title: Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: An instrumental variables approach.
abstract: The objective of this study was to evaluate the impact of regionalization on sepsis survival, to describe the role of inter-hospital transfer in rural sepsis care, and to measure the cost of inter-hospital transfer in a predominantly rural state.
  
  
  
  Observational case-control study using statewide administrative claims data from 2005 to 2014 in a predominantly rural Midwestern state. Mortality and marginal costs were estimated with multivariable generalized estimating equations models and with instrumental variables models.
  
  
  
  A total of 18 246 patients were included, of which 59% were transferred between hospitals. Transferred patients had higher mortality and longer hospital length-of-stay than non-transferred patients. Using a multivariable generalized estimating equations (GEE) model to adjust for potentially confounding factors, inter-hospital transfer was associated with increased mortality (aOR 1.7, 95% CI 1.5-1.9). Using an instrumental variables model, transfer was associated with a 9.2% increased risk of death. Transfer was associated with additional costs of $6897 (95% CI $5769-8024). Even when limiting to only those patients who received care in the largest hospitals, transfer was still associated with $5167 (95% CI $3696-6638) in additional cost.
  
  
  
  The majority of rural sepsis patients are transferred, and these transferred patients have higher mortality and significantly increased cost of care.
authors.affiliation: Department of Emergency Medicine, Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242. Electronic address: nicholas-mohr@uiowa.edu.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Mohr
authors.affiliation: Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242. Electronic address: kari-harland@uiowa.edu.
authors.forename: Karisa K
authors.initials: KK
authors.lastname: Harland
authors.affiliation: Department of Health Management and Policy, University of Iowa College of Public Health, 145 N. Riverside Drive, N244 CPHB, Iowa City, IA 52242. Electronic address: dan-shane@uiowa.edu.
authors.forename: Dan M
authors.initials: DM
authors.lastname: Shane
authors.affiliation: Department of Emergency Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 1008 RCP, Iowa City, IA 52242. Electronic address: azeemuddin-ahmed@uiowa.edu.
authors.forename: Azeemuddin
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Division of Critical Care, Department of Anesthesia, Division of Emergency Medicine, One Brookings Drive, CB 8072, St. Louis, MO 63130. Electronic address: fullerb@wustl.edu.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Fuller
authors.affiliation: Department of Epidemiology, University of Iowa College of Public Health, 145 N. Riverside Drive, S441A CPHB, Iowa City, IA 52242. Electronic address: james-torner@uiowa.edu.
authors.forename: James C
authors.initials: JC
authors.lastname: Torner
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D015986:Confounding Factors, Epidemiologic; D005260:Female; D017048:Health Care Costs; D017052:Hospital Mortality; D006761:Hospitals; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D015146:Midwestern United States; D015999:Multivariate Analysis; D010360:Patient Transfer / Q000191:economics / Q000706:statistics & numerical data*; D012424:Rural Population; D018805:Sepsis / Q000191:economics / Q000401:mortality; D012772:Shock, Septic / Q000191:economics / Q000401:mortality*; D055815:Young Adult
keywords: Emergency medical services; Emergency service, hospital; Health care economics and organizations; Health services; Hospitals, rural; Sepsis