Rates, Predictors and Variability of Interhospital Transfers: A National Evaluation

Abstract

IMPORTANCE

Interhospital transfer (IHT) remains a largely unstudied process of care.

OBJECTIVE

To determine the nationwide frequency of, patient and hospital-level predictors of, and hospital variability in IHT.

DESIGN

Cross-sectional study.

SETTING

Centers for Medicare and Medicaid 2013 100% Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

PATIENTS

Beneficiaries ≥65 years and older enrolled in Medicare A and B, with an acute care hospitalization claim in 2013.

EXPOSURES

Patient and hospital characteristics of transferred and nontransferred patients.

MEASUREMENTS

Frequency of interhospital transfers (IHT); adjusted odds of transfer of each patient and each hospital characteristic; and variability in hospital transfer rates.

RESULTS

Of 6.6 million eligible beneficiaries with an acute care hospitalization, 101,507 (1.5%) underwent IHT. Selected characteristics associated with greater adjusted odds of transfer included: patient age 74-85 years (odds ratio [OR], 2.38 compared with 65-74 years; 95% confidence intervals [CI], 2.33-2.43); nonblack race (OR, 1.17; 95% CI, 1.13-1.20); higher comorbidity (OR, 1.37; 95% CI, 1.36-1.37); lower diagnosis-related group–weight (OR, 2.02; 95% CI, 1.95-2.09); fewer recent hospitalizations (OR, 1.87; 95% CI, 1.79-1.95); and hospitalization in the Northeast (OR, 1.40; 95% CI, 1.27-1.55). Higher case mix index of the hospital was associated with a lower adjusted odds of transfer (OR, 0.36; 95% CI, 0.30-0.45). Variability in hospital transfer rates remained significant after adjustment for patient and hospital characteristics (variance 0.28, P = 0.01).

CONCLUSIONS

In this nationally representative evaluation, we found that a sizable number of patients undergo IHT. We identified both expected and unexpected patient and hospital-level predictors of IHT, as well as unexplained variability in hospital transfer rates, suggesting lack of standardization of this complex care transition. Our study highlights further investigative avenues to help guide best practices in IHT.