Distance, Quality, or Relationship? Interhospital Transfer of Heart Attack Patients

We empirically investigate the pattern of where heart attack patients are transferred between hospitals. Using 2011 Florida State Emergency Department and Inpatient Databases, we demonstrate the relative importance of three key factors in determining transfer destinations: (1) the distance between sending and receiving hospitals, (2) publicly-reported quality measures of receiving hospitals, and (3) the relationship between sending and receiving hospitals as indicated by whether they are affiliated with the same multihospital system. Our conditional logit analysis shows that hospital relationship plays a more dominant role in determining transfer destinations than distance and quality. This result is robust to three alternative specifications of choice sets using distance ranking, radius circles, and Hospital Referral Regions, and also robust to alternative measures of distance and quality. Using 30-day readmission rate to evaluate the health outcome of transferred patients, we find that relationship-based transfers led to worse outcome than distance-based and quality-based transfers. We also find that nonprofit hospitals are more likely to conduct quality-based transfers and less likely to conduct relationship-based transfers than their for-profit counterparts. Our study calls for reevaluating the current practice of relationship-driven routing of heart attack patients—selecting transfer destinations based on quality or distance can potentially decrease hospital readmission rate