Race and ethnicity may affect whether and where hospitals transfer patients

UNIVERSITY PARK, Pa. —  Black patients in Florida are transferred to public hospitals more often than white patients, even when comparing patients from the same hospital with similar health conditions and the same insurance, according to new research led by Charleen Hsuan, assistant professor of health policy and administration at Penn State. Before 1986, hospitals would sometimes transfer patients who could not afford care to public hospitals or other safety net hospitals. These safety net hospitals often had poorer health outcomes for their patients than their private counterparts. In 1986, a new federal law curtailed transfers of patients solely because they could not pay, but concerns remain about the reasons that patients are transferred from one hospital to another, Hsuan said.

Over three million patients are transferred between hospitals in the U.S. each year, according to the Centers for Disease Control and Prevention. While transfers typically occur because the original hospital cannot provide needed treatment, a variety of factors affect where or if a patient is transferred.

Hsuan and an interdisciplinary team of researchers studied more than 1.2 million emergency department transfers in Florida to understand whether individuals from different ethnic and racial groups were treated equitably. Their results, published recently in Health Services Research, revealed that Black patients were more likely to be transferred to public hospitals than white patients.

Public hospitals and other safety net hospitals often do not perform as well as private hospitals on quality measures, according to the researchers. Patients in public hospitals and other safety net hospitals are more likely to be readmitted to the hospital and may be more likely to acquire an infection while in the hospital, according to prior research. Hsuan said the poorer performance is often the result of overcrowding, which has been linked to worse outcomes for patients throughout a hospital, as her previous research demonstrated.

“Transfers can be very risky for seriously ill patients — and many emergency department patients are very unwell — so it is critically important that transfers are used properly and judiciously,” Hsuan said.

The researchers examined the records of 1,265,588 adult patients who were transferred from 187 emergency departments in Florida hospitals between 2010 and 2019. Data from 2020 onward were not used because the COVID-19 pandemic changed how and when hospitals transferred patients.

Because the data were collected only in Florida, these results may not generalize to the entire United States, according to researchers. Florida, however, is the third most populous state in the nation and home to over 22 million people, and Hsuan said the results need to be addressed whether or not they reflect the situation in the entire U.S.

The researchers analyzed six models, each of which explored specific aspects of how hospital transfers relate to a variety of factors, including patient race and ethnicity, patient insurance status, patient medical conditions, referring hospital urbanicity or rurality, and the market of hospitals around the referring hospital.

According to Hsuan, every model was important because each of these factors can affect whether and where a hospital transfers a patient. A rural hospital may be more likely to transfer a patient to a better-equipped regional hub hospital, public or not. A patient with Medicaid may be transferred differently than a patient with private insurance, and both may be transferred differently than a patient with no insurance.

The researchers compared the hospital transfer rates of non-Hispanic Black patients, Hispanic patients and non-Hispanic white patients. Results for Hispanic patients varied based on the specific conditions of the transfer, but Black patients were consistently transferred to public hospitals more often than white patients across all six models. The only times Black patients were not transferred more than white patients were a few specific medical conditions — like strokes and heart attacks — for which rigorous transfer protocols exist.

The disparity in the transfer rates varied based on which factors were being considered. Overall, 16.6% of Black patients were transferred to a public hospital while only 11.5% of white patients were. Health care system factors — like hospital market and urbanicity — accounted for most of the disparity. However, when comparing Black and white patients from the same hospital with similar health conditions and the same insurance, there was still an 0.8 percentage point difference in the rate of transfers to public hospitals resulting in more Black patients being transferred than white patients.

“No matter how similar the hospitals or patients were that we compared, a difference between transfer rates to public hospitals for Black and white patients persisted,” Hsuan said. “Even a small percentage difference affects many, many people when your system has millions of transfers.”

The researchers described the racial disparity as “concerning” in their publication. Hsuan said the reason for the disparity needs to be investigated, but addressing the problem is more important than immediately understanding the root cause.

“Our data do not allow us to identify why Black people are transferred to public hospitals more often, but whatever the cause, there is inequality in the system that should be examined and corrected,” Hsuan said. “We need to address this inequality so that a person of any background can enter any emergency department and receive the best possible care to treat their condition and — if needed — potentially save their life.”

Co-authors of this research include David Vanness, Department of Health Policy and Administration at Penn State; Yinan Wang, Department of Health Policy and Administration at Penn State; Douglas Leslie, Department of Public Health Sciences at Penn State; Eleanor Dunham, Department of Emergency Medicine at Penn State; Jeannette Rogowski, Department of Health Policy and Administration at Penn State; Alexis Zebrowski, Department of Emergency Medicine and Department of Population Health Science and Policy at Icahn School of Medicine at Mount Sinai; Brendan Carr, Department of Emergency Medicine and Department of Population Health Science and Policy at Icahn School of Medicine at Mount Sinai; David Buckler, Department of Emergency Medicine at Icahn School of Medicine at Mount Sinai; and Edward Norton, Department of Health Management and Policy and Department of Economics at University of Michigan.

The National Institute on Minority Health and Health Disparities, the Penn State Clinical and Translational Science Institute and the Penn State Social Science Research Institute supported this research.