X-Ray of a Hand
X-Ray of a Hand

One in five orthopedic trauma patients treated in a Houston public hospital emergency department (ED) are repeating the same care they had in another Houston ED due to inefficiencies in our local system of care for the uninsured, a new study shows.

Orthopedic trauma patients who are evaluated in an emergency department and who do not need to be admitted are typically discharged with appropriate follow-up instructions. However, sometimes these EDs refer the patient to another hospital’s ED to receive follow-up care, which is oftentimes a safety net public county hospital, resulting in an indirect referral.

In a paper published recently in Project Muse, Dr. Laura Medford-Davis, assistant professor in emergency medicine at Baylor College of Medicine, examines the frequency and subsequent cost of indirect referrals of orthopedic patients to a safety net hospital.

When an orthopedic trauma patient comes to an ED for care, there are three traditional channels of care following initial treatment; the patient is admitted for inpatient treatment, the patient is discharged with orthopedic follow up, or the patient is transferred to another medical center for orthopedic care. In the Houston area, a fourth channel has emerged; indirect referral.

“An indirect referral refers to a patient who is initially seen and stabilized at a hospital ED and discharged with instructions to follow up with the orthopedic specialist on call. But later, these patients present to a safety net ED with claims that they were told verbally to seek follow-up treatment there for their injury,” said Medford-Davis.

Because these patients are not transferred via an ambulance or transfer center, they arrive to the second ED with no medical records, which means they have to undergo duplicate testing and paperwork and experience a delay in definitive care, which also results in additional cost to the patient and secondary hospital.

The study aimed to characterize indirect referral to a safety net hospital in a large metropolitan area, Houston, by studying the types and number of patients affected, the cost associated with indirect referral and the referring hospitals involved in the initial treatment.

“Our research into indirect referrals presenting to a local public, safety net hospital, tells us several things about the trends in orthopedic trauma care,” said Medford-Davis. “In the study, we examine 1,162 ED patients who came to the ED with orthopedic injury over a six-month timeframe. During this period, 20 percent of the patients had already been seen for their injury at another Houston-area ED, and almost 90 percent of those patients were uninsured, compared to those who came to the safety net hospital through more traditional referral methods.”

Indirect referrals create a number of challenges for both the patient and the secondary hospital who receive the indirect referral. The patient must find the resources to pay for duplicate services and tests at a second hospital, and they are also sacrificing time away from work or family to come in for another visit at a new ED. For the secondary ED, it is faced with the challenge of treating patients who, for the most part, are unable to pay for their services, as well as the cost of hospital resources and identifying physicians to perform the duplicated services.

“The amount of money being spent on performing duplicate care is astounding. In this study alone, the hospital billed roughly $4.9 million for acute treatment of indirectly referred patients, including $526,880.45 for duplicate ED services,” said Medford-Davis.

These numbers, she says, indicate the need for a change in the health information exchange process. To more effectively manage indirect referrals, the secondary hospitals need easier access to X-rays and charts from the first ED to provide a higher quality of care and avoid duplicate care.