Mell Matthew W, Wang Nancy E, Morrison Doug E, Hernandez-Boussard Tina
Department of Surgery, Stanford University, Stanford, Calif.
Department of Surgery, Stanford University, Stanford, Calif.
J Vasc Surg. 2014 Sep;60(3):553-7. doi: 10.1016/j.jvs.2014.02.061. Epub 2014 Apr 24.
Patients receiving interfacility transfer to a higher level of medical care for ruptured abdominal aortic aneurysms (rAAAs) are an important minority that are not well characterized and are typically omitted from outcomes and quality indicator studies. Our objective was to compare patients transferred for treatment of rAAAs with those treated without transfer, with particular emphasis on mortality and resource utilization.
We linked longitudinal data from 2005 to 2010 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and Emergency Department Databases from California, Florida, and New York. Patients were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes. Our main outcome variables were mortality, length of stay, and cost. Data included discharge information on the transfer-out and transfer-in hospital. We used univariate and multivariate analysis to identify variables independently associated with transfer and in-hospital mortality.
Of 4439 rAAA patients identified with intent to treat, 847 (19.1%) were transferred before receiving operative repair. Of those transferred, 141 (17%) died without undergoing AAA repair. By multivariate analysis, increasing age in years (odds ratio [OR] 0.98; 95% confidence interval [CI], 0.97-0.99; P < .001), private insurance vs Medicare (OR, 0.62; 95% CI, 0.47-0.80; P < .001), and increasing comorbidities as measured by the Elixhauser Comorbidity Index (OR, 0.90; 95% CI, 0.86-0.95; P < .001) were negatively associated with transfer. Weekend presentation (OR, 1.23; 95% CI, 1.02-1.47; P = .03) was positively associated with transfer. Transfer was associated with a lower operative mortality (adjusted OR, 0.81; 95% CI, 0.68-0.97; P < .02) but an increased overall mortality when including transferred patients who died without surgery (OR, 1.30; 95% CI, 1.05-1.60; P = .01). Among the transferred patients, there was no significant difference in travel distance between those who survived and those who died (median, 28.7 vs 25.8 miles; P = .07). Length of stay (median, 10 vs 9 days; P = .008), and hospital costs ($161,000 vs $146,000; P = .02) were higher for those transferred.
The survival advantage for patients transferred who received treatment was eclipsed by increased mortality of the transfer process. Including 17% of transferred patients who died without receiving definitive repair, mortality was increased for patients transferred for rAAA repair compared with those not transferred after adjusting for demographic, clinical, and hospital factors. Transferred patients used significantly more hospital resources. Improving systems and guidelines for interfacility transfer may further improve the outcomes for these patients and decrease associated hospital resource utilization.
因腹主动脉瘤破裂（rAAA）而转至更高医疗水平机构接受治疗的患者是一个重要的少数群体，其特征尚未得到充分描述，并且在结局和质量指标研究中通常被忽略。我们的目的是比较因rAAA接受转院治疗的患者与未转院治疗的患者，特别关注死亡率和资源利用情况。
我们将2005年至2010年医疗成本和利用项目（HCUP）中加利福尼亚州、佛罗里达州和纽约州的州住院数据库及急诊科数据库中的纵向数据进行了关联。使用国际疾病分类第九版临床修订本编码来识别患者。我们的主要结局变量为死亡率、住院时间和费用。数据包括转出医院和转入医院的出院信息。我们采用单变量和多变量分析来确定与转院及院内死亡率独立相关的变量。
在4439例确定为有治疗意向的rAAA患者中，847例（19.1%）在接受手术修复前被转院。在这些被转院的患者中，141例（17%）未接受AAA修复即死亡。通过多变量分析，年龄每增加一岁（比值比[OR]0.98；95%置信区间[CI]，0.97 - 0.99；P <.001）、私人保险与医疗保险相比（OR，0.62；95%CI，0.47 - 0.80；P <.001）以及依Elixhauser合并症指数衡量的合并症增加（OR，0.90；95%CI，0.86 - 0.95；P <.001）与转院呈负相关。周末就诊（OR，1.23；95%CI，1.02 - 1.47；P =.03）与转院呈正相关。转院与较低的手术死亡率相关（调整后的OR，0.81；95%CI，0.68 - 0.97；P <.02），但当纳入未接受手术即死亡的转院患者时，总体死亡率增加（OR，1.30；95%CI，1.05 - 1.60；P =.01）。在转院患者中，存活者与死亡者之间的转院距离无显著差异（中位数，28.7英里对25.8英里；P =.07）。转院患者的住院时间更长（中位数，10天对9天；P =.008），住院费用更高（161,000美元对146,000美元；P =.02）。
接受治疗的转院患者的生存优势被转院过程中增加的死亡率所抵消。在调整人口统计学、临床和医院因素后，与未转院的rAAA修复患者相比，转院患者的死亡率增加，其中包括17%未接受确定性修复即死亡的转院患者。转院患者使用了显著更多的医院资源。改善机构间转院的系统和指南可能会进一步改善这些患者的结局并降低相关的医院资源利用。
