title: The association between clinical integration of care and transfer of veterans with acute coronary syndromes from primary care VHA hospitals.
abstract: BACKGROUND
  Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system.
  
  
  METHODS
  Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics.
  
  
  RESULTS
  Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27-0.77, and 0.46, p = 0.002, CI 0.27-0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92-13.48).
  
  
  CONCLUSIONS
  Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.
authors.affiliation: Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA. ann.sales@med.va.gov
authors.forename: Anne E
authors.initials: AE
authors.lastname: Sales
authors.forename: Sandra L
authors.initials: SL
authors.lastname: Pineros
authors.forename: David J
authors.initials: DJ
authors.lastname: Magid
authors.forename: Nathan R
authors.initials: NR
authors.lastname: Every
authors.forename: Nancy D
authors.initials: ND
authors.lastname: Sharp
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
mesh_terms: D000208:Acute Disease; D000368:Aged; D016507:Cardiology Service, Hospital; D002391:Catchment Area, Health; D003327:Coronary Disease / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D006297:Health Services Accessibility; D006787:Hospitals, Veterans / Q000145:classification / Q000458:organization & administration / Q000706:statistics & numerical data*; D006801:Humans; D010360:Patient Transfer / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation; D012044:Regression Analysis; D013577:Syndrome; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D014728:Veterans / Q000706:statistics & numerical data*