Abstract
Background and Purpose
Inter-hospital transfer for ischemic stroke is an essential part of stroke system
of care. This study aimed to understand the national patterns and outcomes of ischemic
stroke transfer.
Methods and Results
This retrospective study examined Medicare beneficiaries aged ≥65 years undergoing
inter-hospital transfer for ischemic stroke in 2012. Cox proportional hazards model
was used to compare 30-day and one-year mortality between transferred patients and
direct admissions from the emergency department (ED admissions). Among 312,367 ischemic
stroke admissions, 5.7% underwent inter-hospital transfer. Using this value as cut-off,
the hospitals were classified into receiving (n = 411), sending (n = 559), and low-transfer (n = 1863) hospitals. Receiving hospitals were larger than low-transfer and sending
hospitals as demonstrated by the median bed number (371, 189, and 88, respectively,
p < 0.001); more frequently to be certified stroke centers (75%, 47%, and 16%, respectively,
p < 0.001); and less commonly located in the rural area (2%, 7%, and 24%, respectively,
p < 0.001). For receiving hospitals, transfer-in patients and ED admissions had comparable
mortality at 30 days (10% vs 10%; adjusted HR [aHR]=1.07; 95% CI, 0.99–1.14) and 1
year (23% vs 24%; aHR=1.03; 95% CI, 0.99–1.08). For sending hospitals, transfer-out
patients, compared to ED admissions, had higher mortality at 30 days (14% vs 11%;
aHR=1.63; 95% CI, 1.39–1.91) and 1 year (30% vs 27%; aHR=1.33; 95% CI, 1.20–1.48).
For low-transfer hospitals, overall transfer-in and transfer-out patients, compared
to ED admissions, had higher mortality at 30 days (13% vs 10%; aHR=1.46; 95% CI, 1.33–1.60)
and 1 year (28% vs 25%; aHR=1.27; 95% CI, 1.19–1.36).
Conclusions
Hospitals in the US, based on their transfer patterns, could be classified into 3
groups that shared distinct characteristics including hospital size, rural vs urban
location, and stroke certification. Transferred patients at sending and low-transfer
hospitals had worse outcomes than their ED admission counterpart.
Key Words
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Article info
Publication history
Published online: September 26, 2020
Accepted:
September 12,
2020
Received in revised form:
September 3,
2020
Received:
July 23,
2020
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105331
Copyright
© 2020 Elsevier Inc. All rights reserved.
