Prolonged Length of Stay at Out-of-State Trauma Centers: Potential Role for Repatriation

The closest Level I trauma center to an injured patient may be in a different state. Because patients treated at out-of-state trauma centers may face barriers to accessing postdischarge care, we hypothesized that patients treated at out-of-state trauma centers have longer length of stay (LOS) than patients treated at in-state trauma centers.

Using the Healthcare Cost and Utilization Project State Inpatient Databases for 13 US states, we included adult patients with a primary injury diagnosis who were treated at a Level I trauma center. We performed mixed-effects negative binomial regression to assess for differences in LOS between patients treated at in-state and out-of-state trauma centers, controlling for the fixed effects of patient demographics, insurance, injury severity and mechanism, medical comorbidity, and discharge venue, as well as the random effect of trauma center state.

We identified 107,098 patients, including 6,950 (6.5%) treated at an out-of-state Level I trauma center. Unadjusted LOS was 1.3 days longer in out-of-state patients (8.0 vs 6.7, p < 0.001). After adjusting for potential confounders, out-of-state patients had 0.78 days longer LOS than in-state patients (95% CI 0.69 to 0.87 days). This effect was greater among the subgroup of patients with Medicaid insurance (1.27 days longer, 95% CI 0.99 to 1.54 days) and those discharged to rehabilitation (1.61 days longer, 95% CI 1.36 to 1.86 days).

Injured patients treated at out-of-state trauma centers have longer LOS than patients treated at in-state trauma centers. Challenges with discharging patients to rehabilitation and limited out-of-state insurance coverage among patients with Medicaid may drive this difference. Repatriation of patients from out-of-state Level I trauma centers to in-state hospitals after completion of the acute phase of care may be an approach to addressing prolonged LOS among out-of-state trauma patients.