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Hsuan C, Vanness DJ, Zebrowski A, Carr BG, Norton EC, Buckler DG, Wang Y, Leslie DL, Dunham EF, Rogowski JA. Racial and ethnic disparities in emergency department transfers to public hospitals. Health Serv Res 2024; 59:e14276. [PMID: 38229568 PMCID: PMC10915485 DOI: 10.1111/1475-6773.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVE To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. DATA SOURCES AND STUDY SETTING ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). STUDY DESIGN Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. DATA COLLECTION/EXTRACTION METHODS We examined 1,265,588 adult ED patients transferred from 187 hospitals. PRINCIPAL FINDINGS Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. CONCLUSIONS Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.
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Affiliation(s)
- Charleen Hsuan
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - David J. Vanness
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Alexis Zebrowski
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Brendan G. Carr
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Edward C. Norton
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
- Department of EconomicsUniversity of MichiganAnn ArborMichiganUSA
| | - David G. Buckler
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Yinan Wang
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Douglas L. Leslie
- Department of Public Health Sciences, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Eleanor F. Dunham
- Department of Emergency Medicine, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Jeannette A. Rogowski
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
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Shannon EM, Fiskio J, Yoon C, Schnipper JL, Mueller SK. Investigating racial and ethnic disparities in interhospital transfer within an academic integrated healthcare system: A matched cohort study. J Hosp Med 2024. [PMID: 38411292 DOI: 10.1002/jhm.13306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/17/2024] [Accepted: 01/28/2024] [Indexed: 02/28/2024]
Abstract
The presence of racial and ethnic disparities in interhospital transfer (IHT) within integrated healthcare systems has not been fully explored. We matched Black and Latinx patients admitted to community hospitals in our integrated healthcare system between June 2015 and December 2019 to White patients by origin hospital, age, time of year, and disease severity. We performed conditional logistic regression models to determine if race or ethnicity was associated with IHT in one of the tertiary academic medical centers in the system, adjusting for covariates. The sample contained 107,895 admissions (82.6% White, 7.8% Black, and 9.6% Latinx). Transfer rates were 2.2% versus 2.2% after the Black/White match and 1.8% versus 1.8% after the Latinx/White match. After adjusting for covariates, there was no association between race or ethnicity and IHT (Black vs. White odds ratio [OR]: 0.87, 95% confidence interval [CI]: 0.72-1.07; Latinx vs. White OR: 1.05, 95% CI: 0.79-1.40). This may be due to reduced barriers to transfer with an integrated healthcare system.
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Affiliation(s)
- Evan Michael Shannon
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Julie Fiskio
- Mass General Brigham, Boston, Massachusetts, USA
| | - Catherine Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Uthappa DM, Ellett TL, Nyarko T, Rikhi A, Parente VM, Ming DY, White MJ. Interfacility Transfer Outcomes Among Children With Complex Chronic Conditions: Associations Between Patient-Level and Hospital-Level Factors and Transfer Outcomes. Hosp Pediatr 2024; 14:e91-e97. [PMID: 38213279 PMCID: PMC10823183 DOI: 10.1542/hpeds.2023-007425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVES Determine patient- and referring hospital-level predictors of transfer outcomes among children with 1 or more complex chronic conditions (CCCs) transferred to a large academic medical center. METHODS We conducted a retrospective chart review of 2063 pediatric inpatient admissions from 2017 to 2019 with at least 1 CCC defined by International Classification of Diseases, Tenth Revision codes. Charts were excluded if patients were admitted via any route other than transfer from a referring hospital's emergency department or inpatient ward. Patient-level factors were race/ethnicity, payer, and area median income. Hospital-level factors included the clinician type initiating transfer and whether the referring-hospital had an inpatient pediatric ward. Transfer outcomes were rapid response within 24 hours of admission, Pediatric Early Warning Score at admission, and hours to arrival. Regression analyses adjusted for age were used to determine association between patient- and hospital-level predictors with transfer outcomes. RESULTS There were no significant associations between patient-level predictors and transfer outcomes. Hospital-level adjusted analyses indicated that transfers from hospitals without inpatient pediatrics wards had lower odds of ICU admission during hospitalization (odds ratio, 0.46; 95% confidence interval, 0.22-0.97) and shorter transfer times (β-coefficient, -2.54; 95% CI, -3.60 to -1.49) versus transfers from hospitals with inpatient pediatrics wards. There were no significant associations between clinician type and transfer outcomes. CONCLUSIONS For pediatric patients with CCCs, patient-level predictors were not associated with clinical outcomes. Transfers from hospitals without inpatient pediatric wards were less likely to require ICU admission and had shorter interfacility transfer times compared with those from hospitals with inpatient pediatrics wards.
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Affiliation(s)
| | | | | | - Aruna Rikhi
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - David Y. Ming
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina
- Division of Hospital Medicine, Department of Pediatrics
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Ofoma UR, Lanter TJ, Deych E, Kollef M, Wan F, Joynt Maddox KE. Patient and Hospital Characteristics Associated With the Interhospital Transfer of Adult Patients With Sepsis. Crit Care Explor 2023; 5:e1009. [PMID: 38046937 PMCID: PMC10688774 DOI: 10.1097/cce.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
IMPORTANCE The interhospital transfer (IHT) of patients with sepsis to higher-capability hospitals may improve outcomes. Little is known about patient and hospital factors associated with sepsis IHT. OBJECTIVES We evaluated patterns of hospitalization and IHT and determined patient and hospital factors associated with the IHT of adult patients with sepsis. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS A total of 349,938 adult patients with sepsis at 329 nonfederal hospitals in California, 2018-2019. MAIN OUTCOMES AND MEASURES We evaluated patterns of admission and outward IHT between low sepsis-, intermediate sepsis-, and high sepsis-capability hospitals. We estimated odds of IHT using generalized estimating equations logistic regression with bootstrap stepwise variable selection. RESULTS Among the cohort, 223,202 (66.4%) were initially hospitalized at high-capability hospitals and 10,870 (3.1%) underwent IHT. Nearly all transfers (98.2%) from low-capability hospitals were received at higher-capability hospitals. Younger age (< 65 yr) (adjusted odds ratio [aOR] 1.54; 95% CI, 1.40-1.69) and increasing organ dysfunction (aOR 1.22; 95% CI, 1.19-1.25) were associated with higher IHT odds, as were admission to low-capability (aOR 2.79; 95% CI, 2.33-3.35) or public hospitals (aOR 1.35; 95% CI, 1.09-1.66). Female sex (aOR 0.88; 95% CI, 0.84-0.91), Medicaid insurance (aOR 0.59; 95% CI, 0.53-0.66), home to admitting hospital distance less than or equal to 10 miles (aOR 0.92; 95% CI, 0.87-0.97) and do-not-resuscitate orders (aOR 0.48; 95% CI, 0.45-0.52) were associated with lower IHT odds, as was admission to a teaching hospital (aOR 0.83; 95% CI, 0.72-0.96). CONCLUSIONS AND RELEVANCE Most patients with sepsis are initially hospitalized at high-capability hospitals. The IHT rate for sepsis is low and more likely to originate from low-capability and public hospitals than from high-capability and for-profit hospitals. Transferred patients with sepsis are more likely to be younger, male, sicker, with private medical insurance, and less likely to have care limitation orders. Future studies should evaluate the comparative benefits of IHT from low-capability hospitals.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO
| | - Tierney J Lanter
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Elena Deych
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Fei Wan
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO
- Center for Advancing Health Services, Policy and Economics Research, Washington University Institute of Public Health, St. Louis, MO
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Mueller SK. Repatriation of Transferred Patients: A Solution for Hospital Capacity Concerns? Jt Comm J Qual Patient Saf 2023; 49:581-583. [PMID: 37739827 DOI: 10.1016/j.jcjq.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Mehta AB, Taylor JK, Day G, Lane TC, Douglas IS. Disparities in Adult Patient Selection for Extracorporeal Membrane Oxygenation in the United States: A Population-Level Study. Ann Am Thorac Soc 2023; 20:1166-1174. [PMID: 37021958 PMCID: PMC10405618 DOI: 10.1513/annalsats.202212-1029oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/05/2023] [Indexed: 04/07/2023] Open
Abstract
Rationale: Disparities in patient selection for advanced therapeutics in health care have been identified in multiple studies, but it is unclear if disparities exist in patient selection for extracorporeal membrane oxygenation (ECMO), a rapidly expanding critical care resource. Objectives: To determine if disparities exist in patient selection for ECMO based on sex, primary insurance, and median income of the patient's neighborhood. Methods: In a retrospective cohort study using the Nationwide Readmissions Database 2016-2019, we identified patients treated with mechanical ventilation (MV) and/or ECMO with billing codes. Patient sex, insurance, and income level for patients receiving ECMO were compared with the patients treated with MV only, and hierarchical logistic regression with the hospital as a random intercept was used to determine odds of receiving ECMO based on patient demographics. Results: We identified 2,170,752 MV hospitalizations with 18,725 cases of ECMO. Among patients treated with ECMO, 36.1% were female compared with 44.5% of patients treated with> MV only (adjusted odds ratio [aOR] for ECMO, 0.73; 95% confidence interval [CI], 0.70-0.75). Of patients treated with ECMO, 38.1% had private insurance compared with 17.4% of patients treated with MV only. Patients with Medicaid were less likely to receive ECMO than patients with private insurance (aOR, 0.55; 95% CI, 0.52-0.57). Patients treated with ECMO were more likely to live in the highest-income neighborhoods compared with patients treated with MV only (25.1% vs. 17.3%). Patients living in the lowest-income neighborhoods were less likely to receive ECMO than those living in the highest-income neighborhoods (aOR, 0.63; 95% CI, 0.60-0.67). Conclusions: Significant disparities exist in patient selection for ECMO. Female patients, patients with Medicaid, and patients living in the lowest-income neighborhoods are less likely to be treated with ECMO. Despite possible unmeasured confounding, these findings were robust to multiple sensitivity analyses. On the basis of previous work describing disparities in other areas of health care, we speculate that limited access in some neighborhoods, restrictive/biased interhospital transfer practices, differences in patient preferences, and implicit provider bias may contribute to the observed differences. Future studies with more granular data are needed to identify and modify drivers of observed disparities.
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Affiliation(s)
- Anuj B. Mehta
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Hospital Association, Denver, Colorado; and
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, Colorado
| | - Jennifer K. Taylor
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Gwenyth Day
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor C. Lane
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Ivor S. Douglas
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Hospital Association, Denver, Colorado; and
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7
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Blumenthal SR, Fryhofer GW, Serra-Lopez V, Pierrie SN, Mehta S. Bias in Care: Impact of Ethnicity on Time to Emergent Surgery Varies Between Subspecialties. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202306000-00007. [PMID: 37311114 DOI: 10.5435/jaaosglobal-d-23-00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Disparity in access to emergency care among minority groups continues to exist despite growing awareness of the effect of implicit bias on public health. In this study, we evaluated ethnicity-based differences in time between admission and surgery for patients undergoing emergent procedures at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. METHODS We conducted a retrospective review of 249,296 National Surgical Quality Improvement Program cases from 2006 to 2018 involving general, orthopaedic, and vascular surgeries. Analysis of variance was used to compare "time to operating room" (OR) between ethnic groups. RESULTS Notable differences in time to OR were noted among general and vascular surgeries but not orthopaedic surgery. Post hoc comparison identified notable variation in general surgery between White and Black/African Americans. In vascular surgery, notable variations were identified between White and Black/African Americans and White and Native Hawaiian/Pacific Islanders. DISCUSSION These findings suggest that certain surgical subspecialties continue to exhibit disparities in care that may manifest as surgical delay, most notably between White and Black/African Americans. Interestingly, variation in time to OR for patients treated by orthopaedic surgery was not notable. Overall, these results highlight the need for additional research into the role of implicit bias in emergent surgical care in the United States.
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Affiliation(s)
- Sarah R Blumenthal
- From the University of Pennsylvania, Philadelphia, PA (Dr. Blumenthal, Dr. Fryhofer, Dr. Serra-Lopez, and Dr. Mehta) and Brooke Army Medical Center (Dr. Pierrie), Fort Sam Houston, TX
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8
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Carvalho-Salemi J, Phillips W, Wong Vega M, Swanson J, Becker PJ, Salemi JL. Malnutrition among Hospitalized Children in the United States: A 2012-2019 Update of Annual Trends. J Acad Nutr Diet 2023; 123:109-116. [PMID: 35659540 DOI: 10.1016/j.jand.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/24/2022] [Accepted: 12/22/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Malnutrition is associated with adverse clinical outcomes and increased health care utilization for hospitalized children. Yet pediatric malnutrition often goes undiagnosed and national prevalence research in this population is scarce. OBJECTIVE The aim was to assess change in the coded diagnosis of malnutrition (CDM) among US hospitalized children given increased awareness of the need for improved recognition and standardized diagnosis. DESIGN Retrospective, cross-sectional analysis using nationally representative data from the Nationwide Inpatient Sample. PARTICIPANTS/SETTING Our sample was 13.2 million hospitalizations from 2012 to 2019 among pediatric patients between age 1 month and 17 years. MAIN OUTCOME MEASURE CDM using International Classification of Diseases Ninth and 10th Revision-Clinical Modification diagnosis codes. STATISTICAL ANALYSES Descriptive statistics and sampling weights were used to estimate the national frequency and prevalence of CDM. Temporal trends in CDM overall and stratified by age, race/ethnicity, and hospital type were analyzed using joinpoint regression. RESULTS CDM prevalence increased from 3.9% in 2012 to 6.4% in 2019. During this period, failure to thrive decreased from 40.6% to 23.3% of all cases with concomitant increases in the diagnosis of protein-calorie malnutrition and children identified with more than one malnutrition subtype. Differences in CDM diagnoses are evident by hospital type, race/ethnicity, and age of the patient. CONCLUSIONS Although pediatric malnutrition continues to be underdiagnosed in hospital settings, this study demonstrates improvement over time. There continues to be a need for continued professional education regarding best practices for diagnosis to improve health care provider knowledge and self-efficacy on this topic, especially in nonteaching hospitals.
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Affiliation(s)
| | | | | | - Justin Swanson
- College of Public Health, University of South Florida, Tampa, Florida
| | | | - Jason L Salemi
- College of Public Health, University of South Florida, Tampa, Florida
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9
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Sakowitz S, Ng A, Williamson CG, Verma A, Hadaya J, Khoraminejad B, Benharash P. Impact of inter-hospital transfer on outcomes of urgent cholecystectomy. Am J Surg 2023; 225:107-112. [PMID: 36182598 DOI: 10.1016/j.amjsurg.2022.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/29/2022] [Accepted: 09/18/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND This study used a national cohort to characterize the impact of inter-hospital transfer status on outcomes following nonelective cholecystectomy for cholecystitis. METHODS Nonelective cholecystectomies were identified using the 2016-2019 National Inpatient Sample. Multivariable models adjusting for patient and hospital characteristics were utilized to assess outcomes of interest. RESULTS Of an estimated 530,696 patients, 5.3% were transferred. Transferred patients were older, more often male, and more likely to report income in the 0th-25th percentile, compared to others. After adjustment, transfer was associated with increased odds of infectious complications (AOR 1.31, 95%CI 1.06-1.60) and non-home discharge (AOR 1.59, 95%CI 1.45-1.74), but not mortality. Transfer was linked to a $600 cost decrement at the operating hospital (95%CI -$880-330). CONCLUSIONS Transfer status is associated with greater postoperative infection, but not mortality. Given that disparities may play a role in transfer decisions, more work must be done to identify transfer drivers and improve patient outcomes.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ayesha Ng
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Baran Khoraminejad
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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10
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Endicott KM, Morton C, Tolaymat B, Toursavadkohi S, Nagarsheth K. Characteristics and Outcomes of Patients Transferred for Treatment of Acute Limb Ischemia. Ann Vasc Surg 2022; 87:515-521. [PMID: 35803462 DOI: 10.1016/j.avsg.2022.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients requiring emergent vascular surgery often undergo transfer from one facility to another for definitive surgical care. In this study, we analyzed morbidity and mortality in patients presenting for emergent lower extremity thrombectomy and embolectomy in the transferred and non-transferred populations. METHODS A retrospective analysis of prospectively collected data was performed utilizing the National Surgical Quality Improvement Program (NSQIP) database for all non-elective, emergent lower extremity embolectomy or thrombectomy (Current Procedural Terminology [CPT] 34201 and 34203) performed between 2011-2014. Demographics, comorbidities, and 30-day complications and outcomes were compared among patients presenting from home versus those presenting from another hospital, emergency department, or nursing home. Multivariate analysis was performed to determine the association between mode of presentation, major complications, and death. RESULTS We identified 1954 patients who underwent emergent lower extremity embolectomy or thrombectomy. 40.7% (795 patients) were identified as transfer patients. Odds of transfer were significantly increased if a patient was functionally dependent (OR 1.95, p <0.001) or had a history of chronic obstructive pulmonary disease (COPD) (OR 1.348, p = 0.05). Odds of transfer were decreased if a patient was of a non-white race (OR 0.511, p <0.001). 11.7% (229) patients in the described cohort died within 30 days of surgery. Those who died were more likely to present to the treating hospital as a transfer (56.3% versus 38.6%, p <0.001). In multivariate analysis, transfer status was significantly associated with 30-day mortality (OR 1.9: 95% CI 1.40-2.64; p <0.001). CONCLUSIONS Patients transferred from an outside hospital or nursing home who present for emergent vascular procedures demonstrated increased mortality compared to those who present from home direct to the emergency department despite similar comorbid conditions. In addition, race was identified as an independent factor for transfer. Further studies are needed to understand the complex interactions between inter-hospital transfer patterns, emergency vascular surgery presentations, and racial biases to improve outcomes for this population.
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Affiliation(s)
- Kendal M Endicott
- Inova Heart and Vascular Institute, Inova Health Systems, Falls Church, VA
| | - Claire Morton
- University of Maryland School of Medicine, Baltimore, MD.
| | - Besher Tolaymat
- Cooper University Hospital, Department of Surgery, Division of Vascular Surgery, Camden, NJ
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD
| | - Khanjan Nagarsheth
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD
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Narita K, Amiya E, Hatano M, Ishida J, Minatsuki S, Tsuji M, Bujo C, Kakuda N, Isotani Y, Ono M, Komuro I. Determining the factors for interhospital transfer in advanced heart failure cases. IJC HEART & VASCULATURE 2022; 40:101035. [PMID: 35601528 PMCID: PMC9118470 DOI: 10.1016/j.ijcha.2022.101035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 01/22/2023]
Abstract
Background There are some patients with advanced heart failure (HF), for whom implantable left ventricular assist device (LVAD) or heart transplantation (HTx) should be considered. Some of them need to be transferred between hospitals. There are few reports on the interhospital transfer of patients with advanced HF and their subsequent clinical course. In this study, we investigated the characteristics and clinical course of patients transferred to a LVAD/HTx center, focusing on the distance between hospitals. Methods We retrospectively examined 141 patients who were transferred to our hospital, considering the indications of LVAD implantation or HTx. We divided the patients into two groups: those referred <33 km (short-distance) and those referred more than 33 km (long-distance). The primary outcome was the composite outcome of increased catecholamine dose, mechanical support, or renal dysfunction within 1 week of transfer. Results Continuous catecholamine infusion was significantly more common in patients in the long-distance group, whereas extracorporeal membrane oxygenation (ECMO) placement was significantly more common in short-distance group. Patients transferred via long distance had significantly higher rates of increased catecholamine doses, mechanical support including intra-aortic balloon pumping (IABP) and ECMO, and renal dysfunction within 1 week of transfer than patients transferred via short distance. Multivariate analysis showed that low body mass index (BMI) and long distance were independent predictive factors for the primary outcome. Conclusions When patients with advanced HF are transferred from far distant hospitals or with low BMI, it may be necessary to devise various measures for interhospital transport.
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Affiliation(s)
- Koichi Narita
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan.,Department of Therapeutic Strategy for Heart Failure, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan.,Advanced Medical Center for Heart Failure, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Shun Minatsuki
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Masaki Tsuji
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Chie Bujo
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Nobutaka Kakuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Yoshitaka Isotani
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, Japan
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Ikeme S, Kottenmeier E, Uzochukwu G, Brinjikji W. Evidence-Based Disparities in Stroke Care Metrics and Outcomes in the United States: A Systematic Review. Stroke 2022; 53:670-679. [PMID: 35105178 DOI: 10.1161/strokeaha.121.036263] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke disproportionately affects racial minorities, and the level to which stroke treatment practices differ across races is understudied. Here, we performed a systematic review of disparities in stroke treatment between racial minorities and White patients. A systematic literature search was performed on PubMed to identify studies published from January 1, 2010, to April 5, 2021 that investigated disparities in access to stroke treatment between racial minorities and White patients. A total of 30 studies were included in the systematic review. White patients were estimated to use emergency medical services at a greater rate (59.8%) than African American (55.6%), Asian (54.7%), and Hispanic patients (53.2%). A greater proportion of White patients (37.4%) were estimated to arrive within 3 hours from onset of stroke symptoms than African American (26.0%) and Hispanic (28.9%) patients. A greater proportion of White patients (2.8%) were estimated to receive tPA (tissue-type plasminogen activator) as compared with African American (2.3%), Hispanic (2.6%), and Asian (2.3%) patients. Rates of utilization of mechanical thrombectomy were also lower in minorities than in the White population. As shown in this review, racial disparities exist at key points along the continuum of stroke care from onset of stroke symptoms to treatment. Beyond patient level factors, these disparities may be attributed to other provider and system level factors within the health care ecosystem.
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Affiliation(s)
- Shelly Ikeme
- CERENOVUS, Johnson & Johnson, Irvine, CA (S.I., E.K.)
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Shannon EM, Zheng J, Orav EJ, Schnipper JL, Mueller SK. Racial/Ethnic Disparities in Interhospital Transfer for Conditions With a Mortality Benefit to Transfer Among Patients With Medicare. JAMA Netw Open 2021; 4:e213474. [PMID: 33769508 PMCID: PMC7998076 DOI: 10.1001/jamanetworkopen.2021.3474] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
IMPORTANCE 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. OBJECTIVE To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit. DESIGN, SETTING, AND PARTICIPANTS 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. EXPOSURES Race/ethnicity. MAIN OUTCOMES AND MEASURES 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. RESULTS 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. CONCLUSIONS AND RELEVANCE 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.
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Affiliation(s)
- Evan Michael Shannon
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jie Zheng
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stephanie K. Mueller
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
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