Elsevier

Journal of Cardiac Failure

Volume 26, Issue 9, September 2020, Pages 762-768
Journal of Cardiac Failure

Patterns of Hospital Bypass and Interhospital Transfer Among Patients With Heart Failure

https://doi.org/10.1016/j.cardfail.2020.04.015Get rights and content

Abstract

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.

Section snippets

Methods

This analysis aimed to (1) describe rural hospital bypass at the county level by excess travel time to admitting hospital, (2) identify factors associated with a higher likelihood of transfer of patients with HF, (3) establish the volume of HF admissions transferred between centers based on hospital characteristics, and (4) quantify the association between hospital transfer and mortality in patients with HF.

Results

Patient (N = 48,163) and hospital characteristics of the study population are described in Table 1. Evidence of rural hospital bypass was seen, as 42.5% and 55.9% of small town and rural residents, respectively, presented to metropolitan hospitals rather than hospitals of similar rurality (P < .001; Table 2). Rural patients demonstrated a mean excess travel time of 28.56 ± 45.60 minutes (median, 5.10 minutes; interquartile range, 42.53) (Figure 2). With each degree of increasing rurality as

Discussion

In this study, we quantify patterns of transfer based on hospital characteristics, identify patient factors associated with likelihood of transfer for HF care, and quantify the association between transfer and mortality. We demonstrate trends of rural hospital bypass and the heterogeneous distribution of excess travel time across rural communities. As expected, patients are most often transferred from rural to more urban hospitals. There are, however, significant disparities in the likelihood

Conclusions

This study provides several characterizations of rural hospital bypass and interhospital transfer for HF care. Hospital bypass occurs in rural communities. Patients are overwhelmingly transferred to metropolitan centers from all sending hospitals. Disparities in the likelihood of transfer exist among patients with HF on the basis of certain characteristics, including sex and age. Transferred patients with HF are at high risk of in-hospital mortality.

Clinical Perspectives

This study has immediate clinical implications for provider consciousness of the patterns and risks of interhospital transfer for HF care. Our identification of bias against transfer in female and aged patients as well as identification of the increased risk of mortality in transfer can help to inform physician consideration of transfer for the individual patient. Our description of rural hospital bypass also helps to inform current policy discussion regarding health care regionalization and

Translational Outlook

To advance systems of regionalized HF care, further characterization of transfer practices and outcomes is needed. Such study should pertain to specific indications for transfer, interventions provided at receiving hospitals, and patient outcome by transfer indication in order to identify those patients with HF most likely to benefit from transfer. The ability to identify patients with HF in need of advanced therapies early, perhaps even through remote monitoring devices in the outpatient

Disclosures

None.

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  • Cited by (0)

    Supported by a Patient Centered Outcomes Research Program Pilot Funds Award.

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