Session X - Polytrauma II

Sat., 10/22/05 Polytrauma II, Paper #41, 9:00 am

Patient Dumping into Level 1 Trauma Centers: Fact or Fiction?

Chad W. Tingey; Kenneth J. Koval, MD; Robert V. Cantu, MD;
Kevin F. Spratt, PhD; (n-all authors)
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA

Purpose: Federal law mandates that patient transfer to a level 1 trauma center occurs only if the care or specialty needed to treat cannot be offered at the lower level center. At many level 1 trauma centers there is a sentiment that other factors may also promote transfer. Currently, support of the notion of "dumping" or transfer of patients due to factors outside the guidelines is anecdotal. The purpose of this study was to review patients transferred to level 1 trauma centers in comparison to nontransferred patients to determine if characteristics outside the guidelines predict transfer.

Methods: A retrospective review was conducted using the National Trauma Data Base Version 4.0. The cohort selected were patients transferred to level 1 trauma centers (n=39,936). The control was defined as patients treated at lower level trauma centers who were not transferred (n=101,229). Only patients with a minor Injury Severity Score of 0 to 9 were compared across the cohort and the control groups to eliminate the severity of trauma as a potential reason for transfer. Predictors were patient age, gender, and race; insurance status; comorbidity severity; and time of day transfer was received. Adjusted Odds Ratios (ORs) for each predictor controlling for all other predictors were obtained using logistic regression.

Results: All ORs were statistically significant (P0.001). Table 1 summarizes results for the six predictors.

Table 1. Summary of Results

 Predictor Adjusted OR   99% CI  Interpretation A > B: A More Likely to be Transferred than B
 Age  2.19  2.07-2.31  0-64 > 65+ age group by119%
 Gender  1.37  1.33-1.43  Male > female by 37%
 Race  1.35  1.29-1.42  Blacks > whites by 35%
 Insurance  1.16  1.12-1.21  Uninsured > insured by 16%
 Comorbidity  1.55  1.41-1.70  Higher comorbidity index > lower comorbidity index by 55%
 Time  2.16  2.08-2.24  Night transfers > daytime transfers by 116%


Conclusion/Significance: These results support the notion of patient dumping. Although some of the ORs were not particularly large, when considering the volume of patients sent to lower level trauma centers even a 16% increase in transfers associated with lack of insurance translates into many thousands of transfers to level 1 centers outside of current federal guidelines.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.