Health insurance status may determine trauma center care

Patients with severe injuries initially evaluated at non-trauma center emergency departments are less likely to be transferred to a trauma center if they have insurance, according to study published online ahead of print in JAMA Surgery.

Trauma injuries account for 42 million emergency department visits and two million hospital admissions across the nation. Timely care in a designated trauma center has been shown to reduce mortality by up to 25%.

According to researchers at the Perelman School of Medicine at the University of Pennsylvania and the Stanford University School of Medicine, the counterintuitive finding suggests that insured patients are more at risk for receiving suboptimal trauma care than are uninsured patients.

The study was based on an analysis of more than 4,500 trauma cases reported at 636 hospitals in a 2009 Nationwide Emergency Department Sample put together by the Agency for Healthcare Research and Quality. The team, led by M. Kit Delgado, MD, an instructor in the department of emergency medicine, faculty fellow in the Center for Epidemiology and Biostatistics and the Leonard Davis Institute of Health Economics at Penn, used multivariate regression analysis to determine differences in transfer rates by insurance status after controlling for patient, injury, and hospital characteristics. 

Although a majority of severely injured trauma patients are initially brought to trauma centers, at least one-third are taken to non-trauma centers. In these cases, emergency room doctors must assess the injuries and decide whether to admit the patient or transfer them to a trauma center. Their decisions usually depend on the injury-how severe it is, what the cause was, or whether the hospital has specialists to handle particular types of injuries.

“We identified several factors associated with whether patients with life-threatening injuries were transferred out of non-trauma center emergency departments,” said Dr. Delgado. “Of concern, we found that some non-clinical factors are associated with whether patients were admitted there or transferred out. We found insured patients initially taken to a non-trauma center had an 11% to 14% higher rate of admission at the non-trauma center. Based on what we know from previous studies, these data suggest that insured patients may be at risk for receiving suboptimal care compared with the care they could receive at the trauma center.”

Trauma systems were developed two to three decades ago to ensure that severely injured patients could receive optimal care no matter where they are injured, according to Dr. Delgado. “This led to the creation of field triage criteria promoted by the CDC for ambulance providers to ensure that life-threatening injuries are accurately detected at the scene of injury to facilitate the transport of these patients directly to trauma centers,” he said.

While the CDC and American College of Surgeons have promoted a goal that 95% of patients with severe injuries should receive their definitive care in trauma centers, several studies have shown that that goal is falling short.

“For one reason or another, at least one-third of patients with life-threatening injuries present initially to non-trauma center EDs,” Dr. Delgado said. “Previous smaller-scale studies have shown that insurance status was one of the factors shown to be associated with where patients received definitive care for their injuries.”

With the recent creation of the Nationwide Emergency Department Sample, a 20% sample of ED visits in the United States, there was finally a way to analyze whether insurance status is associated with the decision to transfer versus the decision to admit these patients, adjusting for differences in patient, injury, and hospital characteristics, according to Dr. Delgado. 

“Until proven otherwise, the findings suggest that patients with life-threatening injuries who have any type of insurance are more likely to be admitted to non-trauma centers rather than transferred, and thus are at risk for suboptimal care based on what we know from previous studies,” he said.  “We were not able to measure outcomes because most databases, like this one, do not allow you to find out what the outcomes are once transferred.  We are designing a series of studies with the few states that have created databases that allow us to track outcomes of transfer to determine whether patients with insurance who are kept in non-trauma center have worse outcomes.”

In the meantime, non-trauma center hospitals should work together with their local trauma center to more clearly define which patients would benefit from transfer and establish protocols to facilitate this process, according to Dr. Delgado.

“Similar protocols have been successfully for the rapid transfer of ST elevation myocardial infarction out of emergency departments of hospitals that do not provide emergency catheterization,” he said. “Only by working together can hospitals ensure that best possible outcomes for people in their communities for time-sensitive critical conditions such as trauma that require a high degree of coordinated, specialized care.

“Managed care companies should consider policies that ensure that their covered patients have access to the best possible acute care for time-sensitive critical conditions such as trauma,” Dr. Delgado added. “Such policies may include splitting some reimbursement with the transferring hospital for conditions for which there is a clearly demonstrated benefit associated with transfer to a regional hospital.”