Decision-Making in the Interhospital Transfer of Medicine Patients: A Novel Conceptual Model

Interhospital transfer (IHT), the movement of patients between acute care hospitals, has traditionally been based on the need to provide patients with care not available at the hospital to which they initially present. However, additional factors influencing medicine transfer decision-making and their interplay have not been described within a comprehensive framework.

The objective of the study is to characterize and integrate factors shaping IHT decision-making for medicine patients into a comprehensive conceptual model.

This is a qualitative study using focus groups guided by clinical cases and semistructured discussion guides as part of the POINT Study ("Identification and Prevention of Potentially Inappropriate Inter-Hospital Transfer," AHRQ R01 HS028621). Data were analyzed using thematic analysis with deductive and inductive approaches.

We used purposive convenience sampling to recruit patients/families, clinicians, and hospital leadership from 18 academic medical centers in the POINT Study and their affiliates. Patient/family representatives were recruited from a volunteer patient family advisory council.

IHT decision-making themes were identified through thematic analysis.

Seven 1-h focus groups included 39 participants from 13 tertiary hospitals and their affiliates. We grouped factors that shape IHT decision-making into themes and subthemes and describe their interactions. Specifically, we identified that medical necessity and contextual factors (e.g., hospital capacity) influence transfer decisions, with contextual factors playing a larger role than previously recognized. Participants also considered patient-, clinician-, and organization-level outcomes, as well as constraints imposed by IHT processes and the broader healthcare ecosystem. Based on these findings, we developed a conceptual model that captures the interrelationships among factors, potential IHT outcomes, and system constraints that influence IHT decision-making.

IHT decision-making reflects a complex interplay of medical necessity, contextual factors, anticipated outcomes, and system constraints. Our conceptual model provides a nuanced understanding of these dynamics and offers targets for improving transfer processes and supporting informed IHT decision-making.