Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non-Trauma Center Emergency Departments Disparities by Insurance Status
Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non-Trauma Center Emergency Departments Disparities by Insurance Status
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DOI：
10.1001/jamasurg.2013.4398
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发表时间：
2014-05-01
期刊：
影响因子：
16.9
通讯作者：
Wang, N. Ewen
中科院分区：
文献类型：
--
作者：
Delgado, M. Kit;Yokell, Michael A.;Wang, N. Ewen
在美国，创伤是导致65岁之前潜在寿命损失的主要原因。在指定的创伤中心及时护理已被证明可将死亡率降低25%。然而，在这方面，许多严重受伤的病人最初在非创伤中心急诊科（ED）就诊后没有被转移到创伤中心。为了确定与决定接收而不是转移最初在非创伤中心急诊科就诊的严重受伤病人相关的病人水平和医院水平因素，创伤中心急诊室，并确定是否有保险的病人更有可能被接纳比转移相比，未投保的病人。设计，设置，回顾性分析2009年全国急诊科样本。我们纳入了在非创伤中心18 - 64岁患者中因严重创伤（损伤严重度评分>15）而遇到的所有艾德。我们排除了艾德出院和艾德死亡。我们通过保险状况量化了入院与转院之间的绝对风险差异，同时调整了年龄，性别，损伤机制，损伤严重程度评分，周末入院和就诊月份，城市与农村状况以及家庭邮政编码的家庭收入中位数，以及每年的艾德就诊量和教学状况以及美国地区。主要结果和指标住院患者与转入另一个急性护理结果：2009年，共有来自636个非创伤中心急诊室的4513个观察结果可用于分析，代表了19312个非创伤中心艾德重大创伤就诊的全国加权人口。总体而言，2009年有54.5%的患者入住非创伤中心。与没有保险的患者相比，有医疗补助的患者入院与转院的调整后绝对风险高14.3%（95%CI，9.2%-19.4%），有私人保险的患者高11.2%（95%CI，6.9%-15.4%）。其他与入院和转院相关的因素包括严重的腹部损伤（风险差异，15.9%; 95% CI，9.4%-22.3%），城市教学医院vs非教学医院（风险差异，26.2%; 95% CI，15.2%-37.2%）和年度艾德访视量（风险差，3.4%; 95%可信区间，每年艾德就诊次数每增加10000次，就增加1.6%-5.3%）。创伤中心急诊室不太可能被转移，如果投保，并在接受次优创伤护理的风险。在监测和优化创伤医院间的转移和结果在人口水平的努力是必要的。
IMPORTANCE Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non-trauma center emergency departments (EDs).OBJECTIVES To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non-trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients.DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non-trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region.MAIN OUTCOMES AND MEASURES Inpatient admission vs transfer to another acute care facility.RESULTS In 2009, a total of 4513 observations from 636 non-trauma center EDs were available for analysis, representing a nationally weighted population of 19 312 non-trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non-trauma center. Compared with patients without insurance, 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. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non-teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10 000 annual ED visits).CONCLUSIONS AND RELEVANCE Patients with severe injuries initially evaluated at non-trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.