title: Comparison of community and referral intensive care unit patients in a tertiary medical center: evidence for referral bias in the critically ill.
abstract: OBJECTIVE
  To determine the existence of referral bias in the critically ill by comparing the clinical and epidemiologic characteristics of community (Olmsted County, MN residents) and referral (non-Olmsted County residents) patients admitted to the intensive care unit.
  
  
  METHODS
  Retrospective, cohort study.
  
  
  METHODS
  Academic tertiary care medical center.
  
  
  METHODS
  Patients admitted to the medical and surgical intensive care units at Mayo Medical Center from 1995 to 2004.
  
  
  METHODS
  None.
  
  
  RESULTS
  Residency status, demographics, Acute Physiology and Chronic Health Evaluation III score, intensive care unit admission diagnosis and treatment status, intensive care unit and hospital mortality, length of stay, and travel distances to Mayo Clinic. Referral patients with a medical intensive care unit admission were more severely ill, had greater mortality rates and length of stay and were more likely to receive an active intensive care unit intervention compared with community patients (p < 0.0001). Referral and community patients who had a surgical intensive care unit admission had similar severity of illness, length of stay, and intensive care unit mortality rate. Hospital mortality rate was lower in the referral surgical patients compared with community surgical patients (p = 0.0001). When adjusted for severity of illness, intensity of treatment, and admission source, community and referral medical intensive care unit patients had a similar risk of hospital death, whereas referral surgical patients had a lower risk of hospital death compared with community patients. Referral patients who had a medical intensive care unit admission and traveled greater distances to Mayo Clinic had greater mortality rates and length of stay; those who had a surgical intensive care unit admission and traveled greater distances had lower mortalities and length of stay.
  
  
  CONCLUSIONS
  Patients who resided outside of our local community and who had medical admissions to the intensive care unit were more severely ill, had greater mortality rates, and had longer length of stay compared with community patients. Our findings support the existence of referral bias in critically ill medical patients at our tertiary medical center.
authors.affiliation: Division of Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA. seferian.edward@mayo.edu
authors.forename: Edward G
authors.initials: EG
authors.lastname: Seferian
authors.forename: Bekele
authors.initials: B
authors.lastname: Afessa
authors.forename: Ognjen
authors.initials: O
authors.lastname: Gajic
authors.forename: Mark T
authors.initials: MT
authors.lastname: Keegan
authors.forename: Rolf D
authors.initials: RD
authors.lastname: Hubmayr
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003153:Community Health Services / Q000592:standards* / Q000639:trends; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010343:Patient Admission / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000145:classification / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016019:Survival Analysis; D014481:United States