Lauge Sokol‐Hessner, MD

Serious illnesses challenge patients, their families, clinicians, and the health systems that care for them. In this issue of the Journal of Hospital Medicine, Cowen and coauthors shed light on the experience of inpatients on medical and surgical services with a high risk of mortality on admission, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems Surveys (HCAHPS).[1] In their study population, even after adjustment for some confounders, these patients tended to rate responsiveness of hospital staff and communication by doctors lower than patients with a low risk of mortality on admission.

A more generalizable frame than admission risk of mortality is to consider the patients they identified as high risk to be patients with serious illness. Using this frame will be helpful in understanding the implications of their results, but it is important to acknowledge that for several reasons, the data in this study may not represent the entire population of seriously ill patients. First, there may be patients at lower risk of mortality who would qualify as having a serious illness. Second, the study's data were from only a few hospitals in 1 healthcare system. Third, 93% of patients at high risk of mortality on admission did not return surveys. Despite these significant limitations, there are still important insights to be gleaned from their work.

Before exploring what they found, it is also important to note that it can be challenging to know what to make of HCAHPS scores. For instance, patients with higher HCAHPS scores have been found to have higher costs of care and higher mortality.[2] Satisfied patients are not clearly better off. However, what if, for purposes of learning, the scores serve as a window into the seriously ill patient's experience, helping inform an understanding of the challenges and opportunities for improvement?

One of the key findings of this study was that seriously ill patients rated responsiveness by hospital staff worse than those who were not as ill. Patients were asked 2 questions as part of the composite measure: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

It is not difficult to imagine how seriously ill patients might have more intense care needs that would result in more requests for help, nor is it difficult to imagine how some proportion of those requests might not be handled in a timely fashion. Objective research shows higher rates of call button requests have been associated with slower response times, and it appears there is a complex relationship with staffing levels and the intensity of work on the floor.[3] Certainly there may be times that patients want a quick response after pressing a call button, but do not need one, and a lot of time could be spent discussing these quandaries. However, there are also times when a patient describes having called for help, really needing it, yet no one came. At least some of the time, responsiveness is a matter of respect, especially considering the vulnerability of seriously ill patients and the issue of dignity around toileting.

Another key finding was about communication by doctors, and the questions patients answered were: During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand?

There is a growing and important body of literature about communication with seriously ill patients.[4] Consider some of the data about patients with advanced cancer. Evidence suggests the majority of such patients want to know their prognosis, and that when it is discussed it does not worsen the patient‐physician relationship, sadness, or anxiety.[5] Despite this, among physicians who have formulated a prognosis for patients with advanced cancer, even if they were asked directly by those patients about their prognosis, 23% of the time they would communicate no prognosis. Forty percent of the time they would communicate a different prognosis than what they had formulated, with 70% of those being optimistically discrepant.[6] Although data are more limited, there is evidence that hospitalists are similarly wary to acknowledge when patients are at risk of dying.[7]

Although certainly other aspects of communication by doctors with seriously ill patients contributed to this study's findings, this issue of acknowledging and discussing the serious illness itself is important to highlight. Healthcare professionals have an ethical obligation to respect patients' autonomy by helping them make informed decisions about their care. Having these conversations can be challenging, but training programs and conversation guides are showing promise.[8] If health professionals do not try to ensure that seriously ill patients understand their diagnosis, prognosis, and full range of treatment options in patient‐centered ways, then by definition patients cannot be making informed decisions. It is a matter of respect.

This study's most important contribution is how it focuses attention on the domains of responsiveness by hospital staff and communication by doctors, encouraging a deeper dive to consider what else is known about these topics. Allowing that the lower scores from seriously ill patients might reflect more than just poor satisfaction reveals that at least some proportion of the time, these patients are experiencing disrespect. The work then becomes clear: What are the ways in which health professionals should reliably be demonstrating respect toward patients, especially those who are seriously ill? It is there, in the process of developing a reliable practice of respect, that consensus about how to improve the patient experience is most likely to be found.

Serious illnesses challenge patients, their families, clinicians, and the health systems that care for them. In this issue of the Journal of Hospital Medicine, Cowen and coauthors shed light on the experience of inpatients on medical and surgical services with a high risk of mortality on admission, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems Surveys (HCAHPS).[1] In their study population, even after adjustment for some confounders, these patients tended to rate responsiveness of hospital staff and communication by doctors lower than patients with a low risk of mortality on admission.

A more generalizable frame than admission risk of mortality is to consider the patients they identified as high risk to be patients with serious illness. Using this frame will be helpful in understanding the implications of their results, but it is important to acknowledge that for several reasons, the data in this study may not represent the entire population of seriously ill patients. First, there may be patients at lower risk of mortality who would qualify as having a serious illness. Second, the study's data were from only a few hospitals in 1 healthcare system. Third, 93% of patients at high risk of mortality on admission did not return surveys. Despite these significant limitations, there are still important insights to be gleaned from their work.

Before exploring what they found, it is also important to note that it can be challenging to know what to make of HCAHPS scores. For instance, patients with higher HCAHPS scores have been found to have higher costs of care and higher mortality.[2] Satisfied patients are not clearly better off. However, what if, for purposes of learning, the scores serve as a window into the seriously ill patient's experience, helping inform an understanding of the challenges and opportunities for improvement?

One of the key findings of this study was that seriously ill patients rated responsiveness by hospital staff worse than those who were not as ill. Patients were asked 2 questions as part of the composite measure: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

It is not difficult to imagine how seriously ill patients might have more intense care needs that would result in more requests for help, nor is it difficult to imagine how some proportion of those requests might not be handled in a timely fashion. Objective research shows higher rates of call button requests have been associated with slower response times, and it appears there is a complex relationship with staffing levels and the intensity of work on the floor.[3] Certainly there may be times that patients want a quick response after pressing a call button, but do not need one, and a lot of time could be spent discussing these quandaries. However, there are also times when a patient describes having called for help, really needing it, yet no one came. At least some of the time, responsiveness is a matter of respect, especially considering the vulnerability of seriously ill patients and the issue of dignity around toileting.

Another key finding was about communication by doctors, and the questions patients answered were: During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand?

There is a growing and important body of literature about communication with seriously ill patients.[4] Consider some of the data about patients with advanced cancer. Evidence suggests the majority of such patients want to know their prognosis, and that when it is discussed it does not worsen the patient‐physician relationship, sadness, or anxiety.[5] Despite this, among physicians who have formulated a prognosis for patients with advanced cancer, even if they were asked directly by those patients about their prognosis, 23% of the time they would communicate no prognosis. Forty percent of the time they would communicate a different prognosis than what they had formulated, with 70% of those being optimistically discrepant.[6] Although data are more limited, there is evidence that hospitalists are similarly wary to acknowledge when patients are at risk of dying.[7]

Although certainly other aspects of communication by doctors with seriously ill patients contributed to this study's findings, this issue of acknowledging and discussing the serious illness itself is important to highlight. Healthcare professionals have an ethical obligation to respect patients' autonomy by helping them make informed decisions about their care. Having these conversations can be challenging, but training programs and conversation guides are showing promise.[8] If health professionals do not try to ensure that seriously ill patients understand their diagnosis, prognosis, and full range of treatment options in patient‐centered ways, then by definition patients cannot be making informed decisions. It is a matter of respect.

This study's most important contribution is how it focuses attention on the domains of responsiveness by hospital staff and communication by doctors, encouraging a deeper dive to consider what else is known about these topics. Allowing that the lower scores from seriously ill patients might reflect more than just poor satisfaction reveals that at least some proportion of the time, these patients are experiencing disrespect. The work then becomes clear: What are the ways in which health professionals should reliably be demonstrating respect toward patients, especially those who are seriously ill? It is there, in the process of developing a reliable practice of respect, that consensus about how to improve the patient experience is most likely to be found.

Serious illnesses challenge patients, their families, clinicians, and the health systems that care for them. In this issue of the Journal of Hospital Medicine, Cowen and coauthors shed light on the experience of inpatients on medical and surgical services with a high risk of mortality on admission, as measured by Hospital Consumer Assessment of Healthcare Providers and Systems Surveys (HCAHPS).[1] In their study population, even after adjustment for some confounders, these patients tended to rate responsiveness of hospital staff and communication by doctors lower than patients with a low risk of mortality on admission.

A more generalizable frame than admission risk of mortality is to consider the patients they identified as high risk to be patients with serious illness. Using this frame will be helpful in understanding the implications of their results, but it is important to acknowledge that for several reasons, the data in this study may not represent the entire population of seriously ill patients. First, there may be patients at lower risk of mortality who would qualify as having a serious illness. Second, the study's data were from only a few hospitals in 1 healthcare system. Third, 93% of patients at high risk of mortality on admission did not return surveys. Despite these significant limitations, there are still important insights to be gleaned from their work.

Before exploring what they found, it is also important to note that it can be challenging to know what to make of HCAHPS scores. For instance, patients with higher HCAHPS scores have been found to have higher costs of care and higher mortality.[2] Satisfied patients are not clearly better off. However, what if, for purposes of learning, the scores serve as a window into the seriously ill patient's experience, helping inform an understanding of the challenges and opportunities for improvement?

One of the key findings of this study was that seriously ill patients rated responsiveness by hospital staff worse than those who were not as ill. Patients were asked 2 questions as part of the composite measure: During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?

It is not difficult to imagine how seriously ill patients might have more intense care needs that would result in more requests for help, nor is it difficult to imagine how some proportion of those requests might not be handled in a timely fashion. Objective research shows higher rates of call button requests have been associated with slower response times, and it appears there is a complex relationship with staffing levels and the intensity of work on the floor.[3] Certainly there may be times that patients want a quick response after pressing a call button, but do not need one, and a lot of time could be spent discussing these quandaries. However, there are also times when a patient describes having called for help, really needing it, yet no one came. At least some of the time, responsiveness is a matter of respect, especially considering the vulnerability of seriously ill patients and the issue of dignity around toileting.

Another key finding was about communication by doctors, and the questions patients answered were: During this hospital stay, how often did doctors treat you with courtesy and respect? During this hospital stay, how often did doctors listen carefully to you? During this hospital stay, how often did doctors explain things in a way you could understand?

There is a growing and important body of literature about communication with seriously ill patients.[4] Consider some of the data about patients with advanced cancer. Evidence suggests the majority of such patients want to know their prognosis, and that when it is discussed it does not worsen the patient‐physician relationship, sadness, or anxiety.[5] Despite this, among physicians who have formulated a prognosis for patients with advanced cancer, even if they were asked directly by those patients about their prognosis, 23% of the time they would communicate no prognosis. Forty percent of the time they would communicate a different prognosis than what they had formulated, with 70% of those being optimistically discrepant.[6] Although data are more limited, there is evidence that hospitalists are similarly wary to acknowledge when patients are at risk of dying.[7]

Although certainly other aspects of communication by doctors with seriously ill patients contributed to this study's findings, this issue of acknowledging and discussing the serious illness itself is important to highlight. Healthcare professionals have an ethical obligation to respect patients' autonomy by helping them make informed decisions about their care. Having these conversations can be challenging, but training programs and conversation guides are showing promise.[8] If health professionals do not try to ensure that seriously ill patients understand their diagnosis, prognosis, and full range of treatment options in patient‐centered ways, then by definition patients cannot be making informed decisions. It is a matter of respect.

This study's most important contribution is how it focuses attention on the domains of responsiveness by hospital staff and communication by doctors, encouraging a deeper dive to consider what else is known about these topics. Allowing that the lower scores from seriously ill patients might reflect more than just poor satisfaction reveals that at least some proportion of the time, these patients are experiencing disrespect. The work then becomes clear: What are the ways in which health professionals should reliably be demonstrating respect toward patients, especially those who are seriously ill? It is there, in the process of developing a reliable practice of respect, that consensus about how to improve the patient experience is most likely to be found.

Interhospital transfers (IHTs) to academic medical centers (AMCs) or their affiliated hospitals may benefit patients who require unique specialty and procedural services. However, IHTs also introduce a potentially risky transition of care for patients suffering from complex or unstable medical problems.[1] Components of this risk include the dangers associated with transportation and the disrupted continuity of care that may lead to delays or errors in care.[2, 3] Furthermore, referring and accepting providers may face barriers to optimal handoffs including a lack of shared communication standards and difficulty accessing external medical records.[3, 4, 5] Although some authors have recommended the creation of formal guidelines for interhospital transfer processes for all patients to mitigate the risks of transfer, the available guidelines governing the IHT triage and communication process are limited to critically ill patients.[6]

A recent study of a diverse patient and hospital dataset demonstrated that interhospital transfer patients have a higher risk of mortality, increased length of stay (LOS), and increased risk of adverse events as compared with non‐transfer patients.[7] However, it is unknown if these findings persist in the population of patients transferred specifically to AMCs or their affiliated hospitals (the combination is hereafter referred to as academic health systems [AHSs]). AMCs provide a disproportionate share of IHT care for complex patients and have a vested interest in improving the outcomes of these transitions.[8] Prior single‐center studies of acute care adult medical patients accepted to AMCs have shown that IHT is associated with a longer LOS, increased in‐hospital mortality, and higher resource use.[9, 10] However, it is difficult to generalize from single‐center studies due to the variation in referral practices, geography, and network characteristics. Additionally, AMC referral systems, patient mix, and utilization of hospitalists have likely changed substantially in the nearly 2 decades since those reports were published.

Hospitalists and general internists often manage the transfer acceptance processes for internal medicine services at receiving hospitals, helping to triage and coordinate care for IHT patients. As a result, it is important for hospitalists to understand the characteristics and outcomes of the IHT population. In addition to informing the decision making around transfer for a given patient, such an understanding is the foundation for helping providers and institutions begin to systematically identify and mitigate peritransfer risks.

We conducted this large multicenter study to describe the characteristics and outcomes of a current, nationally representative IHT patient population discharged by hospitalists and general internists at AHSs. To identify unique features of the IHT population, we compared patients transferred from another hospital to an AHS to those admitted to the AHS directly from the AHS's emergency department (ED). Based on our anecdotal experiences and the prior single‐center study findings in adult medical populations,[9, 10] we hypothesized that the IHT population would be sicker, stay in the hospital and intensive care unit (ICU) longer, and have higher costs and in‐hospital mortality than ED patients. Although there may be fundamental differences between the 2 groups related to disease and patient condition, we hypothesized that outcome differences would persist even after adjusting for patient factors such as demographics, disease‐specific risk of mortality, and ICU utilization.

PATIENTS AND METHODS

We conducted a retrospective cohort study using data from the University HealthSystem Consortium (UHC) Clinical Database and Resource Manager (CDB/RM). UHC is an alliance of 120 academic medical centers and 300 of their affiliated hospitals for the purposes of collaboration on performance improvement. Each year, a subset of participating hospitals submits data on all of their inpatient discharges to the CDB/RM, which totals approximately 5 million records. The CDB/RM includes information from billing forms including demographics, diagnoses, and procedures as captured by International Classification of Diseases, Ninth Revision (ICD‐9) codes, discharge disposition, and line item charge detail for the type of bed (eg, floor, ICU). Most hospitals also provide detailed charge information including pharmacy, imaging, blood products, lab tests, and supplies. Some hospitals do not provide any charge data. The Beth Israel Deaconess Medical Center and University of Washington institutional review boards reviewed and approved the conduct of this study.

We included all inpatients discharged by hospitalists or general internal medicine physicians from UHC hospitals between April 1, 2011 and March 31, 2012. We excluded minors, pregnant patients, and prisoners. One hundred fifty‐eight adult academic medical centers and affiliated hospitals submitted data throughout this time period. Our primary independent variable, IHT status, was defined by patients whose admission source was another acute care institution. ED admissions were defined as patients admitted from the AHS ED whose source of origination was not another hospital or ambulatory surgery site.

RESULTS

DISCUSSION

Our study of IHT patients ultimately discharged by hospitalists and general internists at US academic referral centers found significantly increased average LOS, costs, and in‐hospital mortality compared with patients admitted from the ED. The increased risk of mortality persisted after adjustment for patient characteristics and variables representing endogenous risk of mortality, and in more homogeneous subgroups after stratification by presence and timing of ICU utilization. These data confirm findings from single‐center studies and suggest that observations about the difference between IHT and ED populations may be generalizable across US academic hospitals.

Our work builds on 2 single‐center studies that examined mixed medical and surgical academic IHT populations from the late 1980s and early 1990s,[9, 10] and 1 studying surgical ICU patients in 2013.[17] These studies demonstrated longer average LOS, higher costs, and higher mortality rates (in both adjusted and unadjusted analyses). Our work confirmed these findings utilizing a more current, multicenter large dataset of IHT patients ultimately discharged by hospitalists and general internists. Our work is unique from a larger, more recent study[7] in that it focuses on patients transferred to academic health systems, and therefore has particular relevance to those settings. In addition, we divided patients into subpopulations based on the timing of ICU utilization, and found that in each of these populations, IHT remained independently associated with in‐hospital mortality.

Our analysis does not explain why the outcomes of IHTs are worse, but plausible contributing factors include that (1) patients chosen for IHT are at higher risk of death in ways uncaptured by established mortality risk scores, (2) referring, transferring, or accepting providers and institutions have provided inadequate care, (3) the transfer process itself involves harm, (4) socioeconomic bias in selection for IHT,[18] or (5) some combination of the above. Regardless of the causes of the worse outcomes observed in these outside‐hospital transfers, as these patients are colloquially known at accepting hospitals, they present challenges to everyone involved. Referring providers may feel a sense of urgency as these patients' needs exceed their management capabilities. The process is often time consuming and burdensome for referring and accepting providers because of poorly developed systems.[19] The transfer often takes patients further from their home and may make it more difficult for family to participate in their care. The transfer may delay care if the accepting institution cannot immediately accept the patient or if the time in transport is prolonged, which could result in decompensation at a critical juncture. For providers inheriting such patients, the stress of caring for these patients is compounded by the difficulty obtaining records about the prior hospitalization.[20] This frustrating experience is often translated into unfounded judgment of the institution that referred the patient and the care provided there.[21] It is important for hospitalists making decisions throughout the transfer process and for hospital leaders who determine staffing levels, measure the quality of care, manage hospital networks, or write hospital policy to appreciate that the transfer process itself may contribute to the challenges and poor outcomes we observe. Furthermore, regardless of the cause for the increased mortality that we observed, our findings imply that IHT patients require careful evaluation, management, and treatment.

Many accepting institutions have transfer centers that facilitate these transitions, utilizing protocols and templates to standardize the process.[22, 23] Future research should focus on the characteristics of these centers to learn which practices are most efficacious. Interventions to mitigate the known challenges of transfer (including patient selection and triage, handoff communication, and information sharing) could be tested by randomized studies at referring and accepting institutions. There may be a role for health information exchange or the development of enhanced pretransfer evaluation processes using telemedicine models; there is evidence that information sharing may reduce redundant imaging.[24] Perhaps targeted review of IHTs admitted to a non‐ICU portion of the hospital and subsequently transferred to the ICU could identify opportunities to improve triaging protocols and thus avert some of the bad outcomes observed in this subpopulation. A related future direction could be to create protected forumsusing the patient safety organization framework[25]to facilitate the discussion of interhospital transfer outcomes among the referring, transporting, and receiving parties. Lastly, future work should investigate the reasons for the different proportions of black patients in the ED versus IHT cohorts. Our finding that black race was associated with lower risk of mortality has been previously reported but may also benefit from more investigation.[26]

There are several limitations of our work. First, despite extensive adjustment for patient characteristics, due to the observational nature of our study it is still possible that IHTs differ from ED admissions in ways that were unaccounted for in our analysis, and which could be associated with increased mortality independent of the transfer process itself. We are unable to characterize features of the transfer process, such as the reason for transfer, differences in transfer processes among hospitals, or the distance and mode of travel, which may influence outcomes.[27] Because we used administrative data, variations in coding could incorrectly estimate the complexity or severity of illness on admission, which is a previously described risk.[28] In addition, although our dataset was very large, it was limited by incomplete charge data, which limited our ability to measure ICU utilization in our full cohort. The hospitals missing ICU charge data are of variable sizes and are distributed around the country, limiting the chance of systematic bias. Finally, in some settings, hospitalists may serve as the discharging physician for patients admitted to other services such as the ICU, introducing heterogeneity and bias to the sample. We attempted to mitigate such bias through our subgroup analysis, which allowed for comparisons within more homogeneous patient groupings.

In conclusion, our large multicenter study of academic health systems confirms the findings of prior single‐center academic studies and a large general population study that interhospital transfer patients have an increased average LOS, costs, and adjusted in‐hospital mortality than patients admitted from the ED. This difference in mortality persisted even after controlling for several other predictors of mortality. Our findings emphasize the need for future studies designed to clarify the reason for the increased risk and identify targets for interventions to improve outcomes for the interhospital transfer population.

Interhospital transfers (IHTs) to academic medical centers (AMCs) or their affiliated hospitals may benefit patients who require unique specialty and procedural services. However, IHTs also introduce a potentially risky transition of care for patients suffering from complex or unstable medical problems.[1] Components of this risk include the dangers associated with transportation and the disrupted continuity of care that may lead to delays or errors in care.[2, 3] Furthermore, referring and accepting providers may face barriers to optimal handoffs including a lack of shared communication standards and difficulty accessing external medical records.[3, 4, 5] Although some authors have recommended the creation of formal guidelines for interhospital transfer processes for all patients to mitigate the risks of transfer, the available guidelines governing the IHT triage and communication process are limited to critically ill patients.[6]

A recent study of a diverse patient and hospital dataset demonstrated that interhospital transfer patients have a higher risk of mortality, increased length of stay (LOS), and increased risk of adverse events as compared with non‐transfer patients.[7] However, it is unknown if these findings persist in the population of patients transferred specifically to AMCs or their affiliated hospitals (the combination is hereafter referred to as academic health systems [AHSs]). AMCs provide a disproportionate share of IHT care for complex patients and have a vested interest in improving the outcomes of these transitions.[8] Prior single‐center studies of acute care adult medical patients accepted to AMCs have shown that IHT is associated with a longer LOS, increased in‐hospital mortality, and higher resource use.[9, 10] However, it is difficult to generalize from single‐center studies due to the variation in referral practices, geography, and network characteristics. Additionally, AMC referral systems, patient mix, and utilization of hospitalists have likely changed substantially in the nearly 2 decades since those reports were published.

Hospitalists and general internists often manage the transfer acceptance processes for internal medicine services at receiving hospitals, helping to triage and coordinate care for IHT patients. As a result, it is important for hospitalists to understand the characteristics and outcomes of the IHT population. In addition to informing the decision making around transfer for a given patient, such an understanding is the foundation for helping providers and institutions begin to systematically identify and mitigate peritransfer risks.

We conducted this large multicenter study to describe the characteristics and outcomes of a current, nationally representative IHT patient population discharged by hospitalists and general internists at AHSs. To identify unique features of the IHT population, we compared patients transferred from another hospital to an AHS to those admitted to the AHS directly from the AHS's emergency department (ED). Based on our anecdotal experiences and the prior single‐center study findings in adult medical populations,[9, 10] we hypothesized that the IHT population would be sicker, stay in the hospital and intensive care unit (ICU) longer, and have higher costs and in‐hospital mortality than ED patients. Although there may be fundamental differences between the 2 groups related to disease and patient condition, we hypothesized that outcome differences would persist even after adjusting for patient factors such as demographics, disease‐specific risk of mortality, and ICU utilization.

PATIENTS AND METHODS

We conducted a retrospective cohort study using data from the University HealthSystem Consortium (UHC) Clinical Database and Resource Manager (CDB/RM). UHC is an alliance of 120 academic medical centers and 300 of their affiliated hospitals for the purposes of collaboration on performance improvement. Each year, a subset of participating hospitals submits data on all of their inpatient discharges to the CDB/RM, which totals approximately 5 million records. The CDB/RM includes information from billing forms including demographics, diagnoses, and procedures as captured by International Classification of Diseases, Ninth Revision (ICD‐9) codes, discharge disposition, and line item charge detail for the type of bed (eg, floor, ICU). Most hospitals also provide detailed charge information including pharmacy, imaging, blood products, lab tests, and supplies. Some hospitals do not provide any charge data. The Beth Israel Deaconess Medical Center and University of Washington institutional review boards reviewed and approved the conduct of this study.

We included all inpatients discharged by hospitalists or general internal medicine physicians from UHC hospitals between April 1, 2011 and March 31, 2012. We excluded minors, pregnant patients, and prisoners. One hundred fifty‐eight adult academic medical centers and affiliated hospitals submitted data throughout this time period. Our primary independent variable, IHT status, was defined by patients whose admission source was another acute care institution. ED admissions were defined as patients admitted from the AHS ED whose source of origination was not another hospital or ambulatory surgery site.

RESULTS

DISCUSSION

Our study of IHT patients ultimately discharged by hospitalists and general internists at US academic referral centers found significantly increased average LOS, costs, and in‐hospital mortality compared with patients admitted from the ED. The increased risk of mortality persisted after adjustment for patient characteristics and variables representing endogenous risk of mortality, and in more homogeneous subgroups after stratification by presence and timing of ICU utilization. These data confirm findings from single‐center studies and suggest that observations about the difference between IHT and ED populations may be generalizable across US academic hospitals.

Our work builds on 2 single‐center studies that examined mixed medical and surgical academic IHT populations from the late 1980s and early 1990s,[9, 10] and 1 studying surgical ICU patients in 2013.[17] These studies demonstrated longer average LOS, higher costs, and higher mortality rates (in both adjusted and unadjusted analyses). Our work confirmed these findings utilizing a more current, multicenter large dataset of IHT patients ultimately discharged by hospitalists and general internists. Our work is unique from a larger, more recent study[7] in that it focuses on patients transferred to academic health systems, and therefore has particular relevance to those settings. In addition, we divided patients into subpopulations based on the timing of ICU utilization, and found that in each of these populations, IHT remained independently associated with in‐hospital mortality.

Our analysis does not explain why the outcomes of IHTs are worse, but plausible contributing factors include that (1) patients chosen for IHT are at higher risk of death in ways uncaptured by established mortality risk scores, (2) referring, transferring, or accepting providers and institutions have provided inadequate care, (3) the transfer process itself involves harm, (4) socioeconomic bias in selection for IHT,[18] or (5) some combination of the above. Regardless of the causes of the worse outcomes observed in these outside‐hospital transfers, as these patients are colloquially known at accepting hospitals, they present challenges to everyone involved. Referring providers may feel a sense of urgency as these patients' needs exceed their management capabilities. The process is often time consuming and burdensome for referring and accepting providers because of poorly developed systems.[19] The transfer often takes patients further from their home and may make it more difficult for family to participate in their care. The transfer may delay care if the accepting institution cannot immediately accept the patient or if the time in transport is prolonged, which could result in decompensation at a critical juncture. For providers inheriting such patients, the stress of caring for these patients is compounded by the difficulty obtaining records about the prior hospitalization.[20] This frustrating experience is often translated into unfounded judgment of the institution that referred the patient and the care provided there.[21] It is important for hospitalists making decisions throughout the transfer process and for hospital leaders who determine staffing levels, measure the quality of care, manage hospital networks, or write hospital policy to appreciate that the transfer process itself may contribute to the challenges and poor outcomes we observe. Furthermore, regardless of the cause for the increased mortality that we observed, our findings imply that IHT patients require careful evaluation, management, and treatment.

Many accepting institutions have transfer centers that facilitate these transitions, utilizing protocols and templates to standardize the process.[22, 23] Future research should focus on the characteristics of these centers to learn which practices are most efficacious. Interventions to mitigate the known challenges of transfer (including patient selection and triage, handoff communication, and information sharing) could be tested by randomized studies at referring and accepting institutions. There may be a role for health information exchange or the development of enhanced pretransfer evaluation processes using telemedicine models; there is evidence that information sharing may reduce redundant imaging.[24] Perhaps targeted review of IHTs admitted to a non‐ICU portion of the hospital and subsequently transferred to the ICU could identify opportunities to improve triaging protocols and thus avert some of the bad outcomes observed in this subpopulation. A related future direction could be to create protected forumsusing the patient safety organization framework[25]to facilitate the discussion of interhospital transfer outcomes among the referring, transporting, and receiving parties. Lastly, future work should investigate the reasons for the different proportions of black patients in the ED versus IHT cohorts. Our finding that black race was associated with lower risk of mortality has been previously reported but may also benefit from more investigation.[26]

There are several limitations of our work. First, despite extensive adjustment for patient characteristics, due to the observational nature of our study it is still possible that IHTs differ from ED admissions in ways that were unaccounted for in our analysis, and which could be associated with increased mortality independent of the transfer process itself. We are unable to characterize features of the transfer process, such as the reason for transfer, differences in transfer processes among hospitals, or the distance and mode of travel, which may influence outcomes.[27] Because we used administrative data, variations in coding could incorrectly estimate the complexity or severity of illness on admission, which is a previously described risk.[28] In addition, although our dataset was very large, it was limited by incomplete charge data, which limited our ability to measure ICU utilization in our full cohort. The hospitals missing ICU charge data are of variable sizes and are distributed around the country, limiting the chance of systematic bias. Finally, in some settings, hospitalists may serve as the discharging physician for patients admitted to other services such as the ICU, introducing heterogeneity and bias to the sample. We attempted to mitigate such bias through our subgroup analysis, which allowed for comparisons within more homogeneous patient groupings.

In conclusion, our large multicenter study of academic health systems confirms the findings of prior single‐center academic studies and a large general population study that interhospital transfer patients have an increased average LOS, costs, and adjusted in‐hospital mortality than patients admitted from the ED. This difference in mortality persisted even after controlling for several other predictors of mortality. Our findings emphasize the need for future studies designed to clarify the reason for the increased risk and identify targets for interventions to improve outcomes for the interhospital transfer population.

Interhospital transfers (IHTs) to academic medical centers (AMCs) or their affiliated hospitals may benefit patients who require unique specialty and procedural services. However, IHTs also introduce a potentially risky transition of care for patients suffering from complex or unstable medical problems.[1] Components of this risk include the dangers associated with transportation and the disrupted continuity of care that may lead to delays or errors in care.[2, 3] Furthermore, referring and accepting providers may face barriers to optimal handoffs including a lack of shared communication standards and difficulty accessing external medical records.[3, 4, 5] Although some authors have recommended the creation of formal guidelines for interhospital transfer processes for all patients to mitigate the risks of transfer, the available guidelines governing the IHT triage and communication process are limited to critically ill patients.[6]

A recent study of a diverse patient and hospital dataset demonstrated that interhospital transfer patients have a higher risk of mortality, increased length of stay (LOS), and increased risk of adverse events as compared with non‐transfer patients.[7] However, it is unknown if these findings persist in the population of patients transferred specifically to AMCs or their affiliated hospitals (the combination is hereafter referred to as academic health systems [AHSs]). AMCs provide a disproportionate share of IHT care for complex patients and have a vested interest in improving the outcomes of these transitions.[8] Prior single‐center studies of acute care adult medical patients accepted to AMCs have shown that IHT is associated with a longer LOS, increased in‐hospital mortality, and higher resource use.[9, 10] However, it is difficult to generalize from single‐center studies due to the variation in referral practices, geography, and network characteristics. Additionally, AMC referral systems, patient mix, and utilization of hospitalists have likely changed substantially in the nearly 2 decades since those reports were published.

Hospitalists and general internists often manage the transfer acceptance processes for internal medicine services at receiving hospitals, helping to triage and coordinate care for IHT patients. As a result, it is important for hospitalists to understand the characteristics and outcomes of the IHT population. In addition to informing the decision making around transfer for a given patient, such an understanding is the foundation for helping providers and institutions begin to systematically identify and mitigate peritransfer risks.

We conducted this large multicenter study to describe the characteristics and outcomes of a current, nationally representative IHT patient population discharged by hospitalists and general internists at AHSs. To identify unique features of the IHT population, we compared patients transferred from another hospital to an AHS to those admitted to the AHS directly from the AHS's emergency department (ED). Based on our anecdotal experiences and the prior single‐center study findings in adult medical populations,[9, 10] we hypothesized that the IHT population would be sicker, stay in the hospital and intensive care unit (ICU) longer, and have higher costs and in‐hospital mortality than ED patients. Although there may be fundamental differences between the 2 groups related to disease and patient condition, we hypothesized that outcome differences would persist even after adjusting for patient factors such as demographics, disease‐specific risk of mortality, and ICU utilization.

PATIENTS AND METHODS

We conducted a retrospective cohort study using data from the University HealthSystem Consortium (UHC) Clinical Database and Resource Manager (CDB/RM). UHC is an alliance of 120 academic medical centers and 300 of their affiliated hospitals for the purposes of collaboration on performance improvement. Each year, a subset of participating hospitals submits data on all of their inpatient discharges to the CDB/RM, which totals approximately 5 million records. The CDB/RM includes information from billing forms including demographics, diagnoses, and procedures as captured by International Classification of Diseases, Ninth Revision (ICD‐9) codes, discharge disposition, and line item charge detail for the type of bed (eg, floor, ICU). Most hospitals also provide detailed charge information including pharmacy, imaging, blood products, lab tests, and supplies. Some hospitals do not provide any charge data. The Beth Israel Deaconess Medical Center and University of Washington institutional review boards reviewed and approved the conduct of this study.

We included all inpatients discharged by hospitalists or general internal medicine physicians from UHC hospitals between April 1, 2011 and March 31, 2012. We excluded minors, pregnant patients, and prisoners. One hundred fifty‐eight adult academic medical centers and affiliated hospitals submitted data throughout this time period. Our primary independent variable, IHT status, was defined by patients whose admission source was another acute care institution. ED admissions were defined as patients admitted from the AHS ED whose source of origination was not another hospital or ambulatory surgery site.

RESULTS

DISCUSSION

Our study of IHT patients ultimately discharged by hospitalists and general internists at US academic referral centers found significantly increased average LOS, costs, and in‐hospital mortality compared with patients admitted from the ED. The increased risk of mortality persisted after adjustment for patient characteristics and variables representing endogenous risk of mortality, and in more homogeneous subgroups after stratification by presence and timing of ICU utilization. These data confirm findings from single‐center studies and suggest that observations about the difference between IHT and ED populations may be generalizable across US academic hospitals.

Our work builds on 2 single‐center studies that examined mixed medical and surgical academic IHT populations from the late 1980s and early 1990s,[9, 10] and 1 studying surgical ICU patients in 2013.[17] These studies demonstrated longer average LOS, higher costs, and higher mortality rates (in both adjusted and unadjusted analyses). Our work confirmed these findings utilizing a more current, multicenter large dataset of IHT patients ultimately discharged by hospitalists and general internists. Our work is unique from a larger, more recent study[7] in that it focuses on patients transferred to academic health systems, and therefore has particular relevance to those settings. In addition, we divided patients into subpopulations based on the timing of ICU utilization, and found that in each of these populations, IHT remained independently associated with in‐hospital mortality.

Our analysis does not explain why the outcomes of IHTs are worse, but plausible contributing factors include that (1) patients chosen for IHT are at higher risk of death in ways uncaptured by established mortality risk scores, (2) referring, transferring, or accepting providers and institutions have provided inadequate care, (3) the transfer process itself involves harm, (4) socioeconomic bias in selection for IHT,[18] or (5) some combination of the above. Regardless of the causes of the worse outcomes observed in these outside‐hospital transfers, as these patients are colloquially known at accepting hospitals, they present challenges to everyone involved. Referring providers may feel a sense of urgency as these patients' needs exceed their management capabilities. The process is often time consuming and burdensome for referring and accepting providers because of poorly developed systems.[19] The transfer often takes patients further from their home and may make it more difficult for family to participate in their care. The transfer may delay care if the accepting institution cannot immediately accept the patient or if the time in transport is prolonged, which could result in decompensation at a critical juncture. For providers inheriting such patients, the stress of caring for these patients is compounded by the difficulty obtaining records about the prior hospitalization.[20] This frustrating experience is often translated into unfounded judgment of the institution that referred the patient and the care provided there.[21] It is important for hospitalists making decisions throughout the transfer process and for hospital leaders who determine staffing levels, measure the quality of care, manage hospital networks, or write hospital policy to appreciate that the transfer process itself may contribute to the challenges and poor outcomes we observe. Furthermore, regardless of the cause for the increased mortality that we observed, our findings imply that IHT patients require careful evaluation, management, and treatment.

Many accepting institutions have transfer centers that facilitate these transitions, utilizing protocols and templates to standardize the process.[22, 23] Future research should focus on the characteristics of these centers to learn which practices are most efficacious. Interventions to mitigate the known challenges of transfer (including patient selection and triage, handoff communication, and information sharing) could be tested by randomized studies at referring and accepting institutions. There may be a role for health information exchange or the development of enhanced pretransfer evaluation processes using telemedicine models; there is evidence that information sharing may reduce redundant imaging.[24] Perhaps targeted review of IHTs admitted to a non‐ICU portion of the hospital and subsequently transferred to the ICU could identify opportunities to improve triaging protocols and thus avert some of the bad outcomes observed in this subpopulation. A related future direction could be to create protected forumsusing the patient safety organization framework[25]to facilitate the discussion of interhospital transfer outcomes among the referring, transporting, and receiving parties. Lastly, future work should investigate the reasons for the different proportions of black patients in the ED versus IHT cohorts. Our finding that black race was associated with lower risk of mortality has been previously reported but may also benefit from more investigation.[26]

There are several limitations of our work. First, despite extensive adjustment for patient characteristics, due to the observational nature of our study it is still possible that IHTs differ from ED admissions in ways that were unaccounted for in our analysis, and which could be associated with increased mortality independent of the transfer process itself. We are unable to characterize features of the transfer process, such as the reason for transfer, differences in transfer processes among hospitals, or the distance and mode of travel, which may influence outcomes.[27] Because we used administrative data, variations in coding could incorrectly estimate the complexity or severity of illness on admission, which is a previously described risk.[28] In addition, although our dataset was very large, it was limited by incomplete charge data, which limited our ability to measure ICU utilization in our full cohort. The hospitals missing ICU charge data are of variable sizes and are distributed around the country, limiting the chance of systematic bias. Finally, in some settings, hospitalists may serve as the discharging physician for patients admitted to other services such as the ICU, introducing heterogeneity and bias to the sample. We attempted to mitigate such bias through our subgroup analysis, which allowed for comparisons within more homogeneous patient groupings.

In conclusion, our large multicenter study of academic health systems confirms the findings of prior single‐center academic studies and a large general population study that interhospital transfer patients have an increased average LOS, costs, and adjusted in‐hospital mortality than patients admitted from the ED. This difference in mortality persisted even after controlling for several other predictors of mortality. Our findings emphasize the need for future studies designed to clarify the reason for the increased risk and identify targets for interventions to improve outcomes for the interhospital transfer population.