The ball's in your court: Trends, causes, outcomes, and costs of patient transfer for pediatric testicular torsion

Background

The transfer of pediatric patients with testicular torsion from community hospitals to pediatric centers can be a time and resource-intensive step toward emergent surgical intervention.

Objective

We sought to describe trends of patient transfer in our state and compare clinical outcomes and health system costs between patients transferred and treated primarily at a pediatric center.

Study design

This retrospective cohort study compared patients aged 1–18 years who presented directly to a pediatric center to those transferred for acute testicular torsion from 2018 to 2023. Exclusion criteria included age <1 year, non-urgent surgery, and admission from clinic. Patient age, BMI, Tanner stage, ASA class, insurance coverage, and presentation time were covariates. Group characteristics and times from symptom onset to initial ED presentation to surgery were compared via two-sided Student's t-tests. Clinical outcomes (orchiectomy, testicular atrophy) were compared via Fisher's exact tests. Costs from transferring hospitals were estimated from costs at our institution, and medical transport costs were extrapolated from contract prices between transport agencies and the pediatric center to compare total episode-of-care cost.

Results

A total of 133 cases (37 primaries, 96 transfers) met inclusion criteria. Transfers increased over the study period (67%–75%). There were no significant differences in age, Tanner stage, ASA score, BMI, or time of day of presentation between groups. Median transfer distance was 12 miles (IQR 7–22) and time was 1 h (IQR 1–2). More than half of cases (53%) were transferred due to hospital policy regarding surgical treatment of minors, and 25% due to lack of urology coverage. Time from initial ED site to OR was nearly doubled for the transfer group (median 4.5 vs 2.5 h, p = 0.02). Despite a higher rate of orchiectomy in the primary group (43 vs 22%, p = 0.01), this difference was not significant after stratification by symptom duration. The estimated average cost of care for patients transferred was twice that of primary patients ($15,082 vs $6898).

Discussion

Transfer of pediatric patients in our state for testicular torsion has increased in recent years. Hospital policies and local urology coverage are primary drivers of patient transfer which nearly doubled time to surgical intervention and more than doubled cost of care. Clinical outcomes were driven by delayed presentation.

Conclusion

Transfer of pediatric patients for testicular torsion nearly doubles time to surgical intervention and more than doubles cost of care. Restrictive hospital policies and gaps in rural hospital urology coverage present opportunities to improve the quality and efficiency of care for these children.

Summary table.

Empty Cell	Overall	Primary	Transfer	p-value
N	133	37	96
Care Timeline (Median hours [IQR])
Symptom onset to ED presentation	6 (2–48)	18.5 (3.5–72)	4 (2–25.8)	0.01
Initial ED presentation to OR	4 (3–5)	2.5 (2–3)	4.5 (3.3–5.8)	0.02
Decision to transfer care to arrival at DCH	1 (1–2)
Orchiectomy stratified by time to presentation
Early (<6 h)	1 (1.5)	0 (0)	1 (1.8)	0.63
Moderate (6–24 h)	0 (0)	0 (0)	0 (0)
Late (>24 h)	36 (76.6)	16 (88.9)	20 (69.0)	0.12
Estimated mean total cost of care		$6898	$15,082	<0.01