(32) What is the Incidence and Costs Associated with Interfacility Emergency Department Transfer for Head and Neck Infections Treated by Oral and Maxillofacial Surgeons?

Abstract: Much attention has focused recently on the low percentage of oral and maxillofacial surgeons (OMS) with on-call responsibilities at local hospitals.1 A 2022 survey of practicing OMS demonstrated that 63.0% had 7 days or less of on-call duties per month.2 Treatment of head and neck infections is considered urgent, and is a core component of OMS training. The interfacility emergency department (ED) transfer of odontogenic infections is common, however, often unnecessary. The purpose of this study is to determine the incidence of interfacility ED transfers for head and neck infections and to estimate the associated cost burden.

A retrospective cohort study was performed of all interfacility ED transfers for head and neck infections over a 6-month period at our main hospital. An electronic medical record (EMR) query was performed for all oral surgery residents using the search term “transfer”. Inclusion criteria: ED presentation 01/01/22 to 06/30/22; direct ED to ED transfer; completed consultation by OMS for infection. The search identified 1,099 unique records, and a subsequent manual search was performed using the inclusion criteria. IRB approval was obtained (UIC IRB #2022-0031).

Over a 6-month period, 122 interfacility ED transfers occurred for head and neck infections (74 male, 48 female; average age 45.6 years). The subjects presented from 45 unique hospitals, and 42 unique zip codes. The average distance of transfer was 22.0 miles. Weekend transfers (Friday/Saturday/Sunday) accounted for 64 of 122 transfers (52.5%). Patient insurance coverage included 79 Medicare/Medicaid (64.8%), 30 private insurance (24.6%), and 13 uninsured (10.7%). Of the 122 transfers, 57 patients were subsequently treated in our ED (46.7%), 56 patients were managed in our operating room (45.9%), and 9 patients received antibiotics or no treatment (7.4%). Of the patients treated in the ED, the average time from admission to discharge was 6.9 hours (range: 3-16, SD ±3.15). Repeat computed-tomography (CT) scans were performed 27 times (27/122; 22.1%).

There was no statistically significant association between insurance coverage and miles transferred (PPO/Private 25.9 miles; Medicare/Medicaid 21.5 miles; uninsured 16.1 miles; one-way ANOVA f-ratio 1.56; p = 0.2138), or between treatment performed and miles transferred (no treatment 23.3 miles; ED 22.1 miles; OR 21.6 miles; One-way ANOVA f-ratio 0.05; p = 0.9640). Although weekend transfers occurred more often than expected (52.5% real v 42.9% expected), this was not statistically significant (chi-square test; p-value=0.1585). Using the City of Chicago and Medicare/Medicaid ambulance fee schedule, the average cost of ambulance transport was $2,910.98 to $17,968.74 per patient, for a total cost of $352,242.80 to $2,185,483.91 respectively.3,4 Based on the 2022 Physician Fee Schedule, the 27 repeat CT scans resulted in an additional cost total of $5,391.36 (CPT 70488; $199.68 per patient).

The interfacility transfer of head and neck infections are common and contribute to substantial healthcare costs. Treatment by OMS at the initial presentation ED would result in significant healthcare cost savings. Further studies are needed to determine how the incidence of interfacility ED transfers would be altered by a higher participation of OMS with on-call responsibilities, or with an increase in reimbursement for the management of head and neck infections.

References
1. Lee CC, et al. Interfacility Emergency Department Transfer for Mandibular Fractures in the United States. J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac Surg. 2022;80(11):1757-1768.
2. Dang RR, et al. Lifestyle and career satisfaction among US-based oral and maxillofacial surgeons: Results of a nationwide survey. Oral Surg Oral Med Oral Pathol Oral Radiol. Published online November 11, 2022:S2212-4403(22)01245-7.
3. City of Chicago. Ambulance Bills. Accessed March 22, 2023. https://www.chicago.gov/city/en/depts/fin/supp_info/revenue/ambulance_bills.html
4. CMS.gov. Ambulance Archive & Legacy Files. Accessed March 22, 2023. https://www.cms.gov/medicare/ambulance-fee-schedule-zip-code-files/ambulance-archive-legacy-files