TY - JOUR
T1 - Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock
T2 - An instrumental variables approach
AU - Mohr, Nicholas M.
AU - Harland, Karisa K.
AU - Shane, Dan M.
AU - Ahmed, Azeemuddin
AU - Fuller, Brian M.
AU - Torner, James C.
N1 - Publisher Copyright:
© 2016 Elsevier Inc.
PY - 2016/12/1
Y1 - 2016/12/1
N2 - Purpose The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state. Materials and methods Observational case–control study using statewide administrative claims data from 2005 to 2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations models and with instrumental variables models. Results A total of 18 246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable generalized estimating equations (GEE) model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95% CI 1.5–1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of $6897 (95% CI $5769–8024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with $5167 (95% CI $3696–6638) in additional cost. Conclusions The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.
AB - Purpose The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state. Materials and methods Observational case–control study using statewide administrative claims data from 2005 to 2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations models and with instrumental variables models. Results A total of 18 246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable generalized estimating equations (GEE) model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95% CI 1.5–1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of $6897 (95% CI $5769–8024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with $5167 (95% CI $3696–6638) in additional cost. Conclusions The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.
KW - Emergency medical services
KW - Emergency service, hospital
KW - Health care economics and organizations
KW - Health services
KW - Hospitals, rural
KW - Sepsis
UR - http://www.scopus.com/inward/record.url?scp=84995563960&partnerID=8YFLogxK
U2 - 10.1016/j.jcrc.2016.07.016
DO - 10.1016/j.jcrc.2016.07.016
M3 - Article
C2 - 27546770
AN - SCOPUS:84995563960
SN - 0883-9441
VL - 36
SP - 187
EP - 194
JO - Journal of Critical Care
JF - Journal of Critical Care
ER -