Potentially avoidable emergency department transfers among Medicare beneficiaries

Introduction

Transfer of patients between hospitals is common, costly, and over 20 % are estimated to be avoidable, meaning patients do not receive specialized interventions once transferred. Older adults are more likely to be transferred and may be at increased risk for developing delirium or other complications due to transfer. We aimed to determine the frequency of potentially avoidable transfer (PAT) among older adults; identify conditions most likely to involve a PAT; and describe factors associated with PAT.

Methods

We performed a retrospective analysis of ED visits resulting in transfer to another hospital from 2008 to 2019 among Medicare fee-for-service beneficiaries 65 years and older. We defined PAT based on resource use at the receiving hospital – transfers resulting in a treat-and-release ED visit, observation stay, or inpatient hospitalization for 2 days or less who received no intensive care or advanced procedure and were discharged alive. We identified conditions with the highest rates of PAT and used multivariable logistic regression to identify the independent association of patient, diagnosis, hospital, and community-linked characteristics with PAT.

Results

Among ∼3 million transfers, 11.3 % met criteria for PAT. Transferring hospitals varied in their rates of PAT, with a median (IQR) rate of 10.3 % (7.2–14.6). Conditions with high rates of PAT included transient cerebral ischemia (35.3 %), nonspecific chest pain (25.5 %), syncope (22.9 %), other fractures (18.4 %), and intracranial injury (16.9 %). These conditions were also associated with PAT in multivariable logistic regression (average marginal effect [AME] 28.2 % (95 %CI 27.4–29.1), 20.6 % (19.8–21.5), 19.2 % (18.5–19.9), 13.4 % (12.9–13.9), and 12.8 % (12.2–13.4), respectively, compared to transfers for sepsis). Patients who were age 85 and older, female, non-White, had fewer comorbidities, and large, for-profit, teaching, and critical access hospitals, and counties with high uninsurance rates were associated with higher likelihood of PAT. Safety net and rural hospitals, and hospitals in counties with high poverty rates were associated with lower likelihood of PAT.

Discussion

PATs were common in transfers of older adults, particularly among a subset of neurologic, cardiovascular, and injury-related conditions. These conditions may represent ideal targets for intervention to decrease rates of avoidable transfer. Research exploring hospital variation in transfer practices and the impact of PAT on older adults' health outcomes are also needed.