med. 2007;356(21):2165-2175.PubMedGoogle ScholarCrossref
30.
Durbin  DR, Giardino  AP, Shaw  KN, Harris  MC, Silber  JH.  The effect of insurance status on likelihood of neonatal interhospital transfer.  Pediatrics. 1997;100(3):E8. doi:10.1542/peds.100.3.e8.PubMedGoogle ScholarCrossref
31.
Bosk  EA, Veinot  T, Iwashyna  TJ.  Which patients and where: a qualitative study of patient transfers from community hospitals.  Med Care. 2011;49(6):592-598.PubMedGoogle ScholarCrossref
32.
Veinot  TC, Bosk  EA, Unnikrishnan  KP, Iwashyna  TJ.  Revenue, relationships and routines: the social organization of acute myocardial infarction patient transfers in the United States.  Soc Sci Med. 2012;75(10):1800-1810.PubMedGoogle ScholarCrossref
33.
Pietz  K, Byrne  MM, Daw  C, Petersen  LA.  The effect of referral and transfer patients on hospital funding in a capitated health care delivery system.  Med Care. 2007;45(10):951-958.PubMedGoogle ScholarCrossref
34.
Pilgrim  R, Martinez  R, Jouriles  N,  et al; 2010 Academic Emergency Medicine Consensus Conference, Beyond Regionalization: Integrated Networks of Care.  Administrative challenges to regionalization.  Acad Emerg Med. 2010;17(12):1359-1363.PubMedGoogle ScholarCrossref
35.
Nichol  G, Aufderheide  TP, Eigel  B,  et al; American Heart Association Emergency Cardiovascular Care Committee; Council on Arteriosclerosis, Thrombosis, and Vascular Biology; Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Cardiovascular Nursing; Council on Clinical Cardiology; Advocacy Committee; Council on Quality of Care and Outcomes Research.  Regional systems of care for out-of-hospital cardiac arrest: a policy statement from the American Heart Association.  Circulation. 2010;121(5):709-729.PubMedGoogle ScholarCrossref
36.
Carr  BG, Conway  PH, Meisel  ZF, Steiner  CA, Clancy  C.  Defining the emergency care sensitive condition: a health policy research agenda in emergency medicine.  Ann Emerg Med. 2010;56(1):49-51.PubMedGoogle ScholarCrossref
37.
Davis  K.  Paying for care episodes and care coordination.  N Engl J Med. 2007;356(11):1166-1168.PubMedGoogle ScholarCrossref
38.
Wiler  JL, Beck  D, Asplin  BR,  et al.  Episodes of care: is emergency medicine ready?  Ann Emerg Med. 2011.PubMedGoogle Scholar
39.
Centers for Disease Control and Prevention.  Injury prevention and control: trauma care.http://www.cdc.gov/traumacare/index.html. Accessed June 1, 2013.
40.
McConnell  KJ, Johnson  LA, Arab  N, Richards  CF, Newgard  CD, Edlund  T.  The on-call crisis: a statewide assessment of the costs of providing on-call specialist coverage.  Ann Emerg Med. 2007;49(6):727-733, 733.e1-733.18. doi:10.1016/j.annemergmed.2006.10.017. PubMedGoogle ScholarCrossref
41.
Haupt  MT, Bekes  CE, Brilli  RJ,  et al; Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine.  Guidelines on critical care services and personnel: recommendations based on a system of categorization of three levels of care.  Crit Care Med. 2003;31(11):2677-2683.PubMedGoogle ScholarCrossref
42.
Haas  B, Jurkovich  GJ, Wang  J, Rivara  FP, Mackenzie  EJ, Nathens  AB.  Survival advantage in trauma centers: expeditious intervention or experience?  J Am Coll Surg. 2009;208(1):28-36.PubMedGoogle ScholarCrossref
Original Investigation
May 2014

Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non–Trauma Center Emergency Departments: Disparities by Insurance Status

Author Affiliations
  • 1Department of Emergency Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 2currently a medical student at Stanford University School of Medicine, Stanford, California
  • 3Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
  • 4Stanford Investigators for Surgery, Trauma, and Emergency Medicine, Stanford University School of Medicine, Stanford, California
  • 5Division of Emergency Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, California
JAMA Surg. 2014;149(5):422-430. doi:10.1001/jamasurg.2013.4398
Abstract

Importance  Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs).

Objectives  To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients.

Design, Setting, and Participants  Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non–trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region.

Main Outcomes and Measures  Inpatient admission vs transfer to another acute care facility.

Results  In 2009, a total of 4513 observations from 636 non–trauma center EDs were available for analysis, representing a nationally weighted population of 19 312 non–trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non–trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non–teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10 000 annual ED visits).

Conclusions and Relevance  Patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

×