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Journal of General Internal Medicine

, Volume 33, Issue 12, pp 2078–2084 | Cite as

Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals: a Cross-Sectional Study

  • Michael G. Usher
  • Christine Fanning
  • Vivian W. Fang
  • Madeline Carroll
  • Amay Parikh
  • Anne Joseph
  • Dana Herrigel
Original Research

Abstract

Background

Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized.

Objective

To identify the association between insurance coverage and mortality of patients transferred between hospitals.

Design

We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers.

Setting

Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers.

Patients

The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals.

Measurements

Adjusted inpatient mortality and 24-h mortality, stratified by insurance status.

Results

Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p = 0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p = 0.026), and earlier in their hospital course (3.9 vs 2.0 days, p = 0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13–1.36, p < 0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11–1.60, p < 0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses.

Limitations

This is an observational study where transfer appropriateness cannot be directly assessed.

Conclusions

Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.

KEY WORDS

inter-hospital transfers health disparities insurance hospital ownership 

Notes

Acknowledgments

We would like to thank Anne Marie Webber-Main PhD for her critical review of a draft of this paper and writing clarification.

Prior Presentation

This paper was presented at the Society of General Internal Medicine National Meeting in May 2016.

Funding

Funding support for this study was provided by the NIH Clinical and Translational Science Award at the University of Minnesota: 8UL1TR000114-02.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have do not have a conflict of interest.

Supplementary material

11606_2018_4687_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 16 kb)

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Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Michael G. Usher
    • 1
  • Christine Fanning
    • 2
  • Vivian W. Fang
    • 3
  • Madeline Carroll
    • 2
  • Amay Parikh
    • 4
  • Anne Joseph
    • 1
  • Dana Herrigel
    • 5
  1. 1.Department of Medicine, Division of General Internal Medicine University of Minnesota Medical SchoolMinneapolisUSA
  2. 2.Department of Medicine, Division of General Internal MedicineRutgers, Robert Wood Johnson Medical SchoolNew BrunswickUSA
  3. 3.Department of Accounting, Carlson School of ManagementUniversity of MinnesotaMinneapolisUSA
  4. 4.Department of Medicine, Divisions of Nephrology and Critical CareRutgers, Robert Wood Johnson Medical SchoolNew BrunswickUSA
  5. 5.Department of Hospital Internal MedicineMayo Clinic FloridaJacksonvilleUSA

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