The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers

Abstract

Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.

Keywords: Clinical Issues; Cost Of Health Care; Emergency Care; Epidemiology; Hospitals; Organization And Delivery Of Care.

Exhibit 2

Average Adjusted Total Cost Per Patient In The Study Sample, By Hospital Level SOURCE Authors’ analysis of the study data. NOTES N = 301; 214 patients. Covariates in the multivariable generalized linear model were hospital type (level 1, level 2, or nontrauma center); age; sex; mechanism of injury (fifteen categories); field triage status (positive or negative); need for field ventilation (intubation or bag-valve mask ventilation); IV placement; Glasgow Coma Scale (see Exhibit 1 Notes); systolic blood pressure ≤90 mmHg; Injury Severity Score (see Note 27 in text); Injury Severity Score based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes; and need for major nonorthopedic surgery, orthopedic surgery, blood transfusion, or interhospital transfer. The numbers above the brackets represent the difference in adjusted estimated per patient cost between the levels of hospitals, including 95% confidence intervals (CI).

Exhibit 3. Average Adjusted Total Cost Per Patient In The Study Sample, By Injury Severity

SOURCE Authors’ analysis of the study data. NOTES N = 301; 214 patients. Covariates in the multivariable generalized linear model were combined Injury Severity Score (see Note 27 in text) and hospital type (nine categories); age; sex; mechanism of injury (fifteen categories); need for field ventilation (intubation or bag-valve mask ventilation); IV placement; Glasgow Coma Scale (see Exhibit 1 Notes); systolic blood pressure ≤90 mmHg; Injury Severity Score based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes; and need for major nonorthopedic surgery, orthopedic surgery, blood transfusion, or interhospital transfer. The numbers above the brackets represent the difference in adjusted estimated per patient cost between the levels of hospitals, including 95% confidence intervals (CI).