Best Practices & Benign Disease
Introduction & Objective : Inpatient urological care is not universally available in the U.S. The inter-hospital transfer of patients represents one avenue to meet this critical need, but to date its use is largely unknown. Therefore, we performed an analysis of all patients transferred to the primary urology service of a metropolitan quaternary care center.
Methods : A cross-sectional retrospective review of all patients transferred to our health system from 9/1/2015-9/30/2017 was performed. Cases with a urology attending as the accepting physician underwent a chart review to confirm a urological diagnosis as the reason for transfer. Transfers were categorized into one of 10 mutually exclusive categories based on the primary diagnosis. We examined the specialty of requesting physician, availability of urology services at the requesting hospital, transfer distance, level of transfer, time to admission, need for surgical management, length of stay, and cost.
Results : A total of 87 primarily urological transfers were identified (0.5% of total transfers to the health system). The majority were transferred at emergent level (68%). This required on average 9.8 hours (SD ±10.9 hours) for arrival. Average travel distance was 37 miles (SD ±25 miles). While 92% of requesting hospitals had an associated urologist, they comprised only 15% of referring physicians. Hospitalists (38%) made up the largest category of referring physicians, followed by emergency medicine (33%). Categories of transfers and management are shown in the figure. Overall, 40% of patients required a procedure during their stay. The median LOS was 4 days (IQR: 2-8 days) and was not significantly different between surgically and medically managed patients (p=0.60). The average total cost per transfer was $30,980, with an average fixed cost of $18,698 and an average variable cost of $12,282.
Conclusions : Despite being a large quaternary care referral center, our institution only received a relatively small number of urological transfers. Urological services were available at almost all referring hospitals. Once accepted, patients were transferred relatively quickly and over short distances. Less than half required a procedure. Future efforts may determine if these patients can safely avoid a transfer by leveraging our expertise through telemedicine with deference given to elective, ambulatory follow up if needed.