title: Acuity, outcomes, and trends in the transfer of surgical patients: a national study.
abstract: BACKGROUND
  With the regionalization of surgical care, reduction in the rural workforce, rising healthcare costs, and increasing focus on surgical outcomes, appropriate transfer of surgical patients is an increasingly important aspect of health care. This study examines patients transferred for surgical intervention through a national sample.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2012 for surgery patients who were transferred from an outside hospital or emergency department (ED) and compared patients undergoing surgery without transfer. Patients were divided into two time periods (TP): 2005-2008 (TP1) and 2008-2012 (TP2) for analysis; patient characteristics and top CPT codes for each TP were collected. Univariate analysis and matched cohorts were used to compare the groups.
  
  
  RESULTS
  Overall, 61,204 patients were transferred and underwent surgery. The rate of transferred surgery patients increased from 3.2% in TP1 to 4.5% in TP2 (p < 0.0001). Compared to non-transferred patients, transferred patients had higher rates of diabetes (23.4 vs. 17.6%, p < 0.0001), tobacco use (27.9 vs. 20.3%, p < 0.0001), Charlson comorbidity index (mean score 1.5 vs. 0.8, p < 0.0001), preoperative sepsis (32.0 vs. 9.4%, p < 0.0001), and need for emergent surgery (41.3 vs. 14.4%, p < 0.0001). From TP1 to TP2, there was an increase in transferred patients who were obese (33.9-36.4%, p < 0.0001) and had emergent transfers (39.6-41.8%, p < 0.0001), with a decrease in diabetic patients (24.7-23.1%, p < 0.0001). From TP1 to TP2, transferred patients had more minor complications (17.7-31.0%, p < 0.0001), but fewer major complications (32.1-23.9%, p < 0.0001) and lower 30-day mortality (11.8-8.1%, p < 0.0001).
  
  
  CONCLUSIONS
  Patients transferred for surgery represent a higher acuity population than non-transferred patients, and the number of transfers continues to rise. Even when matched by comorbidities, transferred patients have worse outcomes. Surgical sub-specialization and physician tiering may complicate future transfer practices. Efficient transfers, effective physician communication, and ready availability of medical records are critical in improving patient transfers.
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
authors.forename: Ciara R
authors.initials: CR
authors.lastname: Huntington
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
authors.forename: Tiffany C
authors.initials: TC
authors.lastname: Cox
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
authors.forename: Laurel J
authors.initials: LJ
authors.lastname: Blair
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
authors.forename: Tanushree
authors.initials: T
authors.lastname: Prasad
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
authors.forename: Amy E
authors.initials: AE
authors.lastname: Lincourt
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
authors.forename: Brent D
authors.initials: BD
authors.lastname: Matthews
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
authors.forename: B Todd
authors.initials: BT
authors.lastname: Heniford
authors.affiliation: Division of GI and Minimally Invasive Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA. Vedra.augenstein@carolinas.org.
authors.forename: Vedra A
authors.initials: VA
authors.lastname: Augenstein
mesh_terms: D015897:Comorbidity; D016208:Databases, Factual; D003920:Diabetes Mellitus / Q000453:epidemiology; D004630:Emergencies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000453:epidemiology; D062072:Patient Acuity; D010360:Patient Transfer / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D018805:Sepsis / Q000453:epidemiology; D012907:Smoking / Q000453:epidemiology; D013514:Surgical Procedures, Operative / Q000401:mortality / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
keywords: Interhospital transfer; NSQIP; Outcomes; Pay-for-performance; Surgery patients