Impact of Transfer Status on Real World Outcomes in Cardiac Surgery
Jared P Beller1, William Z Chancellor1, James H Mehaffey1, Robert B Hawkins1, Clifford E Fonner2, Alan M Speir3, Mohammed A Quader4, Jeffrey B Rich5, Leora T Yarboro1, Nicholas R Teman1, Gorav Ailawadi1
1University of Virginia, Charlottesville, VA;2Virginia Cardiac Services Quality Initiative, Virginia Beach, VA;3INOVA Heart and Vascular Institute, Falls Church, VA;4Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA;5Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
OBJECTIVES: Few single center studies have suggested patients transferred from hospital to hospital for cardiac surgery have increased morbidity. We hypothesized patients transferred from another hospital prior to their operation would have worse outcomes, particularly when transferred from a center that performs cardiac surgery.
METHODS: All patients undergoing coronary artery bypass grafting and/or valve operations with a Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) (2011-2017) were evaluated from a multicenter, statewide STS database. In order to exclude scheduled operations, only patients requiring admission prior to surgery were included. Patients were stratified by admission source and cardiothoracic surgery availability at the transferring center (transfer from cardiothoracic surgery center [CT] vs. Emergency Department [ED] vs. transfer from non-cardiothoracic surgery center [non-CT]). Groups were compared by appropriate univariate analysis. Risk-adjusted outcomes were assessed using STS predicted risks in a hierarchical model to account for center level effects.
RESULTS: A total of 29,748 patients underwent qualified procedures and had a STS risk score. Of these, 13,094 (44%) met the inclusion criteria of admission prior to surgery and included 502 (3.8%) transferred from CT centers, 5,512 (42.1%) admitted through the ED, and 7,072 (54%) admitted as transfers from non-CT centers. Patient demographics, operations performed and comorbid conditions were similar between the ED admissions and those transferred from non-CT centers; however those transferred from CT centers had significantly more advanced disease (lower ejection fraction, more reoperative surgery and more combined coronary and valve surgery, all p<0.01). Operative risk was highest in those transferred from CT centers followed by those admitted from the ED and lowest in the non-CT center transfer group (STS PROM 5.2% vs. 3.7% vs. 3.2%, p<0.001; STS Predicted Risk of Morbidity or Mortality (PROMM) 27.4% vs. 22.1% vs. 20.8%, p<0.001). Expectedly, rates of major morbidity were highest in those transferred from CT centers (23.9% vs. 15.2% vs. 15.0%, p<0.01). In risk-adjusted analysis, admission source was not an independent predictor of mortality (Table). However, patients transferred from a center with CT surgery independently predicted increased odds of major morbidity (OR 1.30, p=0.03) while the risk of major morbidity was similar between ED admissions and transfers from a non-CT center (Table).
CONCLUSIONS: Patients transferred from centers that have cardiothoracic surgery abilities are high risk. Appropriate triage leads to excellent regional outcomes, but risk-adjusted odds of major morbidity remains higher for these patients than those admitted through other sources. When receiving a transfer from a center that performs cardiac surgery, accepting physicians and administrators should be aware of this additional independent risk for major morbidity.
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