Identifying Racial/Ethnic Disparities in Interhospital Transfer: an Observational Study
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Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA, USA; 2Harvard Medical School, Boston, MA, USA.
BACKGROUND: Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ ethnic disparities in IHT have been suggested but are not well-characterized. OBJECTIVE: To evaluate the association between race/ ethnicity and IHT. DESIGN: Cross-sectional analysis of 2016 National Inpatient Sample data. PATIENTS: Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed. MAIN MEASURES: We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis. KEY RESULTS: Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78– 0.89) and Hispanic (OR 0.81, 95% CI 0.75–0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79–0.98). Disparities in IHT by race/ ethnicity varied by region and medical diagnosis. CONCLUSIONS: Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.
Prior Presentations: Poster abstract, Society of Hospital Medicine Annual Meeting, March 25, 2019, National Harbor, MD. Poster “Walk and Talk” Competition, Society of General Internal Medicine Annual Meeting, May 9, 2019, Washington, DC. Received January 8, 2020 Accepted July 7, 2020
KEY WORDS: health disparities; hospital medicine; health services research; interhospital transfer. J Gen Intern Med DOI: 10.1007/s11606-020-06046-z © Society of General Internal Medicine 2020
INTRODUCTION
Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Medicare data suggests that 1.5% of patients,1 including 45% of patients presenting with acute myocardial infarction, are transferred to a different hospital2, 3 and that approximately 9% of all hospital admissions to tertiary care hospitals originated from another facility.4 The potential benefits of IHT include improved access to necessary specialized care, “seco
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