title: Care Transfers for Patients With Upper Extremity Trauma: Influence of Health Insurance Type.
abstract: OBJECTIVE
  To understand the differences in transfer incidence for patients with upper extremity trauma by hospital trauma center designation. We hypothesized that patients with public or no insurance were more likely to be transferred to another facility compared with privately insured patients.
  
  
  METHODS
  Trauma centers are designated by local authorities and verified by the American College of Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of being transferred from one center to another for patients who sustained isolated upper extremity trauma. We used multivariable logistic regression with a clustered variance method to adjust for intrahospital correlation to compare risk-adjusted transfer incidence for patients with upper extremity injuries by trauma center designation.
  
  
  RESULTS
  In 2012, 6,214 patients ages 18-64 with isolated upper extremity trauma presented to 477 hospitals. Overall, transfer incidence was significantly higher among level III trauma centers (26%) compared with level II (11%) or level I (2%) trauma centers. Adjusting for patient and hospital characteristics patients with Medicaid were more likely to be transferred from level III trauma centers to another center compared with privately insured patients.
  
  
  CONCLUSIONS
  Current regulations may not prevent unnecessary patient transfers based on insurance status among level III trauma centers. Policy makers should compensate or provide incentives to hospitals that take care of poorly insured patients.
  
  
  METHODS
  Economic/decision III.
authors.affiliation: Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI. Electronic address: Mahmoudi@med.umich.edu.
authors.forename: Elham
authors.initials: E
authors.lastname: Mahmoudi
authors.affiliation: Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Robert Wood Johnson Clinical Scholars Program, University of California, Los Angeles, CA.
authors.forename: Lee
authors.initials: L
authors.lastname: Squitieri
authors.affiliation: Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI.
authors.forename: Brianna L
authors.initials: BL
authors.lastname: Maroukis
authors.affiliation: Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Chung
authors.affiliation: Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, MI.
authors.forename: Jennifer F
authors.initials: JF
authors.lastname: Waljee
mesh_terms: D000293:Adolescent; D000328:Adult; D001134:Arm Injuries / Q000453:epidemiology / Q000628:therapy*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D014193:Trauma Centers; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Upper extremity injury; access; emergency; transfer; trauma center