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Interhospital Facility Transfers in the United States: A Nationwide Outcomes Study

Hernandez-Boussard, Tina PhD, MPH, MS*; Davies, Sheryl BA; McDonald, Kathryn MA; Wang, N. Ewen MD*

doi: 10.1097/PTS.0000000000000148
Original Articles

Objectives Patient transfers between hospitals are becoming more common in the United States. Disease-specific studies have reported varying outcomes associated with transfer status. However, even as national quality improvement efforts and regulations are being actively adopted, forcing hospitals to become financially accountable for the quality of care provided, surprisingly little is known about transfer patients or their outcomes at a population level. This population-wide study provides timely analyses of the characteristics of this particularly vulnerable and sizable inpatient population. We identified and compared characteristics and outcomes of transfer and nontransfer patients.

Methods With the use of the 2009 Nationwide Inpatient Sample, a nationally representative sample of U.S. hospitalizations, we examined patient characteristics, in-hospital adverse events, and discharge disposition for transfer versus nontransfer patients in this observational study.

Results We identified 1,397,712 transfer patients and 31,692,211 nontransfer patients. Age, sex, race, and payer were significantly associated with odds of transfer (P < 0.05). Transfer patients had higher risk-adjusted inpatient mortality (4.6 versus 2.1, P < 0.01), longer length of stay (13.3 versus 4.5, P < 0.01), and fewer routine disposition discharges (53.6 versus 68.7, P < 0.01). In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients (P < 0.05).

Conclusions Our results suggest that transfer patients have inferior outcomes compared with nontransfer patients. Although they are clinically complex patients and assessing accountability as between the transferring and receiving hospitals is methodologically difficult, transfer patients must nonetheless be included in quality benchmark data to assess the potential impact this population has on hospital outcome profiles. With hospital accountability and value-based payments constituting an integral part of health care reform, documenting the quality of care delivered to transfer patients is essential before accurate quality assessment improvement efforts can begin in this patient population.

From the *Department of Surgery, and †Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California.

Correspondence: Tina Hernandez-Boussard, Population Science Building, Stanford University, 1070 Arastradero Rd, Suite 307, Palo Alto, CA 94306 (e-mail:

The authors disclose no conflict of interest.

Supported by the Agency for Healthcare Research and Quality.

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