Department of Surgery, University of Wisconsin, Madison, WI.
Department of Surgery, Ohio State University, Columbus, OH.
Surgery. 2020 Aug;168(2):280-286. doi: 10.1016/j.surg.2020.01.005. Epub 2020 May 23.
Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database.
We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design.
We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay.
EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.
转入的急诊普外科（EGS）患者是一个脆弱、高发病率的群体。转移（TRAN）与直接入院（DA）患者的转归和医疗保健利用情况主要是使用单一机构或医院系统数据进行研究的，这限制了其普遍性。我们使用国家数据库评估了 EGS 患者的这些结果。
我们确定了在 2008 年至 2011 年全国住院患者样本（NIS）中符合美国创伤外科学会定义的 EGS 诊断标准的年龄≥18 岁的患者的就诊情况。多变量回归分析确定转移状态是否独立预测住院死亡率（逻辑回归）和发病率（存活至出院的患者中存在任何并发症；逻辑回归）、成本（线性回归）和住院时间（存活至出院的患者；线性回归），同时考虑到 NIS 抽样设计。
我们确定了 274145 例 TRAN（未加权 57885 例）和 10456100 例 DA（未加权 2187132 例）就诊。在单变量分析中，与 DA 患者相比，TRAN 患者的合并症评分更高，更有可能拥有医疗保险，并且居住在中位家庭收入较低的地区（p<0.0001）。与 DA 组相比，TRAN 组的死亡率更高（4.4% vs 1.6%；p<0.0001）。TRAN 患者的发病率（存在任何并发症）也更高（38.8% vs 26.1%；p<0.0001）。TRAN 患者的发病率主要归因于泌尿系统（13.7%）、胃肠道（12.9%）和肺部相关（13.3%）并发症。TRAN 患者的中位住院时间为 4.3 天，而 DA 患者为 3.0 天（p<0.0001）。TRAN 患者的中位费用更高（8935 美元对 7167 美元；p<0.0001）。回归分析确定，在调整后，TRAN 患者的死亡率、发病率、成本以及住院时间均具有统计学显著意义。
转入的 EGS 患者的住院发病率和死亡率更高，住院时间和成本也更高。随着诊断为 EGS 病症的患者的数量和年龄增加，而 EGS 劳动力减少，医院之间的转运会增加。确定与转院患者不良结局相关的风险因素可以为绩效改进举措的设计提供信息，并为这一脆弱的患者群体提供有限的资源。
