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.

Every year in the United States, approximately 4.7 million cancer‐related hospitalizations and 1.2 million hospital discharges with cancer as the principal diagnosis occur.[1] Limited evidence suggests that hospitalization of the cancer patient is associated with increased morbidity and mortality[2]; average length of survival of patients with advanced cancer after unplanned hospitalization is 3 to 5 months.[3] Furthermore, hospitalization of the cancer patient presents unique challenges in goals of care discussions and patient preferences. Given the high burden of cancer‐related hospitalization and limited survival in patients with advanced cancer, we must consider how hospitalists provide care for these patients. In this article, we describe the Hospital Medicine Service at Memorial Sloan Kettering Cancer Center (MSKCC) and use a hypothetical illustrative case (italicized) to provide a guide for inpatient care of the medical patient with advanced cancer while reviewing the current literature.

CLINICAL EXAMPLE

Mrs. A is a 70‐year‐old woman with recently diagnosed unresectable pancreatic adenocarcinoma, currently undergoing palliative chemotherapy with gemcitabine, who is admitted to the hospital with progressive early satiety, nausea, and increased abdominal girth. She attributes these symptoms to side effects of chemotherapy and presented to the emergency room when she developed intractable nausea and vomiting. How should her acute symptoms be evaluated and addressed? What is the hospitalist's role in her long‐term oncologic care? Is Mrs. A aware that her symptoms may be due to progression of disease rather than chemotherapy side effects? What is the best way to deliver information to Mrs. A? Who else should be involved in her care? What are her options upon discharge from the hospital?

HOSPITAL MEDICINE AT MSKCC

The Hospital Medicine Service at MSKCC consists of 7 full‐time academic hospitalists who attend on the gastrointestinal oncology, lymphoma, and general medicine inpatient services, as well as a larger number of nocturnists who work exclusively at night. In addition to being board certification in internal medicine, 1 member is board certified in medical oncology and 4 members are board certified in hospice and palliative medicine. In a recent article, we describe our experience with patients on our inpatient gastrointestinal oncology service; patients with pancreatic cancer accounted for a quarter of all inpatient admissions, and 90% of all patients had been diagnosed with metastatic disease.[4]

HOSPITALIZATION OF THE PATIENT WITH ADVANCED CANCER AND ROLE OF THE HOSPITALIST

Hospitalization of the patient with advanced cancer leads to an intense examination of health status in the face of terminal illness and an opportunity to explore patient preferences and define goals of care. It is a unique opportunity whereby hospitalists, serving as the primary inpatient physician for these patients, can encourage critical analysis of health and stimulate conversations about care. Hospitalization is a time of intense scrutiny and can reveal previously unknown medical, social, cultural, psychological, and spiritual concerns that often declare themselves in acute illness.[2, 3]

Care requires consideration not only of the malignancy and its complications, but also comorbidities that affect quality of life in terminal illness. Coordinating care in the hospitalized patient with advanced cancer is paramount; hospitalists are experts in hospital‐based care processes and can efficiently organize care between a patient's oncologist, consultants, nursing staff, social work, and case management. Coordination of care may possibly shorten length of stay, improve efficiency, and improve patient satisfaction. As hospitalists at a major cancer center, our experience has informed us of many issues involving care of these patients. Therefore, we offer the following guidelines.

PRACTICAL GUIDELINES FOR COORDINATING CARE IN HOSPITALIZED PATIENTS WITH ADVANCED CANCER

CONCLUSIONS

Although this article provides a guide based on our experience and review of the literature, there are several potential areas of further investigation for hospitalists caring for patients with advanced cancer. Research areas including examining the impact of hospitalist versus oncologist inpatient care on length of stay, readmissions, resource utilization, patient satisfaction, and outcomes for patients with a broad array of cancer diagnosis remains to be delineated. Issues involving patient‐physician communication are also of interest to assess patients' preferences in the communication of bad news by hospitalists versus primary oncologists. The role of hospitalists as providers of primary palliative care in the inpatient setting and the impact on outcomes also warrants further investigation. Finally, the effects of formal use of guides such as the one proposed deserve further attention.

The care of the hospitalized patient with advanced cancer can be extremely gratifying, although the challenges are significant. An organized approach to maximizing opportunities, improving quality, and enhancing patient well‐being has been outlined in this article. Because patients with advanced cancer have complicated medical, surgical, nursing, spiritual, and social needs, the hospitalist‐led multidisciplinary team is very well suited for this population.

Every year in the United States, approximately 4.7 million cancer‐related hospitalizations and 1.2 million hospital discharges with cancer as the principal diagnosis occur.[1] Limited evidence suggests that hospitalization of the cancer patient is associated with increased morbidity and mortality[2]; average length of survival of patients with advanced cancer after unplanned hospitalization is 3 to 5 months.[3] Furthermore, hospitalization of the cancer patient presents unique challenges in goals of care discussions and patient preferences. Given the high burden of cancer‐related hospitalization and limited survival in patients with advanced cancer, we must consider how hospitalists provide care for these patients. In this article, we describe the Hospital Medicine Service at Memorial Sloan Kettering Cancer Center (MSKCC) and use a hypothetical illustrative case (italicized) to provide a guide for inpatient care of the medical patient with advanced cancer while reviewing the current literature.

CLINICAL EXAMPLE

Mrs. A is a 70‐year‐old woman with recently diagnosed unresectable pancreatic adenocarcinoma, currently undergoing palliative chemotherapy with gemcitabine, who is admitted to the hospital with progressive early satiety, nausea, and increased abdominal girth. She attributes these symptoms to side effects of chemotherapy and presented to the emergency room when she developed intractable nausea and vomiting. How should her acute symptoms be evaluated and addressed? What is the hospitalist's role in her long‐term oncologic care? Is Mrs. A aware that her symptoms may be due to progression of disease rather than chemotherapy side effects? What is the best way to deliver information to Mrs. A? Who else should be involved in her care? What are her options upon discharge from the hospital?

HOSPITAL MEDICINE AT MSKCC

The Hospital Medicine Service at MSKCC consists of 7 full‐time academic hospitalists who attend on the gastrointestinal oncology, lymphoma, and general medicine inpatient services, as well as a larger number of nocturnists who work exclusively at night. In addition to being board certification in internal medicine, 1 member is board certified in medical oncology and 4 members are board certified in hospice and palliative medicine. In a recent article, we describe our experience with patients on our inpatient gastrointestinal oncology service; patients with pancreatic cancer accounted for a quarter of all inpatient admissions, and 90% of all patients had been diagnosed with metastatic disease.[4]

HOSPITALIZATION OF THE PATIENT WITH ADVANCED CANCER AND ROLE OF THE HOSPITALIST

Hospitalization of the patient with advanced cancer leads to an intense examination of health status in the face of terminal illness and an opportunity to explore patient preferences and define goals of care. It is a unique opportunity whereby hospitalists, serving as the primary inpatient physician for these patients, can encourage critical analysis of health and stimulate conversations about care. Hospitalization is a time of intense scrutiny and can reveal previously unknown medical, social, cultural, psychological, and spiritual concerns that often declare themselves in acute illness.[2, 3]

Care requires consideration not only of the malignancy and its complications, but also comorbidities that affect quality of life in terminal illness. Coordinating care in the hospitalized patient with advanced cancer is paramount; hospitalists are experts in hospital‐based care processes and can efficiently organize care between a patient's oncologist, consultants, nursing staff, social work, and case management. Coordination of care may possibly shorten length of stay, improve efficiency, and improve patient satisfaction. As hospitalists at a major cancer center, our experience has informed us of many issues involving care of these patients. Therefore, we offer the following guidelines.

PRACTICAL GUIDELINES FOR COORDINATING CARE IN HOSPITALIZED PATIENTS WITH ADVANCED CANCER

CONCLUSIONS

Although this article provides a guide based on our experience and review of the literature, there are several potential areas of further investigation for hospitalists caring for patients with advanced cancer. Research areas including examining the impact of hospitalist versus oncologist inpatient care on length of stay, readmissions, resource utilization, patient satisfaction, and outcomes for patients with a broad array of cancer diagnosis remains to be delineated. Issues involving patient‐physician communication are also of interest to assess patients' preferences in the communication of bad news by hospitalists versus primary oncologists. The role of hospitalists as providers of primary palliative care in the inpatient setting and the impact on outcomes also warrants further investigation. Finally, the effects of formal use of guides such as the one proposed deserve further attention.

The care of the hospitalized patient with advanced cancer can be extremely gratifying, although the challenges are significant. An organized approach to maximizing opportunities, improving quality, and enhancing patient well‐being has been outlined in this article. Because patients with advanced cancer have complicated medical, surgical, nursing, spiritual, and social needs, the hospitalist‐led multidisciplinary team is very well suited for this population.

Every year in the United States, approximately 4.7 million cancer‐related hospitalizations and 1.2 million hospital discharges with cancer as the principal diagnosis occur.[1] Limited evidence suggests that hospitalization of the cancer patient is associated with increased morbidity and mortality[2]; average length of survival of patients with advanced cancer after unplanned hospitalization is 3 to 5 months.[3] Furthermore, hospitalization of the cancer patient presents unique challenges in goals of care discussions and patient preferences. Given the high burden of cancer‐related hospitalization and limited survival in patients with advanced cancer, we must consider how hospitalists provide care for these patients. In this article, we describe the Hospital Medicine Service at Memorial Sloan Kettering Cancer Center (MSKCC) and use a hypothetical illustrative case (italicized) to provide a guide for inpatient care of the medical patient with advanced cancer while reviewing the current literature.

CLINICAL EXAMPLE

Mrs. A is a 70‐year‐old woman with recently diagnosed unresectable pancreatic adenocarcinoma, currently undergoing palliative chemotherapy with gemcitabine, who is admitted to the hospital with progressive early satiety, nausea, and increased abdominal girth. She attributes these symptoms to side effects of chemotherapy and presented to the emergency room when she developed intractable nausea and vomiting. How should her acute symptoms be evaluated and addressed? What is the hospitalist's role in her long‐term oncologic care? Is Mrs. A aware that her symptoms may be due to progression of disease rather than chemotherapy side effects? What is the best way to deliver information to Mrs. A? Who else should be involved in her care? What are her options upon discharge from the hospital?

HOSPITAL MEDICINE AT MSKCC

The Hospital Medicine Service at MSKCC consists of 7 full‐time academic hospitalists who attend on the gastrointestinal oncology, lymphoma, and general medicine inpatient services, as well as a larger number of nocturnists who work exclusively at night. In addition to being board certification in internal medicine, 1 member is board certified in medical oncology and 4 members are board certified in hospice and palliative medicine. In a recent article, we describe our experience with patients on our inpatient gastrointestinal oncology service; patients with pancreatic cancer accounted for a quarter of all inpatient admissions, and 90% of all patients had been diagnosed with metastatic disease.[4]

HOSPITALIZATION OF THE PATIENT WITH ADVANCED CANCER AND ROLE OF THE HOSPITALIST

Hospitalization of the patient with advanced cancer leads to an intense examination of health status in the face of terminal illness and an opportunity to explore patient preferences and define goals of care. It is a unique opportunity whereby hospitalists, serving as the primary inpatient physician for these patients, can encourage critical analysis of health and stimulate conversations about care. Hospitalization is a time of intense scrutiny and can reveal previously unknown medical, social, cultural, psychological, and spiritual concerns that often declare themselves in acute illness.[2, 3]

Care requires consideration not only of the malignancy and its complications, but also comorbidities that affect quality of life in terminal illness. Coordinating care in the hospitalized patient with advanced cancer is paramount; hospitalists are experts in hospital‐based care processes and can efficiently organize care between a patient's oncologist, consultants, nursing staff, social work, and case management. Coordination of care may possibly shorten length of stay, improve efficiency, and improve patient satisfaction. As hospitalists at a major cancer center, our experience has informed us of many issues involving care of these patients. Therefore, we offer the following guidelines.

PRACTICAL GUIDELINES FOR COORDINATING CARE IN HOSPITALIZED PATIENTS WITH ADVANCED CANCER

CONCLUSIONS

Although this article provides a guide based on our experience and review of the literature, there are several potential areas of further investigation for hospitalists caring for patients with advanced cancer. Research areas including examining the impact of hospitalist versus oncologist inpatient care on length of stay, readmissions, resource utilization, patient satisfaction, and outcomes for patients with a broad array of cancer diagnosis remains to be delineated. Issues involving patient‐physician communication are also of interest to assess patients' preferences in the communication of bad news by hospitalists versus primary oncologists. The role of hospitalists as providers of primary palliative care in the inpatient setting and the impact on outcomes also warrants further investigation. Finally, the effects of formal use of guides such as the one proposed deserve further attention.

The care of the hospitalized patient with advanced cancer can be extremely gratifying, although the challenges are significant. An organized approach to maximizing opportunities, improving quality, and enhancing patient well‐being has been outlined in this article. Because patients with advanced cancer have complicated medical, surgical, nursing, spiritual, and social needs, the hospitalist‐led multidisciplinary team is very well suited for this population.

Increasing use of emergency departments (EDs) throughout the United States has become a focus of national healthcare policy and reform efforts. ED growth continues to outpace population growth, with the Institute of Medicine describing our ED systems as fragmented, overburdened, and at the breaking point.[1] Associations between ED crowding and patient dissatisfaction, delays in treatment, medical errors, and patient mortality speak to the urgency of systems improvements.[2] One major factor contributing to ED volumes is the growing number of hospital admissions that begin in EDs. From 1993 to 2006, the proportion of hospitalizations originating in EDs increased from 33.5% to 43.8%, with more than 17 million hospital admissions originating in EDs annually.[3, 4] Despite these challenges, discussions about alternative approaches to hospital admission remain at the periphery of healthcare policy conversations.

Direct admission to the hospital, defined as hospitalization without first receiving care in the hospital's ED, is an alternative approach to hospital admission, and may be a vehicle to both observation and inpatient hospital stays. Direct admissions account for 25% of all nonelective pediatric hospitalizations and 15% of nonelective adult hospitalizations in the United States.[5, 6] This admission approach was considerably more common in the past, facilitated by primary care providers (PCPs) or specialists who provided both outpatient and hospital‐based care for their patients.[4] However, as the number of hospitalists in the United States has grown over the last 30 years, the number of direct admissions has decreased concurrently. In fact, from 2003 to 2009, the number of direct admissions from clinics and physicians' offices decreased by a total of 1.6 million.[4] Although this decline is undoubtedly multifactorial, hospitalists may have contributed, both deliberately and inadvertently, to the shifting epidemiology of hospital admissions. Although many factors influence the source of hospital admissions and admission processes, direct admission has 2 important prerequisites: patients require timely access to outpatient providers for acute care, and hospitals, in partnership with outpatient‐based clinics and practices, require systems to safely and efficiently facilitate admissions without ED involvement. However, we know little about hospital admission systems, developed in the era of hospital medicine, to facilitate admissions independent of the ED.

Direct admission offers a number of potential benefits for both patients and healthcare delivery systems including reductions in the number of sites and providers of care, improved communication and coordination between outpatient and hospital‐based healthcare providers, greater patient and referring physician satisfaction, and reduced ED volumes and subsequent costs.[7] However, there are also risks and potential harms associated with direct admission, including potential delays in initial evaluation and management, inconsistent admission processes, and difficulties determining direct admission appropriateness, all of which could adversely impact patient safety and quality of care.[7, 8, 9] One study of adults with sepsis found that direct admission was associated with increased mortality compared to ED admission, which the authors speculated to be related to less timely care.[9] Similarly, a study of unscheduled adult hospitalizations found that patients admitted directly had higher mortality for time‐sensitive conditions such as acute myocardial infarction and sepsis than patients admitted through EDs, differences not observed among adults admitted with pneumonia, asthma, cellulitis, and several other common, yet frequently less emergent, reasons for hospitalization.[8] Among children with pneumonia, the most common reason for pediatric hospitalization, direct admission has been associated with significantly lower costs than admissions originating in the ED, with no significant differences in rates of transfer to the intensive care unit or hospital readmission.[10]

There is significant variation across both diagnoses and hospitals in rates of direct admission, raising questions about the contextual factors unique to hospital medicine programs that perform a substantial proportion of direct admissions.[5] This variation also highlights opportunities to identify the populations, conditions, and systems that facilitate safe and effective direct admissions. Certainly, direct admission is unlikely to be appropriate for all populations or conditions. Patients requiring emergent care or rapid diagnostic imaging are likely to receive more timely care in the ED; sepsis, acute myocardial infarction, and trauma are but a few examples of conditions for which rapid ED care decreases morbidity and mortality. Similarly, patients for whom the need for hospitalization is uncertainfor example, dehydration, asthmamay be more appropriate for initial ED management followed by re‐evaluation to inform the need for hospitalization. Finally, patients for whom the admitting diagnosis is uncertain and who require consultation for several subspecialists may be more efficiently evaluated in EDs. In our national survey of pediatric direct admission guidelines, less than one‐third of hospitals reported having formal criteria to assess the appropriateness of direct admissions, and respondents' perspectives regarding populations and diagnoses appropriate for this admission approach varied considerably.[7] These results point to the need for further research and quality‐improvement initiatives to inform the development of direct admission guidelines and protocols.

During the last decade, hospitals' discharge processes have been the focus of tremendous research, policy, and quality improvement efforts. The phrase transition of care is now widely understood to describe the changes in patient care that begin with discharge planning and conclude when patients' have established care at home or another healthcare facility. Transitions of care have been a focus of the Journal of Hospital Medicine since its inception, including publication of the Transitions of Care Consensus Policy Statement in 2009, as well as numerous other studies highlighting both risks associated with transitions of care as well as methods to address these.[11, 12, 13, 14, 15, 16] Similar to hospital discharge, hospital admission is an inherent feature of every hospitalization, and admission and discharge processes share many commonalities. Both involve transitions in sites of care, and handoffs between healthcare providers. Most involve changes in medical therapies, including both the addition of new medications and changes to existing treatments. Moreover, both are associated with significant stress to patients and their families. As a result, hospital admissions expose patients to many of same risks that have been the focus of hospital discharge reform: unstructured patient handoffs, poor communication between healthcare providers, and costly, inefficient care. The Society of Hospital Medicine has been a leader in articulating the importance of patient‐centered, clinically relevant medication reconciliation across the healthcare continuum.[17] However, with the exception of this important work, research and policy focused on understanding and improving transitions of care into the hospital have received disproportionately little attention.

To facilitate research and quality improvement efforts focused on hospital admission, we suggest that the transitions of care framework, typically discussed in the context of hospital discharge, be expanded to reflect the different origins of hospitalizations and multiple transitions that can be experienced by patients as they enter the hospital. A broadening of the transitions of care framework to incorporate hospital admissions brings numerous questions previously addressed in hospital‐to‐home transitions to the forefront. How do transitions into the hospital impact patients and healthcare systems? When is direct admission safe and effective, and how does this vary across conditions and hospital settings? What protocols and tools might optimize the associated transitions and reduce the risks of error and harm? There are numerous stakeholders who will undoubtedly bring diverse perspectives to these questionspatients and their families, hospital‐based healthcare providers, PCPs and specialists, ED physicians, and payors.

Increasing ED volumes, long wait times, and rising ED costs speak to the importance of better understanding hospital admission alternatives and the associated risks and benefits. Encouraging more direct admissions may be a solution, but evidence to guide best practices must precede this. The growing presence of round‐the‐clock pediatric and adult hospitalists across the country creates unique opportunities to transform hospital admission systems for the vast number of patients who do not require emergent care. The Affordable Care Act's expansion of insurance coverage and incentivized coordinated care within patient‐centered medical homes creates a unique opportunity for this broadened view of transitions of care. This suggests that the time is ripe for pursuing strategies that will both improve patients' transitions from outpatient to inpatient care and reduce stress on our overburdened emergency departments.

Disclosure: Dr. Lagu was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. She has received consulting fees from the Institute for Healthcare Improvement, under contract to the Centers for Medicare and Medicaid Services (CMS), for her work on a project to help health systems achieve disability competence, and from the Island Peer Review Organization, under contract to CMS, for her work on development of episodes of care for CMS payment purposes (both unrelated to the current work). Dr. Leyenaar was supported by grant number K08HS024133 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors report no conflicts of interest.

Increasing use of emergency departments (EDs) throughout the United States has become a focus of national healthcare policy and reform efforts. ED growth continues to outpace population growth, with the Institute of Medicine describing our ED systems as fragmented, overburdened, and at the breaking point.[1] Associations between ED crowding and patient dissatisfaction, delays in treatment, medical errors, and patient mortality speak to the urgency of systems improvements.[2] One major factor contributing to ED volumes is the growing number of hospital admissions that begin in EDs. From 1993 to 2006, the proportion of hospitalizations originating in EDs increased from 33.5% to 43.8%, with more than 17 million hospital admissions originating in EDs annually.[3, 4] Despite these challenges, discussions about alternative approaches to hospital admission remain at the periphery of healthcare policy conversations.

Direct admission to the hospital, defined as hospitalization without first receiving care in the hospital's ED, is an alternative approach to hospital admission, and may be a vehicle to both observation and inpatient hospital stays. Direct admissions account for 25% of all nonelective pediatric hospitalizations and 15% of nonelective adult hospitalizations in the United States.[5, 6] This admission approach was considerably more common in the past, facilitated by primary care providers (PCPs) or specialists who provided both outpatient and hospital‐based care for their patients.[4] However, as the number of hospitalists in the United States has grown over the last 30 years, the number of direct admissions has decreased concurrently. In fact, from 2003 to 2009, the number of direct admissions from clinics and physicians' offices decreased by a total of 1.6 million.[4] Although this decline is undoubtedly multifactorial, hospitalists may have contributed, both deliberately and inadvertently, to the shifting epidemiology of hospital admissions. Although many factors influence the source of hospital admissions and admission processes, direct admission has 2 important prerequisites: patients require timely access to outpatient providers for acute care, and hospitals, in partnership with outpatient‐based clinics and practices, require systems to safely and efficiently facilitate admissions without ED involvement. However, we know little about hospital admission systems, developed in the era of hospital medicine, to facilitate admissions independent of the ED.

Direct admission offers a number of potential benefits for both patients and healthcare delivery systems including reductions in the number of sites and providers of care, improved communication and coordination between outpatient and hospital‐based healthcare providers, greater patient and referring physician satisfaction, and reduced ED volumes and subsequent costs.[7] However, there are also risks and potential harms associated with direct admission, including potential delays in initial evaluation and management, inconsistent admission processes, and difficulties determining direct admission appropriateness, all of which could adversely impact patient safety and quality of care.[7, 8, 9] One study of adults with sepsis found that direct admission was associated with increased mortality compared to ED admission, which the authors speculated to be related to less timely care.[9] Similarly, a study of unscheduled adult hospitalizations found that patients admitted directly had higher mortality for time‐sensitive conditions such as acute myocardial infarction and sepsis than patients admitted through EDs, differences not observed among adults admitted with pneumonia, asthma, cellulitis, and several other common, yet frequently less emergent, reasons for hospitalization.[8] Among children with pneumonia, the most common reason for pediatric hospitalization, direct admission has been associated with significantly lower costs than admissions originating in the ED, with no significant differences in rates of transfer to the intensive care unit or hospital readmission.[10]

There is significant variation across both diagnoses and hospitals in rates of direct admission, raising questions about the contextual factors unique to hospital medicine programs that perform a substantial proportion of direct admissions.[5] This variation also highlights opportunities to identify the populations, conditions, and systems that facilitate safe and effective direct admissions. Certainly, direct admission is unlikely to be appropriate for all populations or conditions. Patients requiring emergent care or rapid diagnostic imaging are likely to receive more timely care in the ED; sepsis, acute myocardial infarction, and trauma are but a few examples of conditions for which rapid ED care decreases morbidity and mortality. Similarly, patients for whom the need for hospitalization is uncertainfor example, dehydration, asthmamay be more appropriate for initial ED management followed by re‐evaluation to inform the need for hospitalization. Finally, patients for whom the admitting diagnosis is uncertain and who require consultation for several subspecialists may be more efficiently evaluated in EDs. In our national survey of pediatric direct admission guidelines, less than one‐third of hospitals reported having formal criteria to assess the appropriateness of direct admissions, and respondents' perspectives regarding populations and diagnoses appropriate for this admission approach varied considerably.[7] These results point to the need for further research and quality‐improvement initiatives to inform the development of direct admission guidelines and protocols.

During the last decade, hospitals' discharge processes have been the focus of tremendous research, policy, and quality improvement efforts. The phrase transition of care is now widely understood to describe the changes in patient care that begin with discharge planning and conclude when patients' have established care at home or another healthcare facility. Transitions of care have been a focus of the Journal of Hospital Medicine since its inception, including publication of the Transitions of Care Consensus Policy Statement in 2009, as well as numerous other studies highlighting both risks associated with transitions of care as well as methods to address these.[11, 12, 13, 14, 15, 16] Similar to hospital discharge, hospital admission is an inherent feature of every hospitalization, and admission and discharge processes share many commonalities. Both involve transitions in sites of care, and handoffs between healthcare providers. Most involve changes in medical therapies, including both the addition of new medications and changes to existing treatments. Moreover, both are associated with significant stress to patients and their families. As a result, hospital admissions expose patients to many of same risks that have been the focus of hospital discharge reform: unstructured patient handoffs, poor communication between healthcare providers, and costly, inefficient care. The Society of Hospital Medicine has been a leader in articulating the importance of patient‐centered, clinically relevant medication reconciliation across the healthcare continuum.[17] However, with the exception of this important work, research and policy focused on understanding and improving transitions of care into the hospital have received disproportionately little attention.

To facilitate research and quality improvement efforts focused on hospital admission, we suggest that the transitions of care framework, typically discussed in the context of hospital discharge, be expanded to reflect the different origins of hospitalizations and multiple transitions that can be experienced by patients as they enter the hospital. A broadening of the transitions of care framework to incorporate hospital admissions brings numerous questions previously addressed in hospital‐to‐home transitions to the forefront. How do transitions into the hospital impact patients and healthcare systems? When is direct admission safe and effective, and how does this vary across conditions and hospital settings? What protocols and tools might optimize the associated transitions and reduce the risks of error and harm? There are numerous stakeholders who will undoubtedly bring diverse perspectives to these questionspatients and their families, hospital‐based healthcare providers, PCPs and specialists, ED physicians, and payors.

Increasing ED volumes, long wait times, and rising ED costs speak to the importance of better understanding hospital admission alternatives and the associated risks and benefits. Encouraging more direct admissions may be a solution, but evidence to guide best practices must precede this. The growing presence of round‐the‐clock pediatric and adult hospitalists across the country creates unique opportunities to transform hospital admission systems for the vast number of patients who do not require emergent care. The Affordable Care Act's expansion of insurance coverage and incentivized coordinated care within patient‐centered medical homes creates a unique opportunity for this broadened view of transitions of care. This suggests that the time is ripe for pursuing strategies that will both improve patients' transitions from outpatient to inpatient care and reduce stress on our overburdened emergency departments.

Disclosure: Dr. Lagu was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. She has received consulting fees from the Institute for Healthcare Improvement, under contract to the Centers for Medicare and Medicaid Services (CMS), for her work on a project to help health systems achieve disability competence, and from the Island Peer Review Organization, under contract to CMS, for her work on development of episodes of care for CMS payment purposes (both unrelated to the current work). Dr. Leyenaar was supported by grant number K08HS024133 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors report no conflicts of interest.

Increasing use of emergency departments (EDs) throughout the United States has become a focus of national healthcare policy and reform efforts. ED growth continues to outpace population growth, with the Institute of Medicine describing our ED systems as fragmented, overburdened, and at the breaking point.[1] Associations between ED crowding and patient dissatisfaction, delays in treatment, medical errors, and patient mortality speak to the urgency of systems improvements.[2] One major factor contributing to ED volumes is the growing number of hospital admissions that begin in EDs. From 1993 to 2006, the proportion of hospitalizations originating in EDs increased from 33.5% to 43.8%, with more than 17 million hospital admissions originating in EDs annually.[3, 4] Despite these challenges, discussions about alternative approaches to hospital admission remain at the periphery of healthcare policy conversations.

Direct admission to the hospital, defined as hospitalization without first receiving care in the hospital's ED, is an alternative approach to hospital admission, and may be a vehicle to both observation and inpatient hospital stays. Direct admissions account for 25% of all nonelective pediatric hospitalizations and 15% of nonelective adult hospitalizations in the United States.[5, 6] This admission approach was considerably more common in the past, facilitated by primary care providers (PCPs) or specialists who provided both outpatient and hospital‐based care for their patients.[4] However, as the number of hospitalists in the United States has grown over the last 30 years, the number of direct admissions has decreased concurrently. In fact, from 2003 to 2009, the number of direct admissions from clinics and physicians' offices decreased by a total of 1.6 million.[4] Although this decline is undoubtedly multifactorial, hospitalists may have contributed, both deliberately and inadvertently, to the shifting epidemiology of hospital admissions. Although many factors influence the source of hospital admissions and admission processes, direct admission has 2 important prerequisites: patients require timely access to outpatient providers for acute care, and hospitals, in partnership with outpatient‐based clinics and practices, require systems to safely and efficiently facilitate admissions without ED involvement. However, we know little about hospital admission systems, developed in the era of hospital medicine, to facilitate admissions independent of the ED.

Direct admission offers a number of potential benefits for both patients and healthcare delivery systems including reductions in the number of sites and providers of care, improved communication and coordination between outpatient and hospital‐based healthcare providers, greater patient and referring physician satisfaction, and reduced ED volumes and subsequent costs.[7] However, there are also risks and potential harms associated with direct admission, including potential delays in initial evaluation and management, inconsistent admission processes, and difficulties determining direct admission appropriateness, all of which could adversely impact patient safety and quality of care.[7, 8, 9] One study of adults with sepsis found that direct admission was associated with increased mortality compared to ED admission, which the authors speculated to be related to less timely care.[9] Similarly, a study of unscheduled adult hospitalizations found that patients admitted directly had higher mortality for time‐sensitive conditions such as acute myocardial infarction and sepsis than patients admitted through EDs, differences not observed among adults admitted with pneumonia, asthma, cellulitis, and several other common, yet frequently less emergent, reasons for hospitalization.[8] Among children with pneumonia, the most common reason for pediatric hospitalization, direct admission has been associated with significantly lower costs than admissions originating in the ED, with no significant differences in rates of transfer to the intensive care unit or hospital readmission.[10]

There is significant variation across both diagnoses and hospitals in rates of direct admission, raising questions about the contextual factors unique to hospital medicine programs that perform a substantial proportion of direct admissions.[5] This variation also highlights opportunities to identify the populations, conditions, and systems that facilitate safe and effective direct admissions. Certainly, direct admission is unlikely to be appropriate for all populations or conditions. Patients requiring emergent care or rapid diagnostic imaging are likely to receive more timely care in the ED; sepsis, acute myocardial infarction, and trauma are but a few examples of conditions for which rapid ED care decreases morbidity and mortality. Similarly, patients for whom the need for hospitalization is uncertainfor example, dehydration, asthmamay be more appropriate for initial ED management followed by re‐evaluation to inform the need for hospitalization. Finally, patients for whom the admitting diagnosis is uncertain and who require consultation for several subspecialists may be more efficiently evaluated in EDs. In our national survey of pediatric direct admission guidelines, less than one‐third of hospitals reported having formal criteria to assess the appropriateness of direct admissions, and respondents' perspectives regarding populations and diagnoses appropriate for this admission approach varied considerably.[7] These results point to the need for further research and quality‐improvement initiatives to inform the development of direct admission guidelines and protocols.

During the last decade, hospitals' discharge processes have been the focus of tremendous research, policy, and quality improvement efforts. The phrase transition of care is now widely understood to describe the changes in patient care that begin with discharge planning and conclude when patients' have established care at home or another healthcare facility. Transitions of care have been a focus of the Journal of Hospital Medicine since its inception, including publication of the Transitions of Care Consensus Policy Statement in 2009, as well as numerous other studies highlighting both risks associated with transitions of care as well as methods to address these.[11, 12, 13, 14, 15, 16] Similar to hospital discharge, hospital admission is an inherent feature of every hospitalization, and admission and discharge processes share many commonalities. Both involve transitions in sites of care, and handoffs between healthcare providers. Most involve changes in medical therapies, including both the addition of new medications and changes to existing treatments. Moreover, both are associated with significant stress to patients and their families. As a result, hospital admissions expose patients to many of same risks that have been the focus of hospital discharge reform: unstructured patient handoffs, poor communication between healthcare providers, and costly, inefficient care. The Society of Hospital Medicine has been a leader in articulating the importance of patient‐centered, clinically relevant medication reconciliation across the healthcare continuum.[17] However, with the exception of this important work, research and policy focused on understanding and improving transitions of care into the hospital have received disproportionately little attention.

To facilitate research and quality improvement efforts focused on hospital admission, we suggest that the transitions of care framework, typically discussed in the context of hospital discharge, be expanded to reflect the different origins of hospitalizations and multiple transitions that can be experienced by patients as they enter the hospital. A broadening of the transitions of care framework to incorporate hospital admissions brings numerous questions previously addressed in hospital‐to‐home transitions to the forefront. How do transitions into the hospital impact patients and healthcare systems? When is direct admission safe and effective, and how does this vary across conditions and hospital settings? What protocols and tools might optimize the associated transitions and reduce the risks of error and harm? There are numerous stakeholders who will undoubtedly bring diverse perspectives to these questionspatients and their families, hospital‐based healthcare providers, PCPs and specialists, ED physicians, and payors.

Increasing ED volumes, long wait times, and rising ED costs speak to the importance of better understanding hospital admission alternatives and the associated risks and benefits. Encouraging more direct admissions may be a solution, but evidence to guide best practices must precede this. The growing presence of round‐the‐clock pediatric and adult hospitalists across the country creates unique opportunities to transform hospital admission systems for the vast number of patients who do not require emergent care. The Affordable Care Act's expansion of insurance coverage and incentivized coordinated care within patient‐centered medical homes creates a unique opportunity for this broadened view of transitions of care. This suggests that the time is ripe for pursuing strategies that will both improve patients' transitions from outpatient to inpatient care and reduce stress on our overburdened emergency departments.

Disclosure: Dr. Lagu was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. She has received consulting fees from the Institute for Healthcare Improvement, under contract to the Centers for Medicare and Medicaid Services (CMS), for her work on a project to help health systems achieve disability competence, and from the Island Peer Review Organization, under contract to CMS, for her work on development of episodes of care for CMS payment purposes (both unrelated to the current work). Dr. Leyenaar was supported by grant number K08HS024133 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors report no conflicts of interest.