The Structure of Critical Care Transfer Networks.

Abstract

Rationale-Moving patients from low performing hospitals to high performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival.Objective-To characterize the existing critical care network in terms of the pattern of transfers.Methods-In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations.Measurements-We measured the characteristics of the interhospital transfer network and the extent to which ICU patients are referred towards each hospital in that network, a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical and radiologic capabilities.Results-There were 47,820 transfers of critically ill patients among 3,308 hospitals. 4.5% of all critical care stays of any length involved an inter-hospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital position was associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals' centrality.Conclusions-Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.Critical illness is a common and growing part of American medicine. (1) In this paper, we provide the first description of the informal system that has evolved for transferring critically ill Medicare beneficiaries among hospitals. Using nationwide data for 2005, we document the incidence of inter-hospital critical care transfers, and characterize the transfer network. In addition, we test two pre-specified hypotheses about the flow patients in the critical care network. "Centrality" is a hospital-level variable that quantifies the extent to which patients flow towards each hospital. (21) Most fundamentally, hospitals transfer more patients to central hospitals. We define centrality formally in the Methods. We hypothesized that observable hospital organizational characteristics and capabilities (organizational, medical, surgical, and radiologic capabilities) are associated with hospital centrality. Second, we hypothesized that the significant variation between hospitals' centrality in the network is associated with specified hospital characteristics. METHODS Analytic ApproachWe measured the interhospital transfer system using the tools of network analysis. Hospitals are the nodes in the network. Hospitals are connected by trans...

Multilevel social spaces: The network dynamics of organizational fields

“…For our purposes, the primary external decision of consequence concerns the selection of collaboration partners. More specifically, we focus on patient transfers as one of the most frequently studied collaborative relationship observed among hospitals (Iwashyna, 2012;Iwashyna et al, 2009;Lomi & Pallotti, 2012;Veinot et al, 2012). Over time, hospitals may decide to collaborate by sharing clinical cases and knowledge with other hospitals.…”

Investigating the Temporal Dynamics of Interorganizational Exchange: Patient Transfers among Italian Hospitals

“…Patient transfer is one of the most important forms of inter-hospital collaboration (Lee et al 2011;Veinot et al 2012;Iwashyna and Courey 2011;Iwashyna et al, 2009;Lomi and Pallotti, 2012;Mascia et al, 2015;Stadtfeld et al, 2016;Mascia, Pallotti, and Angeli 2016), and typically occurs via direct inter-hospital patient transfers whereby patients discharged from one ("sender") hospital are admitted to another ("recipient") hospital. To be sure, patient transfers are ostensibly intended to promote the patient's health: A transfer occurs when a hospital has patients with complex pathologies for which it does not have adequate diagnostic and therapeutic facilities or clinical competences, or patients with pathologies that may be treated more efficiently and effectively elsewhere.…”

“…Inadequate coordination between hospitals involved in patient transfers has predictable adverse consequences (Lee et al 2011). For these varied reasons patient transfers produce signals of relational collaboration between hospitals (Iwashyna et al 2009;Bolland and Wilson 1994;Van de Ven and Walker 1984).…”

Effect of a Handover Tool on Efficiency of Care and Mortality for Interhospital Transfers

“…2 At tertiary referral centers, 49% of medical intensive care unit (ICU) admissions are transferred from another hospital. 3 Transfer patients have longer length of stay (LOS) than patients admitted directly from the emergency department or clinic.…”