K. L. Kummerow1, S. Phillips1, R. M. Hayes1, J. M. Ehrenfeld1, M. D. Holzman1, K. Sharp1, R. Pierce1, W. Nealon1, B. K. Poulose1 1Vanderbilt University Medical Center,General Surgery,Nashville, TN, USA
Introduction: There is a persistent perception that hospitals disproportionately transfer unfavorably insured patients to referral centers for emergency surgical care. Given both recent changes in payer mix and decreased federal subsidization of referral centers under the Patient Protection and Affordable Care Act, we sought to understand whether unfavorably insured patients are more likely to be designated as emergent transfers.
Methods: A retrospective cohort study was performed of patient transfers from acute care facilities to a general, thoracic, urologic, or vascular surgery service at a tertiary referral center from 2011-2013. Individuals insured by a commercial, Medicare, or federal (VA/Tricare) payer were defined as having favorable insurance. Unfavorable insurance included Medicaid and uninsured. The primary outcome of referring provider transfer designation as emergent versus non-emergent was evaluated using chi-squared test. A multivariable logistic regression model was created to adjust for patient demographics, Elixhauser Comorbidity Score, Acute Physiology Score, and reason for transfer. Intensity of pre-transfer care, measured by the proportion of patients in each group that underwent any procedure at the referring hospital prior to transfer, was evaluated as a secondary outcome.
Results: The study cohort included 1,253 patient transfers. Eighty-three percent were favorably insured while 17% had unfavorable insurance. Favorably insured patients were older (mean age 60 years vs 44, p<0.01) with fewer non-white patients (8% vs 14%, p<0.01) and higher Elixhauser Scores (median 5 (interquartile range 0-13) vs 3 (0-7), p<0.01). More favorably insured patients were transferred for continuity of care (27% vs 16%) and had undergone prior related procedures at the referral center (20% vs 13%, p=0.03). Acute Physiology Scores did not differ in the groups (median 3 (2-5) in favorable, 4 (2-6) in unfavorable, p=0.22). More unfavorably insured patients were designated as emergency transfers (72% vs 59%, p<0.01). The association between unfavorable insurance and emergency transfer designation persisted after adjustment for demographics, comorbidities, acute physiology, and reason for transfer (odds ratio 1.7, 95% CI 1.2-2.5). There was no difference in the proportion of patients that underwent a procedure prior to transfer (17% in favorable insurance group and 12% in unfavorable group, p=0.08).
Conclusion: The data demonstrate that unfavorably insured patients are more likely to be designated as emergent at the time of transfer request. The difference is not related to comorbid conditions or severity of illness. Transfer processes may be improved through clearer definitions of emergent transfer.
