title: Reasons for transfer to a level 1 trauma center and barriers to timely definitive fracture fixation.
abstract: OBJECTIVE
  Our purpose was to compare patients transferred from another hospital to our trauma center with those arriving directly, to identify barriers to care for similar fractures. We hypothesized that the most frequent reason for delayed definitive fixation would be interhospital transfer and that patients would be transferred primarily for 2 reasons: complex patients with more severe injuries and less complex patients without insurance.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  Level 1 trauma center.
  
  
  METHODS
  A total of 1549 skeletally mature patients with 1655 fractures: 379 acetabulum, 301 pelvic ring, 876 femur, and 99 spine.
  
  
  METHODS
  All patients were treated surgically, with early fixation defined as <24 hours after injury.
  
  
  METHODS
  Demographic and injury characteristics were recorded. Reasons for and timing of transfer were determined.
  
  
  RESULTS
  A total of 814 patients (53%) were transferred from another hospital, including 66% of acetabular and 62% of pelvic ring fractures. Transferred patients were older (39.1 vs. 36.6 years, P = 0.002), had more commercial insurance (21% vs. 17%, P = 0.10), and were less often uninsured (27% vs. 31%, P = 0.11). However, the mean Injury Severity Score of uninsured transferred patients was lower than that of the other transferred patients (22.9 vs. 25.8, P < 0.0001). Transfer was not related to weekday or time of injury. A total of 973 patients (63%) had early definitive fixation. Delayed fixation was often for surgeon preference (57%). Transferred patients were more likely to have delayed fixation (43% vs. 31% of nontransferred, P < 0.0001).
  
  
  CONCLUSIONS
  Internal barriers to definitive fracture care were noted, the most frequent of which is surgeon preference. Treatment delays due to transfer accounted for 12% of all delays. Many transferred patients appeared appropriate based on injury complexity. However, over one-fourth of those transferred had low Injury Severity Score and a significantly higher incidence of no insurance. Communication and transparency about these issues may serve to expedite care and to enhance financial stability of larger trauma centers.
  
  
  METHODS
  Prognostic level II.
authors.affiliation: Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Vallier
authors.forename: Nathaniel A
authors.initials: NA
authors.lastname: Parker
authors.forename: Meghan E
authors.initials: ME
authors.lastname: Beddow
mesh_terms: D000328:Adult; D005260:Female; D005592:Fracture Fixation; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013997:Time Factors; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014505:Urban Population