title: Trauma transfers to a rural level 1 center: a retrospective cohort study.
abstract: BACKGROUND
  The regionalization of trauma care, the Emergency Medical Treatment and Active Labor Act of 1986, the advent of Accountable Care Organizations and bundled payments have brought Level 1 trauma centers (TC) to a new crossroads. By protocol, injured patients are preferentially transferred to designated TCs when a higher level of care is indicated. Trauma transfers frequently come during off hours and may not always appear to be related to injury severity. Based on this observation, we hypothesized patients transferred from regional hospitals to Level 1 TCs would have lower injury severity scores (ISS) and unfavorable payor status.
  
  
  METHODS
  We queried our TC registry to identify trauma transfers (TTP) and primary trauma patients (PTP) treated at our level 1 TC between 2004 and 2012. Demographics, payor status, length of stay (LOS), injury severity score (ISS), and discharging service were compared.
  
  
  RESULTS
  5699 TTP and 11147 PTP were identified. Uninsured patients comprised 11 % (n = 602) of TTP compared with 15 % (n = 1,721) of PTP (P < 0.0001). Surprisingly 52 % of TTP were Medicare or HMO (n = 3008) beneficiaries, versus 42 % of PTP being Medicare or HMO (n = 4614) recipients (P < 0.0001). Patients were discharged predominantly by neurosurgery and orthopedic surgery (i.e.: General Adult and General Pediatric comprised <50 % of discharges) for all trauma admissions. Adult and Pediatric Trauma services accounted for 29 % (n = 1674) of TTP versus 45 % of PTP (n = 5045) discharges (P < 0.0001). Mean Injury Severity Score of TTP was found to be 11.5 ± 0.11, in comparison to 11.6 ± 0.11 in PTP (P = 0.42), while mean LOS was 5.6 ± 0.1 days for TTP and 5.9 ± 0.1 days for PTP (P = 0.06).
  
  
  CONCLUSIONS
  These data suggest designated trauma centers should continue to encourage and accept appropriate transfer of trauma patients for surgical subspecialty care. The perception trauma transfers increase institutional fiscal burden is unsubstantiated.
authors.affiliation: Department of Surgery, SUNY Upstate University Hospital, 750 East Adams St, Syracuse, NY 13210 USA.
authors.forename: Sumeet V
authors.initials: SV
authors.lastname: Jain
authors.affiliation: Department of Surgery, SUNY Upstate University Hospital, 750 East Adams St, Syracuse, NY 13210 USA.
authors.forename: Castigliano M
authors.initials: CM
authors.lastname: Bhamidipati
authors.affiliation: Department of Surgery, SUNY Upstate University Hospital, 750 East Adams St, Syracuse, NY 13210 USA.
authors.forename: Robert N
authors.initials: RN
authors.lastname: Cooney
keywords: Cost; Epidemiology; Healthcare access; Trauma transfers