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Interhospital transfer and adverse outcomes after general surgery: implications for pay for performance.
J Am Coll Surg. 2014 Mar; 218(3):393-400.JA

Abstract

BACKGROUND

Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes.

STUDY DESIGN

The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission.

RESULTS

Overall, 7% of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95% CI, 1.45-1.52) and mortality (RR = 2.70; 95% CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95% CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95% CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95% CI, 1.00-1.07; mortality: RR = 0.98; 95% CI, 0.88-1.09; length of stay: 1.08 times longer; 95% CI, 1.04-1.11; readmission: RR = 0.97; 95% CI, 0.88-1.08).

CONCLUSIONS

Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers.

Authors+Show Affiliations

Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD.Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address: tpawlik1@jhmi.edu.

Pub Type(s)

Comparative Study
Journal Article

Language

eng

PubMed ID

24468232

Citation

Lucas, Donald J., et al. "Interhospital Transfer and Adverse Outcomes After General Surgery: Implications for Pay for Performance." Journal of the American College of Surgeons, vol. 218, no. 3, 2014, pp. 393-400.
Lucas DJ, Ejaz A, Haut ER, et al. Interhospital transfer and adverse outcomes after general surgery: implications for pay for performance. J Am Coll Surg. 2014;218(3):393-400.
Lucas, D. J., Ejaz, A., Haut, E. R., Spolverato, G., Haider, A. H., & Pawlik, T. M. (2014). Interhospital transfer and adverse outcomes after general surgery: implications for pay for performance. Journal of the American College of Surgeons, 218(3), 393-400. https://doi.org/10.1016/j.jamcollsurg.2013.11.024
Lucas DJ, et al. Interhospital Transfer and Adverse Outcomes After General Surgery: Implications for Pay for Performance. J Am Coll Surg. 2014;218(3):393-400. PubMed PMID: 24468232.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Interhospital transfer and adverse outcomes after general surgery: implications for pay for performance. AU - Lucas,Donald J, AU - Ejaz,Aslam, AU - Haut,Elliott R, AU - Spolverato,Gaya, AU - Haider,Adil H, AU - Pawlik,Timothy M, Y1 - 2013/11/27/ PY - 2013/08/06/received PY - 2013/11/22/revised PY - 2013/11/22/accepted PY - 2014/1/29/entrez PY - 2014/1/29/pubmed PY - 2014/4/25/medline SP - 393 EP - 400 JF - Journal of the American College of Surgeons JO - J Am Coll Surg VL - 218 IS - 3 N2 - BACKGROUND: Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes. STUDY DESIGN: The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission. RESULTS: Overall, 7% of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95% CI, 1.45-1.52) and mortality (RR = 2.70; 95% CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95% CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95% CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95% CI, 1.00-1.07; mortality: RR = 0.98; 95% CI, 0.88-1.09; length of stay: 1.08 times longer; 95% CI, 1.04-1.11; readmission: RR = 0.97; 95% CI, 0.88-1.08). CONCLUSIONS: Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers. SN - 1879-1190 UR - https://www.unboundmedicine.com/medline/citation/24468232/Interhospital_transfer_and_adverse_outcomes_after_general_surgery:_implications_for_pay_for_performance_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1072-7515(13)01259-3 DB - PRIME DP - Unbound Medicine ER -