Association between interhospital transfer and increased in-hospital mortality in patients with spinal epidural abscesses

BACKGROUND CONTEXT Spinal epidural abscess (SEA) is an uncommon yet serious infection, associated with significant morbidity and mortality. Patients diagnosed with SEA often require surgical interventions or critical care services that are not available at community hospitals and are therefore transferred to tertiary care centers. Little is known about the effects of interhospital transfer on acute outcomes for patients with SEA. PURPOSE To study the effects of interhospital transfer on acute outcomes for patients with SEA. STUDY DESIGN Cross sectional analysis using the 2009 to 2017 National Inpatient Sample (NIS). PATIENT SAMPLE Using the 2009 to 2017 NIS, we identified cases of SEA using ICD, Ninth, or Tenth Revision diagnosis codes 324.1 & G06.1. OUTCOME MEASURES Our primary endpoint was in hospital mortality. METHODS The association between interhospital transfer and inpatient mortality was assessed using multivariable logistic regression to adjust for potential covariates. Patient and hospital factors associated with interhospital transfer were assessed in a secondary analysis. RESULTS A total of 21.5% of patient with SEA were treated after transfer from another hospital. After adjusting for covariates, those who presented after transfer had higher odds of death during hospitalization (OR: 1.51, 95% CI 1.27–1.78, p<.001). Transferred patients were significantly more likely to live in rural communities (11.4 % vs. 5.3 % for nontransferred patients). CONCLUSIONS Interhospital transfer, which occurred more frequently in patients from rural hospitals, was associated with death even after controlling for disease severity. Addressing healthcare delivery disparities across the US, including across the rural-urban spectrum, will require better understanding of the observed increased mortality of interhospital transfer as a preventable source of in-hospital mortality for SEA.

背景情况 脊髓硬膜外脓肿（SEA）是一种不常见但严重的感染，与显著的发病率和死亡率相关。被诊断为SEA的患者通常需要手术干预或重症监护服务，而这些在社区医院无法提供，因此会被转至三级医疗中心。关于医院间转诊对SEA患者急性期预后的影响知之甚少。 目的 研究医院间转诊对SEA患者急性期预后的影响。 研究设计 使用2009年至2017年全国住院患者样本（NIS）进行横断面分析。 患者样本 利用2009年至2017年的NIS，我们使用国际疾病分类第九版或第十版诊断代码324.1和G06.1确定了SEA病例。 预后指标 我们的主要终点是住院死亡率。 方法 使用多变量逻辑回归评估医院间转诊与住院死亡率之间的关联，以调整潜在的协变量。在二次分析中评估了与医院间转诊相关的患者和医院因素。 结果 共有21.5%的SEA患者是从其他医院转诊后接受治疗的。在调整协变量后，转诊后就诊的患者在住院期间死亡的几率更高（比值比：1.51，95%置信区间1.27 - 1.78，p <.001）。转诊患者更有可能居住在农村社区（11.4%，而非转诊患者为5.3%）。 结论 医院间转诊在来自农村医院的患者中更为频繁，即使在控制疾病严重程度后，也与死亡相关。解决美国各地（包括城乡范围内）的医疗服务差异，需要更好地理解所观察到的医院间转诊导致的死亡率增加这一可预防的SEA住院死亡原因。