Session I - Polytrauma
Transfer Patterns to a Level I Trauma Center: Reasons for Transfer and Risk Factors for Dumping
Purpose: Our objective was to assess the indications for and the demographics of patients transferred for orthopaedic conditions to a Level I trauma center.
Materials/Methods: During 2004, all orthopaedic trauma patients transferred to our Level I trauma center (n = 128) by means of a physician-to-physician referral line were prospectively evaluated (IRB-approved). The indication for transfer, the specialty of the referring physician, the patient diagnosis, the perceived case complexity (based on a visual analog scale [VAS] scored after phone conversation with the transferring physician), and the patient insurance status were obtained prior to transfer. On patient arrival, these data were reassessed. As controls, orthopaedic trauma patients presenting primarily to our emergency room (not transferred) were used for comparison of insurance status data.
Results: The transferring physician was an emergency department physician in 88 cases (69%), an orthopaedic surgeon in 32 cases (25%), and a generalist in the other 8 cases (6%). While an orthopaedist was on call at the transferring hospital in 87% of cases, he/she examined the patient prior to transfer in only 50% of cases. In 81 cases (63%), the patient was transferred due to the case difficulty. The perceived case complexity prior to transfer (VAS average 6.3; range, 2-9) was similar to that after acceptance at our hospital (VAS average 6.3; range, 1-9); P >0.05. The reported insurance data prior to transfer was inaccurate in 34 patients (27%). However, for the entire study group, the distribution of reported pretransfer insurance type (23% Medicare, 20% HMO/PPO, 14% workers' compensation, 12% uninsured, 5% Medicaid) was similar to the final insurance type (P >0.05). In the subgroup of patients with low complexity (VAS score <5, n = 20), those without clear indications for tertiary care, 15 (75%) had Medicaid, Medicare, or no insurance. This distribution was significantly different (P <0.05) and represented a worse payor mix than the control group who had presented primarily to our emergency room.
Conclusion: The predominant reason for patient transfer to our Level 1 trauma center was a perceived need for a higher level of care. However, transferred patients with a low level of injury complexity had a significantly worse payor mix than our normal orthopaedic trauma patient population. This represents a high-risk group for dumping.