Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service

Abstract

Background Thousands of neurosurgical emergencies are transferred yearly to tertiary care facilities to assume a higher level of care. Several studies have examined how neurosurgical transfers influence patient outcomes, but characteristics of potentially avoidable transfers have yet to be investigated. Objective To identify whether potentially avoidable transfers represent a significant portion of transfers to a tertiary neurosurgical facility. Methods In this cohort study, we evaluated 916 neurosurgical patients transferred to a tertiary care facility over a 2-year period. Transfers were classified as potentially avoidable when no neurosurgical diagnostic test, intervention, or intensive monitoring was deemed necessary (n=180). The remaining transfers were classified as justifiable (n=736). The main outcomes and measures were age, sex, diagnosis, insurance status, intervention, distance of transfer, length of hospital and intensive care unit (ICU) stay, mortality, discharge disposition, and cost. Results Nearly 20% of transfers were identified as being potentially avoidable. While some of these patients had suffered devastating, irrecoverable neurologic insults, many had innocuous conditions that did not require transfer to a higher level of care. Justifiable transfers tend to involve patients with non-traumatic intracranial hemorrhage and cranial neoplasm. Both groups were admitted to the intensive care unit at the same rate (approximately 70% of patients). Finally, the direct transportation cost of potentially avoidable transfers was $1.46 million over 2 years. Conclusion This study identified frequency and expense of potentially avoidable transfers. There is a need for closer examination of the clinical and financial implications of potentially avoidable transfers.

Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care

“…6 Kuhn et al identified a group of potentially avoidable transfer patients who in retrospect did not require additional workup or neurosurgical intervention and found that 70% of these patients had been admitted to the ICU. 8 In our cohort, 12% of patients admitted to the ICU did not have documented ICU needs and were transferred to a lower level of care within 24 hours. ED transfers had a higher rate of ICU admissions, as our practice is to err toward a higher level of care for patients referred from an ED since they have not been evaluated by a neurosurgeon and may still require additional imaging or medical workup.…”

“…13 Kuhn et al found that the direct transportation costs of avoidable transfers amounted to $1,460,000 over 2 years. 8 Although our study did not address the issue of avoidable transfers in detail, novel approaches and transfer management algorithms are needed to optimize the transfer request system. Kuhn et al retrospectively identified a subgroup of transfer patients who did not require neurosurgical diagnostic testing, intervention, or intensive monitoring after transfer, which accounted for nearly 20% of all transferred patients.…”

“…Interfacility neurosurgical transfers represent an important component of the neurosurgical volume at tertiary care centers and can account for up to one-third of patients admitted to a given neurosurgical ICU. 1,3,6,8 Many transfers are thought to stem from a lack of local neurosurgeons or resources such as 24-hour MRI availability. In a survey of ED directors, 49% reported a lack of on-call physician specialists as a serious problem.…”

“…The most common single diagnosis was primary brain tumor, which differs from previous studies that cited intracranial hemorrhage as the most common transfer diagnosis. 6,8 Our cohort differs since our main academic hospital is not a trauma center; instead, our institution has a separate Level I trauma center that serves the entire metropolitan area. In our cohort, 64% of patients underwent surgery, which is higher than the rate in other published studies.…”

The Global Spine Care Initiative: resources to implement a spine care program

“…The care provided at the tertiary spine care level requires the highest resource intensity and should be limited to those few cases which cannot be managed at the primary and secondary spine care levels. The inappropriate referral to tertiary care can result in significant and unnecessary excessive cost and use of resources associated with such referrals [38].…”