Abstract
Although patients with emergency general surgery (EGS) conditions frequently undergo interhospital transfers, the transfer patterns and associated factors are not well understood. To examine whether patients with EGS conditions are consistently directed to hospitals with more resources and better outcomes. This cohort study performed a network analysis of interhospital transfers among adults with EGS conditions from January 1 to December 31, 2016. The analysis used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in 8 states. A total of 728 hospitals involving 85 415 transfers of 80 307 patients were included. Patients were eligible for inclusion if they were 18 years or older and had an acute care hospital encounter with a diagnosis of an EGS condition as defined by the American Association for the Surgery of Trauma. Data were analyzed from January 1, 2020, to June 17, 2021. Hospital-level measures of size (total bed capacity), resources (intensive care unit [ICU] bed capacity, teaching status, trauma center designation, and presence of trauma and/or surgical critical care fellowships), EGS volume (annual EGS encounters), and EGS outcomes (risk-adjusted failure to rescue and in-hospital mortality). The main outcome was hospital-level centrality ratio, defined as the normalized number of incoming transfers divided by the number of outgoing transfers. A higher centrality ratio indicated more incoming transfers per outgoing transfer. Multivariable regression analysis was used to test the hypothesis that a higher hospital centrality ratio would be associated with more resources, higher volume, and better outcomes. Among 80 307 total patients, the median age was 63 years (interquartile range [IQR], 50-75 years); 52.1% of patients were male and 78.8% were White. The median number of outgoing and incoming transfers per hospital were 106 (IQR, 61-157) and 36 (IQR, 8-137), respectively. A higher log-transformed centrality ratio was associated with more resources, such as higher ICU capacity (eg, >25 beds vs 0-10 beds: β = 1.67 [95% CI, 1.16-2.17]; P < .001), and higher EGS volume (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.78 [95% CI, 0-1.57]; P = .01). However, a higher log-transformed centrality ratio was not associated with better outcomes, such as lower in-hospital mortality (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = 0.30 [95% CI, -0.09 to 0.68]; P = .83) and lower failure to rescue (eg, quartile 4 [highest] vs quartile 1 [lowest]: β = -0.50 [95% CI, -1.13 to 0.12]; P = .27). In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical outcomes. Optimizing transfer destination in the interhospital transfer network has the potential to improve EGS outcomes.
Highlights
A higher log-transformed centrality ratio was associated with more resources, such as higher intensive care unit (ICU) capacity, and higher emergency general surgery (EGS) volume
In this study, EGS transfers were directed to high-volume hospitals with more resources but were not necessarily directed to hospitals with better clinical
In 2016, 728 hospitals were involved in 85 415 transfers of 80 307 patients with EGS conditions in the 8 study states
Summary
More than 3 million admissions of patients with emergency general surgery (EGS) conditions occur annually in the US, accounting for 7.1% of all hospitalizations nationally.[1,2] Emergency general surgury conditions are associated with high mortality and costs, placing substantial burden on the health care system.[1,3,4,5,6,7,8,9,10,11] Interhospital transfers of patients with EGS conditions are common, occurring in up to 13% of all EGS encounters, but little is known about the transfer patterns within the network.[1,12] Acute care hospitals with EGS services are not evenly distributed with regard to population density or need for care and, at present, there are no standardized guidelines in place to direct patients to those hospitals.[1,11,12] This problem creates gaps in access to EGS care that have disproportionate consequences for underserved and rural communities, furthering a need for standardized interhospital transfer guidelines and quality measures.[6,7,12] Benefits of organized regionalization of care that includes standardized triage guidelines and verified specialty-specific centers of excellence have been found for trauma and complex oncologic surgeries.[13,14,15] To design successful EGS care delivery, a better understanding of current transfer patterns and associated hospital characteristics is needed to identify targets for quality improvement, including tools to aid transfer decision-making and the selection of destination hospitals.[12,16]
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