Interhospital transfer and adverse outcomes after general surgery: Implications for pay for performance

Donald J. Lucas, Aslam Ejaz, Elliott Haut, Gaya Spolverato, Adil H. Haider, Timothy M. Pawlik

Research output: Contribution to journalArticle

Abstract

Background Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes. Study Design The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission. Results Overall, 7% of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95% CI, 1.45-1.52) and mortality (RR = 2.70; 95% CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95% CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95% CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95% CI, 1.00-1.07; mortality: RR = 0.98; 95% CI, 0.88-1.09; length of stay: 1.08 times longer; 95% CI, 1.04-1.11; readmission: RR = 0.97; 95% CI, 0.88-1.08). Conclusions Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers.

Original languageEnglish (US)
Pages (from-to)393-400
Number of pages8
JournalJournal of the American College of Surgeons
Volume218
Issue number3
DOIs
StatePublished - Mar 2014

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Incentive Reimbursement
Odds Ratio
Length of Stay
Propensity Score
Mortality
Inpatients
Risk Adjustment
Appendectomy
Cholecystectomy
Statistical Models
Databases
Incidence

ASJC Scopus subject areas

  • Surgery

Cite this

Interhospital transfer and adverse outcomes after general surgery : Implications for pay for performance. / Lucas, Donald J.; Ejaz, Aslam; Haut, Elliott; Spolverato, Gaya; Haider, Adil H.; Pawlik, Timothy M.

In: Journal of the American College of Surgeons, Vol. 218, No. 3, 03.2014, p. 393-400.

Research output: Contribution to journalArticle

Lucas, Donald J. ; Ejaz, Aslam ; Haut, Elliott ; Spolverato, Gaya ; Haider, Adil H. ; Pawlik, Timothy M. / Interhospital transfer and adverse outcomes after general surgery : Implications for pay for performance. In: Journal of the American College of Surgeons. 2014 ; Vol. 218, No. 3. pp. 393-400.
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abstract = "Background Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes. Study Design The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission. Results Overall, 7{\%} of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95{\%} CI, 1.45-1.52) and mortality (RR = 2.70; 95{\%} CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95{\%} CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95{\%} CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95{\%} CI, 1.00-1.07; mortality: RR = 0.98; 95{\%} CI, 0.88-1.09; length of stay: 1.08 times longer; 95{\%} CI, 1.04-1.11; readmission: RR = 0.97; 95{\%} CI, 0.88-1.08). Conclusions Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers.",
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T2 - Implications for pay for performance

AU - Lucas, Donald J.

AU - Ejaz, Aslam

AU - Haut, Elliott

AU - Spolverato, Gaya

AU - Haider, Adil H.

AU - Pawlik, Timothy M.

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N2 - Background Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes. Study Design The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission. Results Overall, 7% of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95% CI, 1.45-1.52) and mortality (RR = 2.70; 95% CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95% CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95% CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95% CI, 1.00-1.07; mortality: RR = 0.98; 95% CI, 0.88-1.09; length of stay: 1.08 times longer; 95% CI, 1.04-1.11; readmission: RR = 0.97; 95% CI, 0.88-1.08). Conclusions Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers.

AB - Background Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes. Study Design The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission. Results Overall, 7% of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95% CI, 1.45-1.52) and mortality (RR = 2.70; 95% CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95% CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95% CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95% CI, 1.00-1.07; mortality: RR = 0.98; 95% CI, 0.88-1.09; length of stay: 1.08 times longer; 95% CI, 1.04-1.11; readmission: RR = 0.97; 95% CI, 0.88-1.08). Conclusions Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers.

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