Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD.
Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
J Am Coll Surg. 2014 Mar;218(3):393-400. doi: 10.1016/j.jamcollsurg.2013.11.024. Epub 2013 Nov 27.
Interhospital transfer is frequent, and transferred patients can have worse outcomes than direct admissions. We sought to define the incidence of interhospital transfer in general surgery and evaluate its association with surgical outcomes.
The 2011 American College of Surgeons NSQIP database was used. Transferred patients were compared with urgent, inpatient direct admissions in a series of increasingly complex risk-adjustment models, including multiple regression using modified Poisson and negative binomial models, as well as propensity scores. Primary outcomes were overall complications, mortality, length of stay, and readmission.
Overall, 7% of inpatient general surgery cases were transferred in. Among urgent cases, there were 6,197 transferred patients and 47,267 direct admissions. The most common procedures for direct admissions were appendectomy and cholecystectomy, and transfers had a more complex and broader range of procedures. On unadjusted analysis, transferred patients had a much higher risk for complications (risk ratio [RR] = 1.48; 95% CI, 1.45-1.52) and mortality (RR = 2.70; 95% CI, 2.48-2.94), as well as a longer length of stay (1.74 times longer; 95% CI, 1.69-1.78) and higher risk of readmission (RR = 1.31; 95% CI, 1.20-1.44). In the most sophisticated model, the propensity score match, the difference in outcomes for transferred patients was only modestly higher or equivalent (complications: RR = 1.03; 95% CI, 1.00-1.07; mortality: RR = 0.98; 95% CI, 0.88-1.09; length of stay: 1.08 times longer; 95% CI, 1.04-1.11; readmission: RR = 0.97; 95% CI, 0.88-1.08).
Interhospital transfer is frequent in surgery. Worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. Pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers.
医院间的转院很常见，转院患者的预后往往比直接入院的患者差。我们旨在确定普外科中转院的发生率，并评估其与手术结果的关系。
使用 2011 年美国外科医师学会 NSQIP 数据库。将转院患者与紧急、住院直接入院的患者进行一系列越来越复杂的风险调整模型比较，包括使用修正泊松和负二项回归模型以及倾向评分的多元回归。主要结果是总体并发症、死亡率、住院时间和再入院率。
总体而言，普外科住院患者中转院的比例为 7%。在紧急情况下，有 6197 例转院患者和 47267 例直接入院患者。直接入院患者最常见的手术是阑尾切除术和胆囊切除术，而转院患者的手术更为复杂，范围更广。在未调整的分析中，转院患者的并发症风险（风险比 [RR] = 1.48；95%置信区间，1.45-1.52）和死亡率（RR = 2.70；95%置信区间，2.48-2.94）均显著升高，住院时间（延长 1.74 倍；95%置信区间，1.69-1.78）和再入院风险（RR = 1.31；95%置信区间，1.20-1.44）也显著升高。在最复杂的模型，即倾向评分匹配中，转院患者的结局差异仅略有升高或相当（并发症：RR = 1.03；95%置信区间，1.00-1.07；死亡率：RR = 0.98；95%置信区间，0.88-1.09；住院时间：延长 1.08 倍；95%置信区间，1.04-1.11；再入院：RR = 0.97；95%置信区间，0.88-1.08）。
外科手术中医院间转院很常见。转院患者预后较差主要是由于患者特征的混杂因素所致，而不是转院本身造成的任何真正危害。按绩效付费的方案应调整转院状态，以避免不公平地惩罚经常接受转院的医院。
