Background

We describe how patient characteristics influence hospital bypass, interhospital transfer, and in-hospital mortality in patients with heart failure in Washington. Rural patients with heart failure may bypass their nearest hospital or be transferred for appropriate therapies. The frequency, determinants, and outcomes of these practices remain uncharacterized.

Methods and Results

Mean excess travel times based on hospital and patient residence ZIP codes were calculated using published methods. Hospitals and servicing areas were coded based on bed size and ZIP code, respectively. Transfer patterns were analyzed using bootstrap inference for clusters. Analysis of mortality and transfer-associated factors was performed using logistic regression with generalized estimating equations. There were 48,163 patients, representing 1106 instances of transfer, studied. The mean excess travel time increased 7.14 minutes per decrease in population density (metropolitan, micropolitan, small town, rural; P < .0001). The rural mean excess travel time was greatest at 28.56 minutes. Transfer likelihood increased with younger age, male gender, admitting hospital rurality, higher Charlson Comorbidity Index, and stroke. Transfer was less likely among women (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.72–0.94) and patients over 70 years old (OR, 0.15–0.46; 95% CI, 0.10–0.65). Adjusting for comorbidities and transfer propensity, transfer exhibited a stronger association with mortality than any other measured patient risk factor (OR, 2.15; 95% CI, 1.69–2.73), excluding stroke (OR, 7.09; 95% CI, 4.99–10.06).

Conclusions

Rural hospital bypass is prevalent among patients with heart failure, although its clinical significance is unclear. Female and older patients were found to have a lesser likelihood of transfer adjusted for other factors. Interhospital transfer is associated with increased mortality when adjusted for comorbidities.

中文翻译：

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心力衰竭患者的医院旁路和医院间转移模式。

背景

我们描述了患者特征如何影响华盛顿心力衰竭患者的医院旁路、院间转运和院内死亡率。患有心力衰竭的农村患者可能会绕过最近的医院或被转移到适当的治疗中。这些做法的频率、决定因素和结果仍然没有特征。

方法和结果

使用已公布的方法计算基于医院和患者住所邮政编码的平均超额旅行时间。医院和服务区分别根据床位大小和邮政编码进行编码。使用集群的 bootstrap 推理来分析传输模式。使用逻辑回归和广义估计方程对死亡率和转移相关因素进行分析。研究了 48,163 名患者，代表 1106 例转移实例。人口密度每降低一次，平均超额出行时间增加 7.14 分钟（大城市、小城市、小城镇、农村；P< .0001）。农村平均超额旅行时间最大，为 28.56 分钟。转移可能性随着年龄较小、男性、入院农村地区、较高的查尔森合并症指数和中风而增加。在女性（比值比 [OR]，0.82；95% 置信区间 [CI]，0.72-0.94）和 70 岁以上患者（OR，0.15-0.46；95% CI，0.10-0.65）中转移的可能性较小。调整合并症和转移倾向后，转移与死亡率的相关性强于任何其他测量的患者风险因素（OR，2.15；95% CI，1.69–2.73），不包括中风（OR，7.09；95% CI，4.99–10.06） .

结论

农村医院旁路在心力衰竭患者中很普遍，尽管其临床意义尚不清楚。发现女性和老年患者在调整其他因素后转移的可能性较小。调整合并症后，院间转运与死亡率增加有关。