Introduction: Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. The literature has been inconclusive regarding outcomes for patients directly-admitted to specialized centers versus those transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the “transfer effect” in a large sample of aneurysmal SAH patients undergoing treatment.

Methods: Using Nationwide Inpatient Sample (NIS) 2002-2007 data, we analyzed outcomes of SAH patients treated with coil or clip procedures. Analyses studied the effect of direct-admit versus transfer admission on mortality, discharge disposition, complications, in-hospital length of stay (LOS) and cost burden.

Results: Of 47,114 patients, 31,711 (67.3%) were direct-admits and 15,403 (32.7%) were transfers. Transfer patients had similar mortality (OR 0.9, p=.13) and complications (OR 0.9, p=.22) as direct-admits. However, transfer patients incurred higher non-routine discharge (OR 1.3, p=.002) than direct-admits. Patients treated in lowest-quintile volume hospitals were 1.6 times more likely to die than those treated at the highest-quintile hospitals (OR 1.6, CI: 1.2-2.0, p=.002). Similar findings were observed when comparing patients treated in second-lowest quintile when compared to highest-volume hospitals (OR 1.4, CI: 1.0-1.9, p=.03). Transfer patients averaged 1 day longer in-hospital stays and $12,244 higher cost than direct-admit patients.

Conclusions: Transfer patients had the same outcomes as the direct-admit SAH patients. Furthermore, we showed that high-volume hospitals had superior outcomes. Therefore, our study supports the growing centralization trend of lower volume hospitals to high volume SAH centers.

Patient Care: This research will help practitioners to decide whether or not is is appropriate to transfer patients with subarachnoid hemorrhage.

Learning Objectives: By the conclusion of this session participants will be able to the assess: (1) The effect of the transfer process in subarachnoid hemorrhage patients (2) To understand the role of hospital volume in determining outcomes of SAH patients (3) To understand the benefits of treatment centralization to higher-volume/specialized hospitals for SAH patients

References: 1.Juraschek SP, Zhang X, Ranganathan VK, Lin VW. United states registered nurse workforce report card and shortage forecast. Am J Med Qual. 2011 2.Barker FG, Carter BS, Ojemann RG, Jyung RW, Poe DS, McKenna MJ. Surgical excision of acoustic neuroma: Patient outcome and provider caseload. Laryngoscope. 2003;113:1332-1343 3.Curry WT, McDermott MW, Carter BS, Barker FG. Craniotomy for meningioma in the united states between 1988 and 2000: Decreasing rate of mortality and the effect of provider caseload. J Neurosurg. 2005;102:977-986 4.Cowan JA, Dimick JB, Henke PK, Huber TS, Stanley JC, Upchurch GR. Surgical treatment of intact thoracoabdominal aortic aneurysms in the united states: Hospital and surgeon volume-related outcomes. J Vasc Surg. 2003;37:1169-1174 5.Smith ER, Butler WE, Barker FG. Craniotomy for resection of pediatric brain tumors in the united states, 1988 to 2000: Effects of provider caseloads and progressive centralization and specialization of care. Neurosurgery. 2004;54:553-563; discussion 563-555 6.Chernov MF. The impact of provider volume on mortality after intracranial tumor resection and outcome and cost of craniotomy performed to treat tumors in regional academic referral centers. Neurosurgery. 2004;54:1027-1028; author reply 1028 7.Elson S. Regionalization of health care from a political and structural perspective. Healthc Manage Forum. 2009;22:6-11; discussion 12-21, 22-37 8.Duncan RP, McKinstry AK. Inpatient transfers and uncompensated care. Hosp Health Serv Adm. 1988;33:237-248 9.Jencks SF, Bobula JD. Does receiving referral and transfer patients make hospitals expensive? Med Care. 1988;26:948-958 10.Borlase BC, Baxter JK, Kenney PR, Forse RA, Benotti PN, Blackburn GL. Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: Cost and outcome prediction. J Trauma. 1991;31:915-918; discussion 918-919 11.Gordon HS, Rosenthal GE. Impact of interhospital transfers on outcomes in an academic medical center. Implications for profiling hospital quality. Med Care. 1996;34:295-309 12.Obremskey W, Henley MB. A comparison of transferred versus direct admission orthopedic trauma patients. J Trauma. 1994;36:373-376 13.Schiff RL, Ansell DA, Schlosser JE, Idris AH, Morrison A, Whitman S. Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med. 1986;314:552-557 14.Ligtenberg JJ, Arnold LG, Stienstra Y, van der Werf TS, Meertens JH, Tulleken JE, et al. Quality of interhospital transport of critically ill patients: A prospective audit. Crit Care. 2005;9:R446-451 15.Duke GJ, Green JV. Outcome of critically ill patients undergoing interhospital transfer. Med J Aust. 2001;174:122-125 16.Durairaj L, Will JG, Torner JC, Doebbeling BN. Prognostic factors for mortality following interhospital transfers to the medical intensive care unit of a tertiary referral center. Crit Care Med. 2003;31:1981-1986 17.Härtl R, Gerber LM, Iacono L, Ni Q, Lyons K, Ghajar J. Direct transport within an organized state trauma system reduces mortality in patients with severe traumatic brain injury. J Trauma. 2006;60:1250-1256; discussion 1256 18.Kollef MH, Von Harz B, Prentice D, Shapiro SD, Silver P, St John R, et al. Patient transport from intensive care increases the risk of developing ventilator-associated pneumonia. Chest. 1997;112:765-773 19.Bellingan G, Olivier T, Batson S, Webb A. Comparison of a specialist retrieval team with current united kingdom practice for the transport of critically ill patients. Intensive Care Med. 2000;26:740-744 20.Westfall JM, Kiefe CI, Weissman NW, Goudie A, Centor RM, Williams OD, et al. Does interhospital transfer improve outcome of acute myocardial infarction? A propensity score analysis from the cardiovascular cooperative project. BMC Cardiovasc Disord. 2008;8:22 21.Hill AD, Fowler RA, Nathens AB. Impact of interhospital transfer on outcomes for trauma patients: A systematic review. J Trauma. 2011;71:1885-1901 22.Healthcare Cost and Utilization Project (HCUP) Databases: Nationwide Inpatient Sample. Rockville MAfHRaQ, 2007 (http://www.hcup-us.ahrq.gov/nisoverview.jsp) [Accessed December 20, 2011]. 23.Hoh BL, Rabinov JD, Pryor JC, Carter BS, Barker FG. In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the united states, 1996-2000: Effect of hospital and physician volume. AJNR Am J Neuroradiol. 2003;24:1409-1420 24.Barker FG, Amin-Hanjani S, Butler WE, Hoh BL, Rabinov JD, Pryor JC, et al. Age-dependent differences in short-term outcome after surgical or endovascular treatment of unruptured intracranial aneurysms in the united states, 1996-2000. Neurosurgery. 2004;54:18-28; discussion 28-30 25.Cowan JA, Ziewacz J, Dimick JB, Upchurch GR, Thompson BG. Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms. J Neurosurg. 2007;107:530-535 26.Shea AM, Reed SD, Curtis LH, Alexander MJ, Villani JJ, Schulman KA. Characteristics of nontraumatic subarachnoid hemorrhage in the united states in 2003. Neurosurgery. 2007;61:1131-1137; discussion 1137-1138 27.Andaluz N, Zuccarello M. Recent trends in the treatment of cerebral aneurysms: Analysis of a nationwide inpatient database. J Neurosurg. 2008;108:1163-1169 28.Crowley RW, Yeoh HK, Stukenborg GJ, Medel R, Kassell NF, Dumont AS. Influence of weekend hospital admission on short-term mortality after intracerebral hemorrhage. Stroke. 2009;40:2387-2392 29.Organization WH. International classification of diseases and related health problems. 1993;2 30.Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8-27 31.Khatri R, Tariq N, Vazquez G, Suri MF, Ezzeddine MA, Qureshi AI. Outcomes after nontraumatic subarachnoid hemorrhage at hospitals offering angioplasty for cerebral vasospasm: A national level analysis in the united states. Neurocrit Care. 2011;15:34-41 32.Shukla R FR, Fisher R. Testing of 3m's apr-drg risk adjustment for hospital mortality outcomes. 2002 33.Shukla R FR, Fisher R. Testing of 3M's APR-DRG Risk Adjustment for Hospital Mortality Outcomes. Abstr Acad Health Serv Res Health Policy Meet, 2002, 19:11.