P. Truche1, R. NeMoyer1, S. Patiño-Franco2, M. Torres3, L. F. Pino4, G. L. Peck1 1Rutgers-Robert Wood Johnson Medical School,Department Of Acute Care Surgery,New Brunswick, NJ, USA 2Universidad de Antioquia,Facultad De Medicina,Medellín, ANTIOQUIA, Colombia 3Red de Salud del Centro E.S.E.,Cali, VALLE DEL CAUCA, Colombia 4Hospital Universitario del Valle – Evaristo García,Cali, VALLE DEL CAUCA, Colombia
Introduction: Surgically treatable conditions account for thirty percent of the global burden of disease. Access to timely and safe surgical care has gained increasing priority in low- and middle-income countries (LMICs). MICs frequently report a large rate of interfacility ambulance transfer, which remains largely under-investigated, reflecting an opportunity to optimize timeliness and safety of definitive surgical treatment. Herein, we investigate surgical burden within interfacility transfers, differentiate the burden with respect to the public and private sectors, and provide a preliminary cost estimate for a large urban city in a middle-income country.
Methods: A large retrospective review was conducted on transfer records for a public emergency medical service in Cali, Colombia. Comparisons were made between public and private healthcare facilities initiating transfer. Chi squared analysis was performed and odds ratios calculated comparing diagnosis, transferring specialty, and facility type. ICD9 codes were subcategorized and compared to transferring specialty using pairwise comparisons with a Bonferroni correction. Cost estimates were performed by comparing collected data with the 2016 ambulance fee schedule.
Results: 31,659 patients were transferred over a 1-year period including 21,790 interfacility transfers. 7,808 (34.6%) of transfers were for surgical conditions with 69.8% of these transfers at a surgeon’s request. Surgical conditions accounted for more transfers among public vs. private facilities (33% vs. 15%; p <.001). Private hospitals transferred to private hospitals 77% of the time, while public hospitals transferred to public hospitals 61% of the time. The most common surgical conditions requiring transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). The odds of transfer originating from a public facility were 4.4x higher in patients with appendicitis (OR=4.4, CI [3.3-5.8times]) and 7.5x higher with wounds (OR= 7.5, CI [5.2-10.8] P<.001]), but not statistically different for fractures (OR = 1.2, CI [0.99-1.3 P<0.06], abdominal pain (OR = 0.99, CI [0.8-1.2] P<0.63), or trauma (OR=0.99, CI [0.8-1.2] P<0.92). Total cost of surgical interfacility transfers was estimated to be 719,420 USD.
Conclusion: Surgical disease contributed to roughly one-third of interfacility ambulance transfers. The most common reasons for transfer reflect basic surgical disease with a significant cost burden to the public health system. Public and private hospitals contribute unequally to transfer burden and tend to transfer to public and private hospitals, respectively. More research is needed to determine the true cost to Colombia’s health system and correlate clinical outcomes to transfer burden to assess and inform implications this may have on infrastructure, workforce, finance, and national surgical system strengthening.