Potential Surprise Charges and Avoidable Transfers of Patients With Traumatic Intracranial Hemorrhage at an Academic Care Center

BACKGROUND AND OBJECTIVES: A lack of widely adopted guidelines assisting trauma systems in triaging mild traumatic brain injury (TBI) patients results in potentially avoidable transfers (PATs) associated with significant economic burden. As both transfers and costs associated with TBI increase, improved patient selection for transfer is needed to deliver quality care and contain costs. This study aims to quantify the rate and patient cost of PATs for mild TBI, as well as characterize demographics, risk factors, and clinical outcomes. METHODS: Retrospective review of 905 patients transferred to University of Wisconsin Hospital with primary intracranial hemorrhage (ICH) diagnoses from 2014 through 2022. PATs were defined as Glasgow Coma Scale (GCS) > 13, not requiring a neurosurgical procedure within 2 weeks (including angiography), and not requiring intensive care unit admission; comparisons were made to all other transfers, which were considered justifiable. RESULTS: Of 905 adult patients with primary ICH diagnoses, 362 (40%) were designated potentially avoidable. Of these, 9% were by air and 88% by ground. PATs are associated with female sex, traumatic subarachnoid hemorrhage, higher admission GCS, lack of anticoagulation use, shorter length of stay (total and non-intensive care unit), rapid discharge (<24 and <48 hours), lower in-hospital and 30/90-day mortality rates, lower 30-day post discharge mortality, higher rate of home discharge, and lower rate of neurosurgery follow-up. Potential surprise out-of-network charges associated with PATs was $101,601 by ground and $523,790 by air. CONCLUSION: A subset of adult mild traumatic ICH patients underwent PATs with significant financial liability related to transfer in the form of surprise out-of-network charges. Overall, PAT traumatic ICH patients had better clinical outcomes, were more likely to be rapidly discharged and less likely to require neurosurgical follow-up. In an era of increasing costs and TBI emergency department visits, trauma systems must do more to deliver quality-focused care and contain costs for TBI patients.