Impact of Interhospital Transfer on Morbidity and Mortality in Acute Pancreatitis

Abstract

Purpose: Interhospital transfers account for a variable proportion of patients with acute pancreatitis at tertiary care referral centers. The aims of this study were to: (1) Characterize the prevalence of transfer patients for AP at a tertiary care referral center, (2) Report outcomes of transfer patients versus nontransfer patients. Methods: A retrospective cohort study was performed utilizing data that had previously been collected prospectively. All inpatients with acute pancreatitis at a tertiary care referral center were captured between June 2005 and December 2007. Acute pancreatitis was defined as 2 of the 3 following criteria: (1) abdominal pain characteristic of acute pancreatitis; (2) serum amylase and/or lipase ≥3 times the upper limit of normal; (3) characteristic findings of acute pancreatitis on imaging. We analyzed demographics, markers of severity within 24 hours (APACHE II and BISAP score) and markers or severity thoughout the hospitalization (pancreatic necrosis, persistent organ failure, ICU admission, hospital length of stay and mortality). The Bedside Index for Severity in Acute Pancreatitis (BISAP) score has been described previously and is comprised of five variables: blood urea nitrogen >25mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age >60 years, and pleural effusion detected on imaging. A point is assigned for each variable present within 24h of presentation and added for a composite score. Continuous variables were analyzed with ANOVA; categorical variables were analyzed with Chi-squared test using SAS 9.1 (Cary, NC). Results: There were 397 episodes of acute pancreatitis. 64 (16%) were transfers. No age, gender or insurance status differences were noted between transfer versus nontransfer cases. There was a higher proportion of whites among the transfer versus the nontransfer patients(94% vs. 62%, p<0.001). In the first 24 hours, transfers were noted to have higher median APACHE II scores (9 vs. 7, p<0.01) and BISAP scores (2 vs. 1, p<0.001) as compared to nontransfers. Transfers suffered a higher proportion of pancreatic necrosis (49% vs. 4%, p<0.0001), persistent organ failure (11% vs. 3%, p<0.01), intensive care admissions (39% vs. 10%, p<0.0001), deaths (8% vs. 3%, p<0.05), and a longer duration of hospital stay (7 days vs. 4 days, p<0.0001) than nontransfers. Conclusion: (1) Transfers are a frequent occurrence for acute pancreatitis at our tertiary care referral center. (2) Transfer patients have increased morbidity and mortality when compared to nontransfer patients. (3) Transfer status should be taken into account when reporting results of clinical studies.