Health systems are increasingly "overtriaging" trauma patients, or unnecessarily transferring them to a different, often to a higher level, facility—an indication of the growing expense of unnecessary healthcare utilization and defensive medicine.
That's the finding from a University of California San Diego Health System researcher, whose report is published in the September issue of the Journal of Trauma. The researchers looked at 51,291 patients from the Nationwide Inpatient Sample from 2000 to 2004 who were originally classified as trauma patients.
They were determined to have been overtriaged if they were sent home alive within 24 hours after their transfer to the second hospital and did not undergo any surgical procedure.
Among the study cohort, there were 3,291, or 6.9%, who were discharged after their transfer, a rate that has been increasingly steadily, the authors wrote, from 563 cases in 2000 to 980 cases in 2004. Extrapolating this to the national population represents "2,685 in 2000 and 4,724 in 2004."
The authors wrote that their study "is the first attempt to examine the problem on a national scale," although one regional study in a young trauma system reported the overtriage rate at 38%.
Among those 20% of the pediatric trauma patients who were discharged one day after their transfer to a second facility, that transfer indicated "it was unlikely they needed to be transferred in the first place."
"This paper highlights the issue of defensive medicine," said David Chang, now director of UCSD's Center for Surgical Systems and Public Health. "We found that pediatric patients (younger than age 18) are most prone to secondary overtriage, which may be due to physicians or hospitals being overly cautious for fear of legal repercussions." Chang was at Johns Hopkins University when the report was prepared.
The authors quantified the cost of secondary overtriage at $5,917 per case, "which is a significant burden considering the average healthcare-related expenditure per person per year in the United States is $8,047."
The paper also noted that many of the overtriaged patients, both adults and children, received CAT scans at the first hospital which "suggests a possible unfamiliarity with diagnostic scanning and interpretation at most hospitals when it comes to trauma patients." In the future, telemedicine with remote radiology consults might solve the problem, "instead of physically sending the patients."
Michael Sise, MD, director of the Scripps Mercy Hospital trauma system in San Diego, acknowledges the problem as "a major issue in terms of the financial burden," and agrees that telemedicine might be part of the solution. Often, he says, the reason the referring hospital transfers the patient is because of a lack of specialists in neurosurgery, orthopedic surgery, and other specialty fields. That doesn't mean the patients didn't need the transfer, he says.
He suggests that rather than deconstructing the trauma system, "we need to take a look at whether it's appropriate, and make sure we can access it for the patients who need it. If we're not going to transfer these patients, there ought to be some way to look at them (remotely) but that system doesn't currently exist."
The authors also found that patients who were rapidly discharged from the second facility were more likely to be male (68.3% versus 50.7%), more likely to be black or Hispanic, 25.2% vs 16.8%), more likely to come from ZIP codes with above-median household incomes (43.4% vs. 38.1%) more likely to be treated at urban hospitals (75.6% vs 66.3%) and more likely to e treated at teaching hospitals (74.9% vs 66.3%).
The authors concluded that the expense "represents a significant cost for government-sponsored medical evacuations and the consumer," but added that secondary overtriage "may be seen as revenue-generating" from the perspective of the hospitals.
"This high cost per overtriaged patient does not reflect the indirect costs the consumer incurs in returning to their home after an unnecessary transfer and discharge.
"Indeed, overtriage may be most inefficient for those who are transferred from large catchment areas, because it is difficult and costly for patients and their families to return home from the hospital," they wrote.