title: The effect of transfer and hospital volume in subarachnoid hemorrhage patients.
abstract: BACKGROUND
  Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. Literature is inconclusive regarding outcomes for patients directly admitted to specialized centers versus transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the "transfer effect" in a large sample of aneurysmal SAH patients undergoing treatment.
  
  
  METHODS
  Using Nationwide Inpatient Sample 2002-2007 data, we analyzed outcomes of SAH patients treated with coil or clip procedures. Analyses studied the effect of direct-admit versus transfer admission on mortality, discharge disposition, complications, length of stay (LOS), and total charges.
  
  
  RESULTS
  Of 47,114 patients, 31,711 (67.3 %) were direct-admits and 15,403 (32.7 %) were transfers. More transfer patients were coiled than direct-admits (45.3 vs. 33.7 %, p < 0.0001) and fewer underwent ventriculostomy (26.6 vs. 31.5 %, p = 0.003). Older age (OR 1.2, p < 0.0001), higher disease severity (OR 1.4, p < 0.0001), lower volume (OR 1.5, p < 0.0001), and ventriculostomy (OR 2.1, p < 0.0001) increased mortality and predicted non-routine discharge, complications, LOS, and charges. Transfer patients had similar mortality (OR 0.9, p = 0.13) and complications (OR 0.9, p = 0.22) as direct-admits, but incurred higher non-routine discharge (OR 1.3, p = 0.002). Analysis of grade V patients demonstrated similar outcomes between direct-admits and transfers; however, charges for treating transfer patients were notably higher ($401,386 vs. $242,774, p = 0.03).
  
  
  CONCLUSIONS
  Patients treated in the lowest volume hospitals were 1.6 times more likely to die than those treated at the highest quintile hospitals. Among the critically ill grade V patients, transfer to higher-volume specialized centers did not increase the likelihood of a poor prognosis.
authors: Department of Neurosurgery, Cedars-Sinai Medical Center, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, 8631 W. Third Street, Suite 800E, Los Angeles, CA 90048, USA.
authors: Miriam
authors: M
authors: Nuño
authors: Chirag G
authors: CG
authors: Patil
authors: Patrick
authors: P
authors: Lyden
authors: Doniel
authors: D
authors: Drazin
mesh_terms: D000328:Adult; D000368:Aged; D016638:Critical Illness / Q000401:mortality; D016208:Databases, Factual / Q000706:statistics & numerical data; D004621:Embolization, Therapeutic / Q000401:mortality; D005260:Female; D006742:Hospital Bed Capacity / Q000191:economics / Q000706:statistics & numerical data*; D017722:Hospital Charges / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D019635:Neurosurgical Procedures / Q000401:mortality; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000191:economics / Q000706:statistics & numerical data*; D011379:Prognosis; D013345:Subarachnoid Hemorrhage / Q000191:economics / Q000401:mortality* / Q000628:therapy*