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Factors Associated with Transfer of Hand Injuries to a Level I Trauma Center: An Analysis of 1,147 Cases
Parag Butala, MD; Mark D. Fisher, MD; Gert Bluschke, MD; David S. Ruch, MD; Marc J. Richard, MD; Scott T. Hollenbeck, MD; Howard Levinson, MD; Fraser J. Leversedge, MD; Detlev Erdmann, MD, PhD, MHSc
Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, NC

Introduction: The transfer of patients with hand injuries to trauma centers involves a commitment of substantial direct and indirect resources by the accepting center. Anecdotal experience suggests that the likelihood of transfer increases during nights, weekends, and holidays and may be associated with patient insurance status. Previous studies have suggested that the uninsured are disproportionately transferred when controlled for injury severity. The purpose of this study was to analyze patterns of hand trauma transfers to a single tertiary care academic medical center with respect to timing and patient insurance status.

Materials and Methods: The authors performed a retrospective chart review and analysis of all patient transfers from 2005 to 2010 at a single Level 1 University Trauma Center. Data categories included timing of transfer, patient demographics, insurance status, comorbidities, diagnosis and procedures performed. These were compared to non-transferred control patients.

Results: A total of 1,147 patients were analyzed. Overall, 32.4% were female, 28% were Black, and 58.1% were White. Contrary to our expectations, transfers were slightly more likely during the day (7am to 7pm) (59% vs 41%) (p-value = 0.0001). Likewise, patients were more likely to present on weekdays rather than weekends (M-Th vs Fri-Sun) (66% vs 33%) (p-value=.001). But further analysis demonstrated multiple associations between referral patterns and insurance status. Although the uninsured were not disproportionately represented overall, they were more frequently transferred at night (53.6% vs 46.4%, p-value = 0.0001). Conversely, patients with private insurance were less likely to be transferred to our hospital at night (36.7% vs 63.7%, p-value = 0.0001). CHAMPUS patients were transferred slightly more frequently on weekends and at nights, and Medicare patients were transferred less frequently on weekends (38.1%, vs 68.8%, p-value = 0.0005). Patients with private insurance were under-represented among hand injury transfers in comparison to the general population in our state (64% vs 50%). When injury diagnosis was included with the analysis, we found that significantly more polytrauma patients with Medicare/Medicaid were transferred compared to privately insured patients. Additionally, not surprisingly, significantly more transfers occurred during the second and third quarters of the year.

Conclusions: Our analysis demonstrates significant associations between insurance status and hand injury transfer patterns, particularly on nights and weekends. The current healthcare climate, including declining numbers of surgeons willing to provide emergency hand care, diminishing reimbursements, and a large uninsured patient population threatens to exacerbate these concerning trends in trauma patient management.

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