Interhospital Transfer and Receipt of Specialty Procedures
The practice of transferring patients between acute care hospitals is variable and largely nonstandardized. Although often-cited reasons for transfer include providing patients access to specialty services only available at the receiving institution, little is known about whether and when patients receive such specialty care during the transfer continuum. We performed a retrospective analysis using 2013 100% Master Beneficiary Summary and Inpatient claims files from Centers for Medicare and Medicaid Services. Beneficiaries were included if they were aged ≥65 years, continuously enrolled in Medicare A and B, with an acute care hospitalization claim, and transferred to another acute care hospital with a primary diagnosis of acute myocardial infarction, gastrointestinal bleed, renal failure, or hip fracture/dislocation. Associated specialty procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) were identified for each diagnosis. We performed descriptive analyses to compare receipt of specialty procedural services between transferring and receiving hospitals, stratified by diagnosis. Across the 19,613 included beneficiaries, receipt of associated specialty procedures was more common at the receiving than the transferring hospital, with the exception of patients with a diagnosis of gastrointestinal bleed. Depending on primary diagnosis, between 32.4% and 89.1% of patients did not receive any associated specialty procedure at the receiving hospital. Our results demonstrate variable receipt of specialty procedural care across the transfer continuum, implying the likelihood of alternate drivers of interhospital transfer other than solely receipt of specialty procedural care.
© 2017 Society of Hospital Medicine
Patients who undergo interhospital transfer (IHT) are felt to benefit from receipt of unique specialty care at the receiving hospital.1 Although only 1.5% of all hospitalized Medicare patients undergo hospital transfer,2 the frequency of transfer is much greater within certain patient populations, as may be expected with diagnoses requiring specialty care.3,4 Existent data demonstrate that 5% of Medicare patients admitted to the intensive care unit (ICU)5 and up to 50% of patients presenting with acute myocardial infarction (AMI) undergo IHT.6
More recent data suggest variability in hospital transfer practices not accounted for by differences in patient or hospital characteristics.2 Although disease-specific guidelines for IHT exist for certain diagnoses,3,4 the process remains largely nonstandardized for many patients,7 leading to ambiguity surrounding indications for transfer. Because limited data suggest worse outcomes for transferred versus nontransferred patients,8 a better understanding of the specialized care patients actually receive across the transfer continuum may help to elucidate potential indications for transfer and ultimately help delineate which patients are most (or least) likely to benefit from transfer and why.
In this national study, we examined a select cohort of transferred patients with diagnoses associated with specific specialty procedural services to determine if they received these procedures and where along the transfer continuum they were performed.
METHODS
We performed a cross-sectional analysis using the Center for Medicare and Medicaid Services 2013 100% Master Beneficiary Summary and Inpatient claims files. Our study protocol was approved by the Partners Healthcare Human Subjects Review Committee.
Beneficiaries were eligible for inclusion if they were aged ≥65 years, continuously enrolled in Medicare A and B, and with an acute care hospitalization claim in 2013, excluding Medicare managed care and end stage renal disease beneficiaries due to incomplete claims data in these groups. We additionally excluded beneficiaries hospitalized at federal or nonacute care hospitals, or critical access hospitals given their mission to stabilize and then transfer patients to referral hospitals.9
Transferred patients were defined as beneficiaries with corresponding “transfer in” and “transfer out” claims, or those with either claim and a corresponding date of admission/discharge from another hospital within 1 day of the claim, as we used in our prior research.2 Beneficiaries transferred to the same hospital, those with greater than 1 transfer within the same hospitalization, or those cared for at hospitals with “outlier” transfer-in rates equal to 100% or transfer-out rates greater than 35% were excluded from analysis given the suggestion of nonstandard claims practices.
We first identified the top 15 primary diagnoses at time of transfer using International Classification of Diseases, Ninth Revision (ICD-9) codes (supplementary Appendix), and then identified those 4 most likely to require specialty procedural services: AMI, gastrointestinal bleed (GI bleed), renal failure, and hip fracture/dislocation. We then chose associated ICD-9 procedure codes for each diagnosis, via expert opinion (authors SM and JS, hospitalist physicians with greater than 20 years of combined clinical experience), erring on overinclusion of procedure codes. We then quantified receipt of associated procedures at transferring and receiving hospitals, stratified by diagnosis.
We further explored the cohort of patients with hip fracture/dislocation who underwent an associated procedure at the transferring but not receiving hospital, examining the frequency with which these patients had other (nonrelated) procedures at the receiving hospital, and identifying which procedures they received.
RESULTS
Of the 101,507 patients transferred to another hospital, 19,613 (19.3%) had a primary diagnosis of AMI, GI bleed, renal failure, or hip fracture/dislocation. Table 1 lists the ICD-9 procedure codes associated with each diagnosis.
Distribution of receipt of specialty procedures at the transferring and receiving hospitals varied by disease (Figure). With the exception of GI bleed, patients more often received specialty procedural care at the receiving than the transferring hospital. Depending on primary diagnosis, between 32.4% and 89.1% of patients did not receive any associated specialty procedure at the receiving hospital.
Of the 370 (22.1%) hip fracture/dislocation patients that received a specialty procedure at the transferring but not receiving hospital, 132 (35.7%) did not receive any procedure at the receiving hospital, whereas the remaining 238 (64.3%) received an unrelated (not associated with the primary diagnosis) procedure. There was great variety in the types of procedures received, the most common being transfusion of blood products (ICD-9 Clinical Modification 9904).
