Transfers to a Public Hospital: A Prospective Study of 467 Patients

New England Journal of Medicine (Impact Factor: 55.87). 03/1986; 314(9):552-7. DOI: 10.1056/NEJM198602273140905
Source: PubMed


In recent years there has been a dramatic increase in the number of patients transferred to public hospitals in the United States. We prospectively studied 467 medical and surgical patients who were transferred from the emergency departments of other hospitals in the Chicago area to Cook County Hospital and subsequently admitted. Eighty-nine percent of the transferred patients were black or Hispanic, and 81 percent were unemployed. Most (87 percent) were transferred because they lacked adequate medical insurance. Only 6 percent of the patients had given written informed consent for transfer. Twenty-two percent required admission to an intensive care unit, usually within 24 hours of arrival. Twenty-four percent were in an unstable clinical condition at the transferring hospital. The proportion of transferred medical-service patients who died was 9.4 percent, which was significantly higher than the proportion of medical-service patients who were not transferred (3.8 percent, P less than 0.01). There was no significant difference in the proportion of deaths on the surgical service between patients who were transferred and those who were not (1.5 vs. 2.4 percent). We conclude that patients are transferred to public hospitals predominantly for economic reasons, in spite of the fact that many of them are in an unstable condition at the time of transfer.

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    • "A number of other investigators have documented the different characteristics and outcomes of patients transferred to tertiary referral centers. Schiff et al. (27), in 1986, examined medical and surgical transfers to Cook County Hospital in Chicago and demonstrated that patients were mainly transferred for economic reasons, with the vast majority being unemployed or otherwise lacking medical insurance. Borlase et al. (16) compared surgical ICU patients according to admission source and found that transfers had a higher mortality, 36%, compared with 12% in nontransfers. "
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    ABSTRACT: Mortality and length of stay are two outcome variables commonly used as benchmarks in rating the performance of medical centers. Acceptance of transfer patients has been shown to affect both outcomes and the costs of health care. Our objective was to compare observed and predicted lengths of stay, observed and predicted mortality, and resource consumption between patients directly admitted and those transferred to the intensive care unit (ICU) of a large academic medical center. Observational cohort study. Mixed medical/surgical ICU of a university hospital. A total of 4,569 consecutive patients admitted to a tertiary care ICU from April 1, 1997, to March 30, 2000. None. Acute Physiology and Chronic Health Evaluation (APACHE) III score, actual and predicted ICU and hospital lengths of stay, actual and predicted ICU and hospital mortality, and costs per admission. Crude comparison of directly admitted and transfer patients revealed that transfer patients had significantly higher APACHE III scores (mean, 60.5 vs. 49.7, p < .001), ICU mortality (14% vs. 8%, p < .001), and hospital mortality (22% vs. 14%, p < .001). Transfer patients also had longer ICU lengths of stay (mean, 6.0 vs. 3.8 days, p < .001) and hospital lengths of stay (mean, 20 vs. 15.9 days, p < .001). Stratified by disease severity using the APACHE III model, there was no difference in either ICU or hospital mortality between the two populations. However, in the transfer group with the lowest predicted mortality of 0-20%, ICU and hospital lengths of stay were significantly higher. In crude cost analysis, transfer patients' costs were $9,600 higher per ICU admission compared with nontransfer patients (95% confidence interval, $6,000-$13,400). Risk stratification revealed that the higher per-patient cost was entirely confined to the transfer patients with the lowest predicted mortality. Patients transferred to a tertiary care ICU are generally more severely ill and consume more resources. However, they have similar adjusted mortality outcomes when compared with directly admitted patients. The difference in resource consumption is mainly attributable to the group of patients in the lowest predicted risk bracket.
    Full-text · Article · Jun 2007 · Critical Care Medicine
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    • "Much of this work was composed of descriptive studies designed to document disparities in care for the poor and uninsured. Among these studies were descriptive analyses of ''patient dumping,'' a practice in which private hospitals transferred uninsured patients to public hospital EDs, regardless of medical condition [7]. This analytic work influenced landmark federal legislation, the Emergency Medical Treatment and Active Labor Act (EMTALA), which established a statutory duty for Medicare-participating hospitals with EDs to serve any person seeking emergency care [8]. "
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    ABSTRACT: This chapter addresses past successes and challenges and then elaborates on the potential for further advances in three areas that bridge emergency medicine and the broader public health and health services research agenda: (1) monitoring health care access; (2) surveillance of diseases, injuries, and health risks; and (3) delivering clinical preventive services. This article also suggests ways to advance policy-relevant research on systems of health and social welfare that impact the health of the public.
    Preview · Article · Dec 2006 · Emergency Medicine Clinics of North America
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    • "pitals receiving patients dumped from other hospitals ran into millions of US dollars [2]. Ansell and Schiff estimated that the total cost per annum to public hospitals in the US, as a direct result of patient dumping, was approximately US$ 1.04 billion [11], while Bernard et al. also indicated that those patients that had been dumped often consumed more hospital resources than other patients because of the delay in their treatment or the high severity of their illnesses [14]. This concurs with our finding of approximately 57% of respondents agreeing that patient dumping led to increased consumption of medical resources (Table 3). "
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    ABSTRACT: Little research has been carried out to explore the issues surrounding patient dumping outside of the US. This study, therefore, uses a national research survey to examine the factors contributing to patient dumping within Taiwan. A self-administered postal survey was undertaken to assess the prevalence of patient dumping in Taiwan, with the study subjects being superintendents of general hospitals. Data from the Bureau of Medical Affairs at the Department of Health in Taiwan were used in conjunction with the Taiwan National Health Insurance Research Database (NHIRD) to obtain estimates of factors potentially contributing to patient dumping. A multiple logistic regression analysis was performed to determine the relationships between the perceived extent of patient dumping occurring within the respondents' healthcare networks, as well as other factors, including the total number of hospitals, total number of hospital beds, the percentages of beds in public, for-profit and teaching hospitals (vis-à-vis all hospital beds), discharges, discharges covered under the case payment system, transferred inpatients, and the perceived degree of competition within each healthcare market. A total of 485 survey questionnaires were distributed, of which 251 were returned, giving a response rate of 51.75%. The responses from 29.9% of the sample group indicated that the perceived extent of patient dumping occurring in their service area was 'serious' or 'very serious'. The regression analysis showed that after controlling for other factors, the superintendents' perceived extent of the patient dumping occurring within their healthcare networks was positively related to the total number of patients covered under the case payment system, the total number of discharged patients, the extent of healthcare market competition and the number of respondent's hospital beds. We conclude from our findings that, under the National Health Insurance system, patient dumping is a widespread problem within Taiwan's healthcare industry.
    Full-text · Article · Jul 2006 · Health Policy
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