Trends and Predictors of Unnecessary Facial Trauma Transfers: A National Analysis of Secondary Overtriage in Adults With Isolated Facial Fractures

BACKGROUND: Secondary overtriage, defined as transfer to a higher level of care without subsequent need for admission, operative intervention, or other advanced inpatient resources, is common among patients with isolated facial fractures and contributes to avoidable health care costs. PURPOSE: The study purpose was to measure temporal trends and identify risk factors for secondary overtriage among adults transferred for isolated facial fractures. STUDY DESIGN, SETTING SAMPLE: This was a retrospective cohort study using the American College of Surgeons National Trauma Data Bank (2007-2023). Adults transferred for management of isolated facial fractures were included. Patients with missing data were excluded. PREDICTOR VARIABLE: The predictor variable was calendar year of transfer, modeled as a categorical variable for descriptive analyses (2007-2015, 2016-2023) and a continuous variable for regression analyses. MAIN OUTCOME VARIABLE: The outcome variable was secondary overtriage, defined as transfer to a receiving emergency department followed by discharge home without surgical intervention for facial fractures or hospital admission. COVARIATES: Covariates included demographic (age, race), clinical (Charlson Comorbidity Index), injury-related (fracture site), and hospital characteristics (teaching status, bed size). ANALYSES: Descriptive, bivariate, and multivariable logistic regression statistics were performed to measure the association between calendar year and secondary overtriage. Statistical significance was set at P < .001. RESULTS: The sample was composed of 110,157 subjects with a mean age of 44.6 (19.8) years, and 79,690 (72.3%) were male. Overall, 30,583 (27.8%) subjects met criteria for secondary overtriage. Overtriage increased from 11% in 2007 to 38% in 2023. Subjects treated in 2016-2023 were 1.65 times more likely to be overtriaged than those treated in 2007-2015 (95% CI: 1.61 to 1.70, P < .001). After adjustment for study covariates, each additional calendar year was associated with 12% increased odds of overtriage (odds ratio (OR) 1.12, 95% CI: 1.11 to 1.12, P < .001). Overtriage was also independently associated with self-pay status (OR: 1.74, 95% CI: 1.67 to 1.82) and university hospitals (OR: 1.65, 95% CI: 1.55 to 1.76) (all P < .001). Mandibular fractures were associated with lower odds of overtriage (OR: 0.22, 95% CI: 0.19 to 0.26, P < .001). CONCLUSIONS AND RELEVANCE: Secondary overtriage increased substantially over time and remains common, affecting over one-third of transferred subjects in recent years.