title: Does Hospital Transfer Impact Outcomes After Colorectal Surgery?
abstract: BACKGROUND
  With increasing public reporting of outcomes and bundled payments, hospitals and providers are scrutinized for morbidity and mortality. The impact of patient transfer before colorectal surgery has not been well characterized in a risk-adjusted fashion.
  
  
  OBJECTIVE
  We hypothesized that hospital-to-hospital transfer would independently predict morbidity and mortality beyond traditional predictor variables.
  
  
  METHODS
  We constructed a retrospective cohort of 158,446 patients who underwent colorectal surgery using the 2009-2013 American College of Surgeons National Surgical Quality Improvement Program database.
  
  
  METHODS
  The study was conducted at a tertiary care hospital.
  
  
  METHODS
  All of the patients who underwent colorectal surgery during the study period were included. Patients were excluded for unknown transfer status or transfer from a chronic care facility.
  
  
  METHODS
  Baseline characteristics were compared by transfer status. Multivariate logistic regression was used to evaluate the impact of transfer on major complications and mortality.
  
  
  RESULTS
  A total of 7259 operations (4.6%) were performed after transfer. Transferred patients had higher rates of complications (p < 0.0001) with significant differences in unplanned endotracheal reintubation, bleeding, organ-space surgical site infection, wound dehiscence, postoperative sepsis, cardiac arrest requiring cardiopulmonary resuscitation, deep venous thrombosis, and myocardial infarction. Transferred patients also had longer hospital stays (9 vs 6 days; p < 0.0001) and a higher risk of death (13.2% vs 2.6%; p < 0.0001). On multivariate analysis, transferred patients had higher mortality rates despite risk adjustment (OR = 1.13 (95% CI, 1.02-1.25); p = 0.019) and were also more likely to have serious complications (OR = 1.12 (95% CI, 1.06-1.19); p < 0.001).
  
  
  CONCLUSIONS
  We were unable to analyze outcomes beyond 30 days, and we did not have information on preoperative evaluation or the reason for patient transfer.
  
  
  CONCLUSIONS
  Hospital-to-hospital transfer independently contributed to patient morbidity and mortality in patients undergoing colorectal surgery. The impact of hospital transfer must be considered when evaluating surgeon and hospital performance, because the increased risk of serious complications or death is not fully accounted for by traditional methods.
authors.affiliation: 1 Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota 2 Colon and Rectal Surgery Associates, St. Paul, Minnesota.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Chow
authors.forename: Wolfgang B
authors.initials: WB
authors.lastname: Gaertner
authors.forename: Christine C
authors.initials: CC
authors.lastname: Jensen
authors.forename: Bradford
authors.initials: B
authors.lastname: Sklow
authors.forename: Robert D
authors.initials: RD
authors.lastname: Madoff
authors.forename: Mary R
authors.initials: MR
authors.lastname: Kwaan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003082:Colectomy; D003108:Colonic Diseases / Q000453:epidemiology / Q000601:surgery*; D003125:Colostomy; D013505:Digestive System Surgical Procedures; D005260:Female; D006323:Heart Arrest / Q000453:epidemiology; D017052:Hospital Mortality; D006801:Humans; D007416:Intestinal Perforation / Q000453:epidemiology / Q000601:surgery; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology; D010360:Patient Transfer / Q000706:statistics & numerical data*; D010538:Peritonitis / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology*; D019106:Postoperative Hemorrhage / Q000453:epidemiology; D019984:Quality Indicators, Health Care; D012002:Rectal Diseases / Q000453:epidemiology / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D018805:Sepsis / Q000453:epidemiology; D013529:Surgical Wound Dehiscence / Q000453:epidemiology; D013530:Surgical Wound Infection / Q000453:epidemiology; D016896:Treatment Outcome; D020246:Venous Thrombosis / Q000453:epidemiology