Discordance Between Patient and Clinician Experiences and Priorities in Rural Interhospital Transfer: A Mixed Methods Study

Mohr, Nicholas M.; Wong, Terrence S.; Faine, Brett; Schlichting, Adam; Noack, Joseph; Ahmed, Azeemuddin

doi:10.1111/jrh.12125

Cited by 20 publications

(28 citation statements)

References 32 publications

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“…This service has been most broadly implemented in telestroke care, providing real-time video consultation by a neurologist to an ED for the purpose of selecting patients for intravenous thrombolysis [32]. In some cases, inter-facility transfers have been avoided with targeted remote care [33][34][35][36] and allowed patients to remain near their families [37],which suggests that specialty telehealth capabilities may improve access, timeliness, and reduce the need for some emergency inter-facility transfers [23]. Some reports have even reported favorable provider-based outcomes related to telehealth implementation [38,39].…”

Section: Discussionmentioning

confidence: 99%

Potentially avoidable Inter-Facility transfer from Veterans Health Administration emergency departments: A cohort study

Mohr

Ward

et al. 2020

BMC Health Serv Res

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Background: Inter-facility transfer is an important strategy for improving access to specialized health services, but transfers are complicated by over-triage, under-triage, travel burdens, and costs. The purpose of this study is to describe ED-based inter-facility transfer practices within the Veterans Health Administration (VHA) and to estimate the proportion of potentially avoidable transfers. Methods: This observational cohort study included all patients treated in VHA EDs between 2012 and 2014 who were transferred to another VHA hospital. Potentially avoidable transfers were defined as patients who were either discharged from the receiving ED or admitted to the receiving hospital for ≤1 day without having an invasive procedure performed. We conducted facility-and diagnosis-level analyses to identify subgroups of patients for whom potentially avoidable transfers had increased prevalence. Results: Of 6,173,189 ED visits during the 3-year study period, 18,852 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p < 0.001), and 22.8% of all VHA-to-VHA transfers were potentially avoidable transfers. The 3 disease categories most commonly associated with inter-facility transfer were mental health (34%), cardiac (12%), and digestive diagnoses (9%). Conclusions: VHA inter-facility transfer is commonly performed for mental health and cardiac evaluation, particularly for patients in rural settings. The proportion that are potentially avoidable is small. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions.

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Section: Discussionmentioning

confidence: 99%

Potentially avoidable Inter-Facility transfer from Veterans Health Administration emergency departments: A cohort study

Mohr

Ward

et al. 2020

BMC Health Serv Res

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“…From our data, it is not possible to determine whether patients sought local care because (1) it was most rapidly available and they perceived that they had a time-sensitive condition, (2) they were transported by ambulance, and emergency medical personnel selected a local hospital for treatment, (3) they anticipated transfer to a tertiary center because of their perceived severity of illness, or (4) because they preferred to receive care from their personal physician. We have reported previously that rural patients value strongly both proximity to home and the comprehensive medical capabilities of the hospital where they receive their care (9), but balancing these factors with their perceived severity of illness and the capabilities of local hospitals can be challenging. (41)…”

Section: Discussionmentioning

confidence: 99%

“…(7) Rural hospitals have unique challenges in providing high-quality critical care (8), yet patients value proximity to home when deciding where they seek inpatient care. (9) This suggests that improving care delivery for sepsis patients presenting to rural community hospitals is an urgent need.…”

Section: Introductionmentioning

confidence: 99%

Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach*

Mohr

Harland

Shane

et al. 2017

Critical Care Medicine

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Objective To identify factors associated with rural sepsis patients’ bypassing rural emergency departments (EDs) to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival. Design, Setting, and Patients Cohort study of adults treated in EDs of a rural Midwestern state with severe sepsis or septic shock between 2005 and 2014, using administrative claims data. Patients residing ≥ 20 miles from a top-decile sepsis volume hospital and < 20 miles from a local hospital were included. Interventions Patients bypassing local rural hospitals to seek care in larger hospitals. Measurements and Main Results A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their ED care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs. 72.7 y, p<0.001) and were more likely to have commercial insurance (19.6% vs. 10.6%, p<0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%, p<0.001), metastatic cancer (5.9% vs 3.2%, p<0.001), and diabetes with complications (25.2% vs. 21.6%, p=0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95%CI 2.2 – 8.9%) in mortality. Conclusions Most rural patients with sepsis seek care in local EDs, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality.

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“…Predicting the clinical course in these critically ill patients can be quite challenging and determining whether a particular rural hospital has the capacity to care for such a patient is complex. Patients often want to remain local for treatment whenever possible, however, transport to a tertiary care centre sometimes becomes necessary [9].…”

Section: Introductionmentioning

confidence: 99%

Chest Pain on the Ward: A Simulation Scenario for Rural Family and Emergency Medicine Trainees

Williams¹,

Crocker²,

Dubrowski³

2020

Cureus

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Chest pain is a frequently encountered emergency room presentation, of which about 15% of cases are due to acute coronary syndromes. Cardiogenic shock is a relatively uncommon complication with associated high morbidity and mortality. Emergency medicine practitioners frequently encounter critically ill patients that require quick, definitive treatment to optimize patient outcomes. These high acuity presentations often are of relatively low occurrence which makes training residents and learners challenging. Simulation-based medical education has been shown to enhance patient outcomes by teaching these high acuity low occurrence (HALO) presentations in a safe environment. Herein we describe a simulation scenario of a patient with cardiogenic shock secondary to acute coronary syndrome. It consists of a step-wise, detailed summary of the case, along with modifiers to adjust the case for repeated use, learning objectives, and a suggested evaluation.

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Discordance Between Patient and Clinician Experiences and Priorities in Rural Interhospital Transfer: A Mixed Methods Study

Abstract: Patients and physicians recognize similar factors that influence patient preferences in interhospital ED transfer, but physicians may overestimate the value of nonmedical influences on decision-making priorities.

Cited by 20 publications

References 32 publications

Potentially avoidable Inter-Facility transfer from Veterans Health Administration emergency departments: A cohort study

Potentially avoidable Inter-Facility transfer from Veterans Health Administration emergency departments: A cohort study

Rural Patients With Severe Sepsis or Septic Shock Who Bypass Rural Hospitals Have Increased Mortality: An Instrumental Variables Approach*

Chest Pain on the Ward: A Simulation Scenario for Rural Family and Emergency Medicine Trainees

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