The Influence of Insurance Status on the Transfer of Femoral Fracture Patients to a Level-I Trauma Center

• Published in: Journal of bone and joint surgery. American volume 2007, Vol.89 (12), p.2625-2631
• Main Authors: Archdeacon, Michael T., MD, Wyrick, John D., MD, Simon, Patrick M., MD
• Format: Article
• Language: English
• Subjects: Orthopedics
• ISSN: 0021-9355
• DOI: 10.1016/S0021-9355(07)73172-7

Background The aim of the present study was to evaluate transfer patterns and insurance status for patients with a femoral fracture who were definitively managed within a six-hospital health-care system. We hypothesized that insurance status significantly influenced transfer of these patients to the level-I trauma center and that the level-I center provided definitive care for a disproportionate percentage of uninsured femoral fracture patients. Methods The present retrospective cohort study was performed within a six-hospital health-care system. The system comprises a single American College of Surgeons-designated level-I trauma center and five nondesignated community hospitals. We identified 243 patients with 251 femoral shaft fractures that had been definitively treated with intramedullary nail fixation within the system. From the health-care system billing database and trauma registries, we obtained diagnosis and procedure codes, insurance status, and trauma center transfer data. Differences in the proportions of uninsured and insured patients were calculated. Results One hundred and seventy-two (71%) of the 243 patients who were definitively managed within our health-care system initially had been taken to the regional level-I center, and thirty-eight patients (16%) had been transferred to the trauma center. Of the thirty-eight patients who had been transferred, eighteen (47%) had met appropriate transfer criteria. Of the twenty patients with an isolated femoral fracture who had been transferred from hospitals with regular orthopaedic coverage, four (20%) had met appropriate transfer criteria. Twenty-two (58%) of the thirty-eight patients who had been transferred were uninsured, and all thirty-three patients who had not been transferred were insured (p = 0.0008); this observation remained when controlling for injury severity and available orthopaedic coverage (p < 0.0001). The proportion of insured patients definitively managed at the trauma center (52%) differed significantly from the proportion of insured patients definitively managed at the community hospitals (100%) (p < 0.0001). Conclusions The majority (71%) of the patients with a femoral fracture who had been managed definitively within our health-care system, regardless of injury severity, had been taken directly to the trauma center. This finding suggests over-triage, which errs on the side of patient well-being. Because there was a significant difference in insurance status between patients