Abstract

Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized. To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit. This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020. Race/ethnicity. The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion. Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P < .001), while Hispanic patients had higher odds of IHT (adjusted odds ratio, 1.14; 95% CI, 1.05-1.24; P = .002) compared with White patients. This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings. Meanwhile, Hispanic patients had higher adjusted odds of transfer. This research highlights the need for the development of strategies to mitigate disparate transfer practices by patient race/ethnicity.

Highlights

  • Interhospital transfer (IHT) of patients from 1 acute care facility to another is becoming an increasingly common occurrence in modern health care

  • After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT, while Hispanic patients had higher odds of IHT compared with White patients

  • This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings

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Summary

Introduction

Interhospital transfer (IHT) of patients from 1 acute care facility to another is becoming an increasingly common occurrence in modern health care. There is a great deal of heterogeneity in transfer practices across the United States.[2,6,7,8] Language surrounding transfer in the Emergency Medical Treatment and Active Labor Act is vague, stating that patients “should” be transferred to a referral hospital if they require procedural care not available at the origin hospital or when “medical benefits outweigh risks,” regardless of payer status, race/ethnicity, sex, income, or other nonclinical factors.[9] While in some instances there are clear guidelines on when to initiate transfer (eg, revascularization for acute myocardial infarction [AMI] and thrombectomy for proximal large vessel stroke), the decision to transfer is often left to clinicians Such decisions are prone to influence by nonclinical factors, such as those mentioned above, leading to variability in practice.[2]

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