Against the current: back-transfer as a mechanism for rural regionalization

This paper investigates back-transfer: the transfer of patients near the end of their acute hospitalization to a local community hospital for the completion of their medical care. We seek to describe factors contributing to back-transfer, with the goal of elucidating the current use of back-transfer and barriers to its more widespread adoption for rural healthcare regionalization.

Observational unmatched case-control.

This was a retrospective study of adults hospitalized in Iowa between 2005 and 2013 to identify back-transferred patients. Demographic, geographic, rurality, procedural, and disease information was compared among cases and control groups using univariate analysis and multivariable logistic regression.

Over the 9-year period, 172,544 back-transfer eligible patients were admitted to 1 of 5 large Iowa hospitals, of which 287 (0.2%) were back-transferred. Back-transferred patients were more likely than their non-back-transferred counterparts to be older, male, and white; to live in large rural areas; and to have public insurance. As inpatients, they had longer median lengths of stay (15 vs 5 days; P <.001), more medical comorbidities, and were more likely to have a cardiac catheterization procedure than the control group.

Back-transfer is a very rare event. While demographic and medical differences between back-transferred patients and controls may partially explain the infrequency, other systematic barriers must exist to limit back-transfer. These barriers likely include legal, financial, logistical, and patient care concerns. Despite the rarity with which it is employed, back-transfer is a promising strategy that could better utilize health resources, especially in rural America.