Nationwide Trends in Transfer of the Surgical Patient

Ciara R Huntington, MD, Tiffany C Cox, MD, Laurel J Blair, MD, Tanushree Prasad, MA, Amy E Lincourt, MBA, PhD, Brent D Matthews, MD, FACS, Vedra A Augenstein, MD, FACS, B T Heniford, MD, FACS. Carolinas Medical Center

Introduction: With regionalization of surgical care, reduction of the rural workforce, rising healthcare costs, and increasing focus on surgical outcomes, appropriate transfer of surgical patients is an increasingly important aspect of health care. Herein, this study examines patients transferred for surgical intervention through a national sample.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 – 2012 for patients who were transferred from an outside hospital or emergency department and compared to patients undergoing surgery without transfer. Patients were divided in to two time periods (TP): 2005-2008(TP1) and 2008-2012(TP2) for analysis; patient characteristics and top CPT codes for each time period were collected. Standard univariate analysis was used to compare the groups.

Results: Over the seven years examined, 61,204 patients were transferred and underwent surgery. Overall, the rate of transferred surgery patients increased from 3.2% in TP1 to 4.5% in TP2 (p<0.0001). The most commonly performed operations after transfer were small bowel resection, exploratory laparotomy, laparoscopic appendectomy, laparoscopic cholecystectomy, colectomy, and carotid endarterectomy. Compared to non-transferred patients in all TP, transferred patients had higher rates of diabetes (23.4% vs 17.6%, p<0.0001), tobacco use (27.9%vs20.3%,p<0.0001), obesity (41.5%vs 35.9%,p<0.0001), Charlson comorbidity index (mean score 1.5vs0.8, P<0.0001), preoperative sepsis (32.0% vs9.4%, p<0.0001), and need for emergent surgery(41.3%vs14.4%,p<0.0001). From TP1 to TP2, there was an increase in the proportion of transferred patients who were Caucasian (82.6% in TP1, 84.9% in TP2; p<0.0001), decrease in diabetic patients (24.7%to 23.1%;p<0.0001), increase in obese patients (33.9%to 36.4%;p<0.0001), and slight decrease in emergent transfers (39.6% to 41.8%;p=0.003). There was a significant increase in minor complications 17.7% to 31.0%(p<0.0001), but an overall decrease in major complications 32.1% to 23.9%(p<0.0001) and 30-day mortality 11.9% to 8.1% (p<0.0001) for transferred patients.

Conclusions: Patients transferred for surgery represent a higher acuity population than non-transferred patients, and the number of these transferred patients continues to rise. Surgical sub-specialization and surgeons competing in regions where insurance companies tier physicians will complicate future transfer practices. Our results indicate there has been some change in the patient characteristics and an improvement in surgical outcomes among those transferred for surgical care in the past decade. Enhancement in patient outcomes may indicate a maturing infrastructure and network adapting to the needs of surgical patients.

Table 1-Characteristics of Transferred Patients (TP1vsTP2)
TP1-2005-2008 TP2-2009-2012 p value
#of Patients 13,131 48,073 NA
%Caucasian 82.6% 84.9% <0.0001
Average CCI 1.75 1.45 <0.0001
%Diabetes 24.7% 23.1% <0.0001
%Obese 33.9% 36.4% <0.0001
%Tobacco Use 28.3% 27.8% NS
%Emergent Cases 39.6% 41.8% <0.0001
%Minor Complications 17.7% 31.0% <0.0001
%Major Complications 32.1% 23.9% <0.0001
30-day Mortality 11.8% 8.1% <0.0001

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