Higher Hospital Costs Linked to Triage Decisions

    • September 10, 2013

It’s well-documented that care provided at trauma centers costs far more than treatment administered at other hospitals. The treatment of serious injuries in adults is currently the number two contributor to United States health care spending. Recent research shows that the additional costs incurred in major trauma centers are well worth it when it comes to saving the lives of critically-injured patients in need of specialized care.

But what happens to the cost-benefit equation when patients with low-risk injuries are triaged into trauma care? Craig Newgard, MD, MPH, a Robert Wood Johnson Foundation (RWJF) Physician Faculty Scholar (2007-2010), set out to answer this question in an analysis of trauma center costs at hospitals in seven regions of the western United States.

“Our research focused on overtriage. We wanted to learn what happens when a primary [first responder] triage team sends someone to a trauma center [who] really does not need trauma care as well as how often this occurs,” Newgard said. “The current triage guidelines are designed to ensure that the system provides the proper care to everyone, but our findings suggest that a large number of low-risk patients are still transported to major trauma centers.”

To create a framework for the study, Newgard, director of the Center for Policy and Research in Emergency Medicine at Oregon Health and Science University, and his co-authors gathered data with the cooperation of institutional review boards, emergency medical services (EMS) agencies, trauma registrars and state data offices. They analyzed information on injured children and adults who were transported to 122 hospitals by 94 EMS agencies.

Their findings were published in the article “The Cost of Overtriage: MoreThan One-Third of Low-Risk Injured Patients Were Taken to Major Trauma Centers,” as a cover story in the September 9 issue of Health Affairs.

“Building the database for this research was my primary project as a Robert Wood Johnson Foundation Physician Faculty Scholar,” Newgard said. “It’s also important to note that unlike other studies assessing  triage decisions, our sample included trauma and non-trauma centers that were compared on a system level.”

How Upstream Care Decisions Drive Costs

The researchers reviewed the primary triage decisions made in the field by EMS workers and firefighters for 301,214 patients. First-responder teams nationwide are instructed to use a single set of federal guidelines to determine whether or not a patient is in need of trauma care.

One of the first and most important study findings for policy-makers, Newgard noted, is that “one third of patients who do not meet field triage guidelines are overtriaged and sent to trauma centers. This group is the source of a large portion of the unnecessary costs identified in our work.”

When looking at patients with both high-risk and low-risk injuries, Newgard found that the per-episode cost of care was $5,590 higher when patients were taken to a level 1 trauma center compared to non-trauma hospitals. Overall, the cost of care would have been reduced by up to 40 percent if all patients not meeting field triage guidelines were triaged to non-trauma centers. “When taken to trauma centers, even patients with minor injuries incurred an additional $4,383 in care costs when compared to non-trauma hospitals,” Newgard said.

This last point is particularly interesting because trauma team mobilization does not take place when a patient with minor injuries arrives at a trauma center. Newgard suggested that “the cost differential was most likely due to the fact that it is simply more expensive to run a trauma center. These are tertiary care hospitals that require 24-hour trauma surgeon and specialized care capability, clinical resources to care for the most complex trauma patients, and they also tend to be teaching institutions. At some point, these costs are going to be passed along to patients.”

Why Overtriage Occurs

While Newgard and his co-researchers, including RWJF Physician Faculty Scholar (2009-2012) Renee Hsia, MD, did not specifically investigate why first responders made triage decisions that were not consistent with national guidelines, they have partnered on another project to address this question.  

“The single most common reason that first responders take patients to trauma centers when they do not meet the criteria is that the patients request it,” Newgard said. Whether these centers have better name recognition locally or the patients may have established a medical home at them, patient choice clearly plays an important role in the decision-making process.

Other factors include hospital proximity—how close a trauma center may be to the injured person. In any case, Newgard added, “we do not have solid data showing that patients without serious injuries actually benefit—in terms of health outcomes—from being treated in trauma centers.”

Ultimately, Newgard said, he hopes that his work will “dispel the myth that all injured patients are sent to non-trauma centers when they do not meet the trauma triage guidelines. We now know that is not true. Perhaps our data can be used to further refine trauma systems and offer additional advice on how the national guidelines should be followed.” In terms of cost, Newgard thinks policy-makers should recognize that early care decisions made even before a patient reaches the hospital can have very large cost implications downstream.


Related Websites

For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.

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Overtriaging trauma patients raises per-patient health care costs by as much as 40 percent.