Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach

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• 作者：Nicholas M. Mohr ; MD ; MS^a ; ^{nicholas-mohr@uiowa.edu" class="auth_mail" title="E-mail the corresponding author} ; ^{mohr.nick@gmail.com" class="auth_mail" title="E-mail the corresponding author} ; Karisa K. Harland ; PhD ; MPH^b ; ^{kari-harland@uiowa.edu" class="auth_mail" title="E-mail the corresponding author} ; Dan M. Shane ; PhD^c ; ^{dan-shane@uiowa.edu" class="auth_mail" title="E-mail the corresponding author} ; Azeemuddin Ahmed ; MD ; MBA^b ; ^{azeemuddin-ahmed@uiowa.edu" class="auth_mail" title="E-mail the corresponding author} ; Brian M. Fuller ; MD ; MSCI^d ; ^{fullerb@wustl.edu" class="auth_mail" title="E-mail the corresponding author} ; James C. Torner ; PhD^e ; ^{james-torner@uiowa.edu" class="auth_mail" title="E-mail the corresponding author}
• 关键词：2010$USD ; US Dollars ; indexed to 2010 values ; 95% CI ; 95% confidence interval ; API ; Application programming interface ; aOR ; Adjusted odds ratios ; BIC ; Bayesian information criteria ; ED ; Emergency department ; GEE ; Generalized estimating equations ; ICD-9-CM ; International Classification of Diseases ; 9th Edition ; Clinical Modification ; RUCA ; Rural Urban Commuting Areas ; STEMI ; ST-elevation myocardial infarction
• 刊名：Journal of Critical Care
• 出版年：2016
• 出版时间：December 2016
• 年：2016
• 卷：36
• 期：Complete
• 页码：187-194
• 全文大小：693 K

文摘

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.