Transferred Patients With Lower Extremity Fractures Are at High-Risk of Major Complications

The role of transfer in orthopedic trauma is being increasingly scrutinized as the U.S. healthcare system transitions to value-based care and bundled payments.

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In the Journal of Orthopaedic Trauma, Mass General Brigham researchers present evidence from a nationwide study that patients transferred for orthopedic trauma surgery are medically sicker, have poorer outcomes, and have a longer length of stay than those directly admitted from home. The authors are trauma fellow Christian A. Pean, MD, MS, Mitchel B. Harris, MD, chief of the Department of Orthopaedic Surgery, Thuan V. Ly, MD, chief of the Orthopaedic Trauma Service, and colleagues.

Methods

For this retrospective study, the researchers consulted the National Surgical Quality Improvement Program database of the American College of Surgeons, representing more than 700 hospitals. They searched for adults with lower-extremity, pelvic or acetabular fractures, given the frequency of those injuries and their effect on mobility and acuity.

Outpatient and elective cases were excluded to ensure patients had similar facility exposure and admission pathways.

The final cohort included 39,497 patients who underwent operative fixation between 2012 and 2019:

• 7,167 patients who were transferred from an acute care inpatient hospital, outside emergency department, nursing home, or other facility
• 32,330 patients admitted directly from home

Patient Characteristics

Transferred patients were significantly more likely than the direct admission group to have factors associated with poor orthopedic outcomes that require perioperative medical management. They were significantly:

• Older (mean age 66 vs. 59; P<0.01)
• More likely to have American Society of Anesthesiologists status >2 (P<0.01)
• More likely to have diabetes (OR, 1.38), chronic obstructive pulmonary disease (OR, 1.64), or preoperative hypoalbuminemia (OR, 1.87)
• More likely to be on dialysis (OR, 1.56)
• More likely to have pelvis/acetabular fractures (OR, 2.5) or femur fractures (OR, 1.98)
• Less likely to have tibia/patella fractures (OR, 0.71) or foot and ankle fractures (OR, 0.58)

Outcomes

Transferred patients also had significantly higher rates of adverse outcomes within 30 days, indicating they are a higher-risk group for hospital systems:

• Mortality—3.3% vs. 1.4% for directly admitted patients (OR, 2.29)
• Major adverse events—10.2% vs. 6.1% (OR, 1.74)
• Infectious complications—7.0% vs. 4.7% (OR, 1.54)
• Readmission rate—5.8% vs. 4.8% (OR, 1.22)
• Length of stay—5.6 vs. 4.4 days (P<0.01)
• Discharge other than to home—63% vs. 38% (OR, 2.75)

Major adverse events were defined as death, ventilator for >48 hours, unplanned intubation, stroke/cerebrovascular accident, pulmonary embolism, cardiac arrest, myocardial infarction, acute renal failure, sepsis, septic shock or return to the operating room.

Transfer remained a significant factor in predicting major adverse events even after adjustment for patient characteristics and fracture type (β=1.197; P<0.01).

The Need for Transfer Guidelines

This study suggests many transferred patients are medically complex and need the well-established medical infrastructures of a level I trauma center. Therefore, transfers to a "higher level" of care do not necessarily reflect the intensity of orthopedic care needed.

Hospitals that accept a high volume of interfacility transfers face exposure to added risk and financial penalties unless the greater needs of these patients are considered in reimbursement models.

Universally accepted guidelines for the transfer of orthopedic trauma patients would help triage them to the appropriate level of care and guide future value-based care models. To be successful, such guidelines will have to incorporate input from anesthesiologists, geriatricians, and acute care specialists about preoperative risk factors, which often cannot be addressed before time-sensitive orthopedic trauma surgery.

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