Disparities in hospital transfer: inequities, patient-centered care, or both?

In the early 1970s, Wennberg and colleagues identified marked geographic variations in the use of numerous medical procedures and hypothesized that these variations highlighted areas of uncertainty in clinical practice (1). Since then, researchers have been examining databases for variations in practices as a means towards improving patient outcomes—identifying which factors reflect attention to patients’ preferences and which nonmedical factors affect clinical decisions negatively. Examination of practice patterns revealed persistent differences in care that were associated with race, sex, and socioeconomic status. For example, analyses of care provided to Medicare beneficiaries with acute myocardial infarction revealed that African Americans were less likely to undergo reperfusion therapy or to receive beta-blockers at discharge (2). Studies conducted with clinically detailed data corroborated these findings (3). Despite the prevalence of inequities, causal pathways remain elusive in most cases. In this issue of the Journal, Gurwitz and colleagues have added another element to the list of procedures and practices for which disparities exist independent of clear clinical causes (4). Using the National Registry of Myocardial Infarction 2 (NRMI 2), a voluntary database composed of patients from 1674 hospitals, they found that hospital transfers were more prevalent among patients who were white, older, and covered under commercial insurance or managed care. Overall, 72% of the 537,283 patients were not transferred to another acute care facility. The likelihood of nontransfer, however, varied among groups. Patients aged 75 years or older were less likely to be transferred than were patients younger than 65 years. Likewise, patients in the Medicare and Medicaid/self-pay group were less likely to be transferred, as compared with commercially insured patients, as were patients who were African American or who had histories of prior heart attack, angina, heart failure, and revascularization. Patients at facilities with less interventional capacity were more likely to be transferred. As the authors point out, identified differences are important because of the role that transfers play in the pathway for some patients for access to and utilization of certain procedures. Understanding why these differences occur may shed light on etiologies that underlie many racial/ethnic and sex disparities more broadly. Possible etiologies that underlie inequities include differences in access to care; patient knowledge, health beliefs, attitudes, and preferences; provider attitudes and beliefs; and communication and bias on the part of providers or the health care system. Further study of determinants of transfers may reveal more about patient preferences and perceptions of quality—the key components of patient-centered care (5). The challenge is to build on these findings such that patient outcomes can be improved, not only for patients in groups for which disparities have been identified but for the broader population of patients with myocardial infarction. Canto et al.’s study of use of thrombolysis for eligible Medicare beneficiaries demonstrated significant differences in care associated with African-American race and female sex; however, only 59% of white men received this treatment, suggesting that reducing disparities and improving quality of care for all are closely related (6). While the NRMI 2 database is an outstanding resource for addressing some questions about transfers, it is limited by a lack of patient-reported data and information on outcomes. Certain decisions not to transfer patients who are very ill may be appropriate because the patients have little likelihood of benefit, wish to remain at the initial hospital, or do not wish to undergo more intensive treatment; the NRMI 2 database does not permit understanding of potential adverse consequences of transfers. Subsequent studies will need to include qualitative data and more detailed data from patients and providers to identify underlying etiologies and to suggest necessary changes. The pathways leading to a decision to transfer are influenced by a multitude of factors that vary depending on which patient subgroup is being evaluated. For example, the decision to transfer a patient from a facility with full interventional capacity is likely to be based on different considerations than a decision to transfer a patient from a facility without invasive capabilities. Prehospital factors include where a patient lives and works, how the patient presents to the health care system, to which facilities a patient perceives that he or she has access, and the patient’s prior experiences with and knowledge of the health care system. Intrahospital factors include the patient’s clinical course, the patient’s preferences, the quality of Am J Med. 2002;112:580 –581. From the Center for Outcomes and Effectiveness Research, Agency for Healthcare Research and Quality, Rockville, Maryland. The opinions in this article are those of the authors and do not represent the official policy of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. Requests for reprints should be addressed to Daniel B. Stryer, MD, or Carolyn Clancy, MD, Center for Outcomes and Effectiveness Research, Agency for Healthcare Research and Quality, 6010 Executive Boulevard, Suite 300, Rockville, Maryland 20852.