• Marc Heincelman, Mulugeta Gebregziabher, Elizabeth Kirkland, Samuel O Schumann, Andrew Schreiner, Phillip Warr, Jingwen Zhang, Patrick D Mauldin, William P Moran, and Don C Rockey.
• Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA. heincelm@musc.edu.
• J Gen Intern Med. 2020 Apr 1; 35 (4): 1127-1134.

BackgroundNational administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED).ObjectiveTo investigate the impact of patient-level data not available in larger administrative datasets on the association between IHT status and in-hospital mortality.DesignRetrospective cohort study with logistic regression analyses to examine the association between IHT status and in-hospital mortality, controlling for covariates that were potential confounders. Model 1: IHT status, admit service. Model 2: model 1 and patient demographics. Model 3: model 2 and disease-specific conditions. Model 4: model 3 and vital signs and laboratory data.ParticipantsNine thousand three hundred twenty-eight adults admitted to Medicine services.Main MeasuresInterhospital transfer status, coded as an unordered categorical variable (IHT vs ED vs clinic), was the independent variable. The primary outcome was in-hospital mortality. Secondary outcomes included unadjusted length of stay and total cost.Key ResultsIHT patients accounted for 180 out of 484 (37%) in-hospital deaths, despite accounting for only 17% of total admissions. Unadjusted mean length of stay was 8.4 days vs 5.6 days (p < 0.0001) and mean total cost was $22,647 vs $12,968 (p < 0.0001) for patients admitted via IHT vs ED respectively. The odds ratios (OR) for in-hospital mortality for patients admitted via IHT compared to the ED were as follows: model 1 OR, 2.06 (95% CI 1.66-2.56, p < 0.0001); model 2 OR, 2.07 (95% CI 1.66-2.58, p < 0.0001); model 3 OR, 2.07 (95% CI 1.63-2.61, p < 0.0001); model 4 OR, 1.70 (95% CI 1.31-2.19, p < 0.0001). The AUCs of the models were as follows: model 1, 0.74; model 2, 0.76; model 3, 0.83; model 4, 0.88, consistent with a good prediction model.ConclusionsPatient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.

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