Patients being dumped to Level 1 trauma centers

Researchers cite patients’ gender, insurance status and race as notable transfer factors.

Issue: December 2005

Trauma centers transfer more men, children and black patients to Level 1 facilities for non-medical reasons, according to research from the Dartmouth-Hitchcock Medical Center.

The practice, known as dumping, violates the federal Emergency Medical Treatment and Active Labor Act (EMTALA). The law stipulates that patients should only be transferred to higher-level trauma centers if they require treatment or specialty care that is not available at the presenting center.

The “anti-dumping law” prevents “private hospitals from transferring or dumping medically difficult or indigent patients on public hospitals for us to take care of,” said researcher Kenneth J. Koval, MD. He presented the findings at the Orthopaedic Trauma Association 21st Annual Meeting.

Koval and his colleagues discovered that children were 150% more likely to be transferred than seniors and Medicaid patients were 68% more likely to be transferred than insured patients. They also found that men proved 43% more likely than women to be moved and black patients were 30% more likely to be transferred than Caucasians. “Transfers were more likely in men, children, blacks, poor, sicker patients and patients with undesirable comorbidities, such as a psychiatric disorder,” Koval said.

The greatest time for transfers is at night, with centers 200% more likely to receive patients in the evening than in the morning or afternoon. “So, in conclusion, non-medical factors including patient age, gender, race and insurance status — all factors not associated with EMTALA — were predictors [for patient transfer] and we feel that patient dumping continues in current trauma practice,” he said.

High transfer rate

Investigators collected information from the National Trauma Databank. The database includes information regarding patient injury and categorizes severity with an ISS score. The researchers gathered data on 133,000 patients listed with a low injury score (ISS scores between one and nine) presenting at lower than Level 1 trauma centers. Of these patients, 73% received treatment at the initial center and 27% were transferred to Level 1 facilities. The transfer rate may seem high, but Koval said, “There’s no other study to compare this.”

The researchers examined predictors for transfer including age, gender, race, insurance status, comorbidity and time of transfer. Outcome measures included transfer, approved hospital charges and facility mortality. Due to the large sample size, investigators used adjusted odds ratios for each predictor. “All ORs [odds ratios] were statistically significant (P=.001),” they wrote in their abstract.

An examination of patient age groups showed that children had the highest chance for transfer. “Children were 10% more likely to be transferred than adults, and seniors were 55% less likely to be transferred than adults,” Koval said. Black patients demonstrated a 115% greater likelihood than Hispanic patients for transfer. “And Hispanics were less likely to be transferred than whites, which may be because there were such a few number of Hispanics in the database,” he said.

Comorbidities

Centers also proved 32% more likely to send patients with comorbidities to Level 1 centers. “Patients with a psychiatric disorder were 300% more likely, chronic drug abuse 170% [and] chronic alcohol abuse 116% more likely than those transferred without those disorders,” Koval said.

Yet, the researchers found no patients with HIV or AIDS in the transfer cohort. “That could be because no one’s asking or they’re afraid to put it in the database for HIPAA, but I can’t believe that nobody has AIDS that’s being transferred,” he said. They also discovered that in-hospital mortality was lower in the transfer group. Koval said this finding could stem from the better-trained staff or care given at Level 1 centers.

Using the database produced most of the limitations of the study. “We can’t verify the accuracy of the data and the standardization of this input,” Koval said. “We can’t also go into and account for other valid reasons for transfer like, if you didn’t have certain resources like a burn unit or the need for specialized care like a neurosurgeon.” The researchers also did not know if patient movement occurred on high-transfer days such as weekends or holidays. Koval said that future research will include these variables.

For more information:
Tingey CW, Koval KJ, Cantu RV. Patient dumping into Level 1 trauma centers: fact or fiction? #41. Presented at the Orthopaedic Trauma Association 21st Annual Meeting. Oct. 19-22, 2005. Ottawa.