Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm

Matthew Mell, Nancy E. Wang, Doug E. Morrison, Tina Hernandez-Boussard

Research output: Contribution to journalArticle

39 Citations (Scopus)

Abstract

Objective: 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. Methods: 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. Results: 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. Conclusions: 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.

Original languageEnglish (US)
Pages (from-to)553-557
Number of pages5
JournalJournal of Vascular Surgery
Volume60
Issue number3
DOIs
StatePublished - Jan 1 2014
Externally publishedYes

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Patient Transfer
Aortic Rupture
Abdominal Aortic Aneurysm
Mortality
Odds Ratio
Confidence Intervals
Comorbidity
Length of Stay
Multivariate Analysis
Databases
Hospital Costs
International Classification of Diseases
Medicare
Hospital Mortality
Insurance
Health Care Costs
Hospital Emergency Service
Inpatients
Demography

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm. / Mell, Matthew; Wang, Nancy E.; Morrison, Doug E.; Hernandez-Boussard, Tina.

In: Journal of Vascular Surgery, Vol. 60, No. 3, 01.01.2014, p. 553-557.

Research output: Contribution to journalArticle

Mell, Matthew ; Wang, Nancy E. ; Morrison, Doug E. ; Hernandez-Boussard, Tina. / Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm. In: Journal of Vascular Surgery. 2014 ; Vol. 60, No. 3. pp. 553-557.
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abstract = "Objective: 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. Methods: 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. Results: 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. Conclusions: 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.",
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N2 - Objective: 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. Methods: 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. Results: 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. Conclusions: 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.

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