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

Designated trauma center care has been shown to reduce mortality in trauma patients by 25%. However, many severely injured trauma patients are not transferred to trauma centers after initial presentation at non–trauma center emergency departments. The purpose of this study was to determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured trauma patients. Additionally, the study addressed whether insured patients are more likely to be admitted rather than transferred when compared with uninsured patients. All emergency department encounters for major trauma (Injury Severity Score > 15) seen at non–trauma centers in patients aged 18 to 64 years in the year 2009 were analyzed in this study using retrospective analysis of the 2009 Nationwide Emergency Department sample. Emergency department discharges and deaths were excluded. The absolute risk difference between admission vs. transfer by insurance status was calculated after adjustment for age, sex, mechanism of injury, Injury Severity Score, and other factors. Compared with uninsured patients, 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. Patients with an Injury Severity Score > 15 initially evaluated at non–trauma center emergency departments were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. The authors suggest that policies allowing sharing of reimbursement between the transferring hospital and the receiving hospital may be a solution to the financial conflict of interest for transferring hospitals.