Patient and Facility Characteristics Associated with Early Mortality After Interhospital Transfer

Outcomes 1. Describe key population characteristics and disparities associated with early mortality after transfer in urban and rural populations.2. Identify key gaps in care leading to early mortality after transfer and lending themselves to potential palliative care intervention. Key Message Early mortality after transfer, i.e., death within 72 hours of interhospital transfer, reflects many of the complex dynamics impacting intensity of care at end-of-life in the United States. In this cohort study of two representative academic hospitals, we sought to define the characteristics, care trajectories, and palliative care needs among patients experiencing early mortality after transfer. Introduction An estimated 20,000-50,000 patients annually die within 72 hours of interhospital transfer. Characteristics and care trajectories of these patients are not well explained. Objectives We sought to describe patients experiencing early mortality after transfer at two major referral centers. Methods Retrospective cohort study of patients ≥18 years who experienced early death after transfer to a medicine service at one of two large academic health centers, serving a rural and an urban area, respectively, from March 2020-August 2022. The primary outcomes were presence and timing of pre-transfer and post-transfer documentation of goals of care (GOC) or prognosis. We also assessed patient, hospital, and pre- and post-transfer care characteristics. Results Among 129 patients experiencing early mortality after transfer, 51.9% (67) were >65 years, 61.2% (79) were male, and 85.3% (110) were white. 80.6% (104) of patients were transferred >50 miles from home. 61.2% (79) were transferred for nonprocedural specialty care. Patients admitted to the rural center were more likely to be admitted to an intensive care unit (89.6% vs 60.9%, p< 0.01) and to travel >50 miles (87.7% vs 47.8%, p< 01).Pre-transfer GOC discussions occurred in 24 cases(18.6%); transferring and receiving clinicians discussed prognosis in 8 (6.2%). Following transfer, GOC discussions occurred for 105 patients (82.9%, 95% CI); 61 discussions (47.2%) occurred ≤24 hours after transfer, and 86 (81.9%) occurred ≤24 hours before death. 29 (22.5%) patients underwent cardiopulmonary resuscitation, and 19 (14.7%) were evaluated by palliative care. Conclusion In our sample, patients who experienced early death after transfer were predominantly older, male and white. The majority traveled >50 miles from home. Further research is needed to evaluate for disparities in transfer, and to describe the potential burdens of end-of-life transfer and assess palliative care needs in this population. Pre-transfer discussion of GOC and prognosis occurred infrequently, suggesting potential targets for improvement. Keywords Management of Medical Interventions / Scientific Research