Insurance status influences emergent designation in surgical transfers.
BACKGROUND
There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs.


METHODS
A retrospective cohort study was performed on patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only.


RESULTS
There were 1295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer nonwhite, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% versus 84%, P < 0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (odds ratio [OR], 1.61; 95% confidence interval [CI], 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR, 2.27; CI, 1.08-4.77).


CONCLUSIONS
The finding that uninsured patients were more likely to be designated as EMCs suggests nonclinical variation that may be mitigated by clearer definitions and increased interfacility coordination to identify patients requiring transfer for EMCs.
Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, Veterans Affairs Medical Center, Nashville, Tennessee. Electronic address: kristy.l.kummerow@vanderbilt.edu.
Kristy
K
Kummerow Broman
Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee.
Sharon
S
Phillips
Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
Rachel M
RM
Hayes
Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee.
Jesse M
JM
Ehrenfeld
Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
Michael D
MD
Holzman
Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
Kenneth
K
Sharp
Section of Hospital Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
Sunil
S
Kripalani
Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
Benjamin K
BK
Poulose
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D006278:Medicare; D008875:Middle Aged; D010360:Patient Transfer / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000191:economics*; D013714:Tennessee; D062606:Tertiary Care Centers / Q000191:economics* / Q000458:organization & administration / Q000706:statistics & numerical data; D014481:United States
EMTALA; Emergency medical condition; Insurance; Interhospital; Transfer; Uninsured