title: Nonmedical factors and the transfer of spine trauma patients initially evaluated at Level III and IV trauma centers.
abstract: BACKGROUND
  The influence of nonmedical factors on the disposition of spine trauma patients, initially seen in less specialized institutions, remains an issue of debate.
  
  
  OBJECTIVE
  To investigate the association of lack of insurance and African-American race with the probability of being transferred to a Level I or II trauma center, after being evaluated in the emergency department (ED) of Level III or IV trauma centers for spine trauma.
  
  
  METHODS
  This was a retrospective cohort study.
  
  
  METHODS
  A total of 14,133 patients who were registered in National Trauma Data Bank (NTDB) from 2009 to 2011 and initially evaluated in the ED of Level III or IV trauma centers for spine trauma were included.
  
  
  METHODS
  The outcome measures were rates of transfer to a higher level of care trauma center.
  
  
  METHODS
  We performed a retrospective cohort study involving spine trauma patients, who were registered in the NTDB between 2009 and 2011. Regression techniques, controlling for clustering at the hospital level, were used to investigate the association of insurance status and race with the possibility of transfer.
  
  
  RESULTS
  Overall, 4,142 patients (29.31%) were transferred to a higher level of care institution, and 9,738 (70.69%) were admitted to a Level III or IV trauma center. Multivariable logistic regression analysis demonstrated an association of uninsured patients with increased possibility of transfer (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.22-1.61). This persisted after using a mixed effects model to control for clustering at the hospital level (OR, 1.65; 95% CI, 1.37-1.96). African-American race was not associated with the decision to transfer, when using a mixed effects model (OR, 1.15; 95% CI, 0.89-1.48). However, African-Americans with Glasgow Coma Scale greater than 8 (OR, 1.40; 95% CI, 1.13-1.74) or Injury Severity Score less than 15 (OR, 1.54; 95% CI, 1.21-1.96) were associated with a higher likelihood of transfer.
  
  
  CONCLUSIONS
  In summary, lack of insurance was associated with increased possibility of transfer to higher level of care institutions, after evaluation in a Level III or IV trauma center ED for spine trauma. The same was true for African-Americans with milder injuries.
authors.affiliation: Department of Surgery, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, One Medical Center Dr, Lebanon, NH 03756, USA.
authors.forename: Symeon
authors.initials: S
authors.lastname: Missios
authors.affiliation: Department of Neurosurgery, Louisiana State University Health Sciences Center, 1541 Kings Hwy, Shreveport, LA 71103, USA. Electronic address: kbekelis@gmail.com.
authors.forename: Kimon
authors.initials: K
authors.lastname: Bekelis
mesh_terms: D000328:Adult; D001741:Black or African American; D005260:Female; D006801:Humans; D019458:Insurance Coverage; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013124:Spinal Injuries / Q000191:economics / Q000453:epidemiology* / Q000208:ethnology; D014193:Trauma Centers / Q000706:statistics & numerical data*
keywords: Insurance coverage; Interfacility transfers; Level III and IV trauma centers; NTDB; Race; Spine trauma