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Cited by 37Health disparities and outcomesHospital Admissions and OutcomesHealthcare Policy and Management

Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare

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Shannon, Evan Michael, Zheng, Jie, Orav, E. John, Schnipper, Jeffrey L., Mueller, Stephanie K.·2021·JAMA Network Open
DOI 10.1001/jamanetworkopen.2021.3474PMC PMC7998076
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Abstract

Importance: Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized. Objective: To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit. Design, Setting, and Participants: This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020. Exposures: Race/ethnicity. Main Outcomes and Measures: The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion. Results: Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P < .001), while Hispanic patients had higher odds of IHT (adjusted odds ratio, 1.14; 95% CI, 1.05-1.24; P = .002) compared with White patients. Conclusions and Relevance: This national evaluation of IHT among patients hospitalized with diagnoses previously found to have mortality benefit with transfer found that, compared with White patients, Black patients had persistently lower adjusted odds of transfer after accounting for patient and hospital characteristics and measured across various hospital settings. Meanwhile, Hispanic patients had higher adjusted odds of transfer. This research highlights the need for the development of strategies to mitigate disparate transfer practices by patient race/ethnicity.

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  • The Emergency Medical Treatment and Active Labor Act requires that all patients be transferred to and accepted by referral hospitals if they require specialized care not available at the original facility.

    “Furthermore, it requires that all patients be transferred to (and must be accepted by) referral hospitals if they require specialized care not available at the original facility.”

    From Racial and ethnic disparities in interhospital transfer for complex emergency general surgical disease across the United States (2023) · cites this paper as [11]

    The Introduction says EMTALA's transfer language is vague: patients “should” be transferred when they need procedural care unavailable at the origin hospital, and transfer decisions are often left to clinicians. It does not say that all such patients must be transferred or that referral hospitals must accept them. No page number is available in our copy. (LLM, conf=0.89)

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  • The Emergency Medical Treatment and Active Labor Act forbids hospitals from denying or limiting emergency treatment to patients based on their ability to pay.

    “The Emergency Medical Treatment and Active Labor Act (EMTALA) forbids hospitals from denying or limiting emergency treatment to patients based on their ability to pay.”

    From Racial and ethnic disparities in interhospital transfer for complex emergency general surgical disease across the United States (2023) · cites this paper as [11]

    The Introduction (page not provided) says EMTALA calls for transfer when needed care is unavailable or the medical benefits outweigh the risks, regardless of payer status. That supports the payment-related principle, but the passage concerns interhospital transfer; it does not state that EMTALA forbids hospitals from denying or limiting emergency treatment generally. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

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Authors
Shannon, E. M., Zheng, J., Orav, E. J., Schnipper, J. L., & Mueller, S. K.
Affiliations
  • Brigham and Women's Hospital (US)
  • Harvard University (US)
Corresponding author
Shannon, Evan Michael
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2021-03-26
Volume
4
Issue
3
Pages
e213474
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2021.3474
PMC
PMC7998076
OpenAlex
W3137396937
Cited by
37
References
39
Citations by year
2026: 7 · 2025: 7 · 2024: 9 · 2023: 10 · 2022: 4
FWCI
3.18
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Social Sciences › Health › Health disparities and outcomes
  • Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
Keywords
interhospital transfer, racial and ethnic disparities, Medicare beneficiaries, Black patients, Hispanic patients, acute myocardial infarction, stroke, sepsis, respiratory diseases, mortality benefit, hospital teaching status, racial bias in medicine, older adults, hospital discharge decisions, length of hospital stay, hospital costs
MeSH terms
Aged, Aged, 80 and over, Cross-Sectional Studies, Ethnicity, Female, Medicare, Hospitalization, Hospitals, Humans, Male, Patient Transfer, Retrospective Studies, United States, Survival Rate, Hospital Mortality, Racial Groups

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