Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals

a Cross-Sectional Study

Michael G Usher, Christine Fanning, Vivian W Fang, Madeline Carroll, Amay Parikh, Anne M Joseph, Dana Herrigel

Research output: Contribution to journalArticle

Abstract

Background: Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized. Objective: To identify the association between insurance coverage and mortality of patients transferred between hospitals. Design: We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers. Setting: Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers. Patients: The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals. Measurements: Adjusted inpatient mortality and 24-h mortality, stratified by insurance status. Results: Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p = 0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p = 0.026), and earlier in their hospital course (3.9 vs 2.0 days, p = 0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13–1.36, p < 0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11–1.60, p < 0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses. Limitations: This is an observational study where transfer appropriateness cannot be directly assessed. Conclusions: Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.

Original languageEnglish (US)
Pages (from-to)2078-2084
Number of pages7
JournalJournal of general internal medicine
Volume33
Issue number12
DOIs
StatePublished - Dec 1 2018

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Insurance Coverage
Cross-Sectional Studies
Mortality
Inpatients
Observational Studies
Databases
Patient Transfer
Tertiary Care Centers
Referral and Consultation
Demography

Keywords

  • health disparities
  • hospital ownership
  • insurance
  • inter-hospital transfers

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural

Cite this

Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals : a Cross-Sectional Study. / Usher, Michael G; Fanning, Christine; Fang, Vivian W; Carroll, Madeline; Parikh, Amay; Joseph, Anne M; Herrigel, Dana.

In: Journal of general internal medicine, Vol. 33, No. 12, 01.12.2018, p. 2078-2084.

Research output: Contribution to journalArticle

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abstract = "Background: Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized. Objective: To identify the association between insurance coverage and mortality of patients transferred between hospitals. Design: We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers. Setting: Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers. Patients: The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals. Measurements: Adjusted inpatient mortality and 24-h mortality, stratified by insurance status. Results: Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p = 0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p = 0.026), and earlier in their hospital course (3.9 vs 2.0 days, p = 0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95{\%} CI 1.13–1.36, p < 0.001) and higher mortality within 24 h (OR 1.33 95{\%} CI 1.11–1.60, p < 0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses. Limitations: This is an observational study where transfer appropriateness cannot be directly assessed. Conclusions: Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.",
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T2 - a Cross-Sectional Study

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AU - Fanning, Christine

AU - Fang, Vivian W

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AU - Parikh, Amay

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AU - Herrigel, Dana

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AB - Background: Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized. Objective: To identify the association between insurance coverage and mortality of patients transferred between hospitals. Design: We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers. Setting: Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers. Patients: The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals. Measurements: Adjusted inpatient mortality and 24-h mortality, stratified by insurance status. Results: Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p = 0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p = 0.026), and earlier in their hospital course (3.9 vs 2.0 days, p = 0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13–1.36, p < 0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11–1.60, p < 0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses. Limitations: This is an observational study where transfer appropriateness cannot be directly assessed. Conclusions: Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.

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