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Original Research |

Insurance Status and the Transfer of Hospitalized Patients: An Observational Study

Janel Hanmer, MD, PhD; Xin Lu, MS; Gary E. Rosenthal, MD; and Peter Cram, MD, MBA
[+] Article and Author Information

From University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Iowa Carver College of Medicine, Center for Comprehensive Access and Delivery Research and Evaluation, and Iowa City Veterans Affairs Medical Center, Iowa City, Iowa; and University of Toronto and University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Grant Support: By a K24 award from National Institute of Arthritis and Musculoskeletal and Skin Diseases (AR062133; Dr. Cram); Center of Innovation Award (CIN 13-412; Drs. Cram and Rosenthal) from the Health Services and Development Service, Veterans Health Administration; Clinical and Translational Science Award (2 UL1 TR000442-06; Dr. Rosenthal) from the National Center for Advancing Translational Science; and in part by grants R01 HL085347 from National Heart, Lung, and Blood Institute and R01 AG033035 from National Institute on Aging at the National Institutes of Health.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1977.

Reproducible Research Statement: Study protocol and statistical code: Available from Dr. Hanmer (e-mail, hanmerjz@upmc.edu). Data set: Available at www.hcup-us.ahrq.gov/tech_assist/centdist.jsp.

Requests for Single Reprints: Janel Hanmer, MD, PhD, University of Pittsburgh Medical Center Montefiore Hospital, Suite W93, 200 Lothrop Street, Pittsburgh, PA 15213; e-mail, hanmerjz@upmc.edu.

Current Author Addresses: Dr. Hanmer: University of Pittsburgh Medical Center Montefiore Hospital, Suite W933, 200 Lothrop Street, Pittsburgh, PA 15213.

Ms. Lu and Dr. Rosenthal: Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242.

Dr. Cram: Division of General Internal Medicine, University of Toronto and University Health Network/Mount Sinai Hospital, 200 Elizabeth Street, Eaton North, Toronto, Ontario, Canada M5G 2C4.

Author Contributions: Conception and design: J. Hanmer, X. Lu, P. Cram.

Analysis and interpretation of the data: J. Hanmer, X. Lu, G.E. Rosenthal, P. Cram.

Drafting of the article: J. Hanmer, P. Cram.

Critical revision of the article for important intellectual content: J. Hanmer, X. Lu, G.E. Rosenthal, P. Cram.

Final approval of the article: J. Hanmer, X. Lu, G.E. Rosenthal, P. Cram.

Provision of study materials or patients: X. Lu.

Statistical expertise: J. Hanmer, X. Lu, P. Cram.

Obtaining of funding: P. Cram.

Administrative, technical, or logistic support: J. Hanmer, X. Lu, P. Cram.

Collection and assembly of data: J. Hanmer, X. Lu, P. Cram.


Ann Intern Med. 2014;160(2):81-90. doi:10.7326/M12-1977
Text Size: A A A

Background: There is little objective evidence to support concerns that patients are transferred between hospitals based on insurance status.

Objective: To examine the relationship between patients’ insurance coverage and interhospital transfer.

Design: Data analyzed from the 2010 Nationwide Inpatient Sample.

Patients: All patients aged 18 to 64 years discharged alive from U.S. acute care hospitals with 1 of 5 common diagnoses (biliary tract disease, chest pain, pneumonia, septicemia, and skin or subcutaneous infection).

Measurements: For each diagnosis, the proportion of hospitalized patients who were transferred to another acute care hospital based on insurance coverage (private, Medicare, Medicaid, or uninsured) was compared. Logistic regression was used to estimate the odds of transfer for uninsured patients (reference category, privately insured) while patient- and hospital-level factors were adjusted for. All analyses incorporated sampling and poststratification weights.

Results: Among 315 748 patients discharged from 1051 hospitals with any of the 5 diagnoses, the percentage of patients transferred to another acute care hospital varied from 1.3% (skin infection) to 5.1% (septicemia). In unadjusted analyses, uninsured patients were significantly less likely to be transferred for 3 diagnoses (P < 0.05). In adjusted analyses, uninsured patients were significantly less likely to be transferred than privately insured patients for 4 diagnoses: biliary tract disease (odds ratio, 0.73 [95% CI, 0.55 to 0.96]), chest pain (odds ratio, 0.63 [CI, 0.44 to 0.89]), septicemia (odds ratio, 0.76 [CI, 0.64 to 0.91]), and skin infections (odds ratio, 0.64 [CI, 0.46 to 0.89]). Women were significantly less likely to be transferred than men for all diagnoses.

Limitation: This analysis relied on administrative data and lacked clinical detail.

Conclusion: Uninsured patients (and women) were significantly less likely to undergo interhospital transfer. Differences in transfer rates may contribute to health care disparities.

Primary Funding Source: National Institutes of Health.

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