title: The structure of critical care transfer networks.
abstract: BACKGROUND
  Moving patients from low-performing hospitals to high-performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival.
  
  
  OBJECTIVE
  To characterize the existing critical care network in terms of the pattern of transfers.
  
  
  METHODS
  In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations.
  
  
  METHODS
  We measured the characteristics of the interhospital transfer network and the extent to which intensive care unit patients are referred to each hospital in that network--a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical, and radiologic capabilities.
  
  
  RESULTS
  There were 47,820 transfers of critically ill patients among 3308 hospitals. 4.5% of all critical care stays of any length involved an interhospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital positions were associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals' centrality.
  
  
  CONCLUSIONS
  Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, MI 48109, USA. tiwashyn@umich.edu
authors.forename: Theodore J
authors.initials: TJ
authors.lastname: Iwashyna
authors.forename: Jason D
authors.initials: JD
authors.lastname: Christie
authors.forename: James
authors.initials: J
authors.lastname: Moody
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
mesh_terms: D016009:Chi-Square Distribution; D003422:Critical Care / Q000458:organization & administration*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data; D019538:Health Care Surveys; D006276:Health Facility Size; D006801:Humans; D007344:Insurance Claim Reporting / Q000706:statistics & numerical data; D007362:Intensive Care Units / Q000458:organization & administration; D007373:Interinstitutional Relations; D007902:Length of Stay / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care; D010360:Patient Transfer / Q000458:organization & administration*; D012017:Referral and Consultation / Q000458:organization & administration*; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D018709:Statistics, Nonparametric; D015996:Survival Rate; D014195:Travel / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology