Predictors of Mortality among Inter-Hospital Transferred Patients in a Middle-Income Country: a Retrospective Cohort Study

Objective: To identify predictors for hospital mortality among inter-hospital transferred patients in low-resource settings of rural hospitals in Thailand.Methods: We conducted a retrospective cohort study of patients transferred from emergency room(ER) of a community hospital to its designated tertiary care hospital in a western province of Thailand. During March 2018 and February 2019, medical records of 412 patients were reviewed and extracted for potential predictor variables and outcomes. We defined deaths within 72 hrs after a transfer as primary outcome and overall hospital mortality as secondary outcome. Multivariate logistic regression analysis was performed to identify predictors of the outcomes adjusted for potential confounders.Results: Out of 412 patients, a total of 37 patients (9.0%) died during the stay in receiving hospital and 18 (4.4%) of them died within 72 hrs after transfer. Top ten primary diagnostic categories included road traffic injuries (19.7%), acute appendicitis (9.7%), and acute myocardial infarction (5.1%). Univariate analysis revealed early mortality (<72 hrs) was associated with NEWS2, Emergency Severity Index (ESI), cardiac arrest prior to transfer, use of vasoactive agents, endotracheal intubation and admitting service. Using multiple logistic regression model adjusted for the predictors identified by univariate analysis, we found early mortality was independently associated with NEWS2 ≥ 9 (compared to NEWS2 0-6) with OR= 17.51(95%CI 3.16-97.00) and vasoactive medication use (OR= 5.46, 95%CI 1.39-21.46). Similarly, overall mortality was also independently associated with NEWS2 ≥ 9(OR= 4.76, 95%CI 1.31–17.36) and vasoactive medication use (OR= 7.51,95%CI 2.76–20.45).Conclusion: This study identified predictors of early (<72 hrs) hospital mortality and overall hospital mortality among ER patients transferred from a rural community hospital to its designated tertiary care hospital in Thailand, a middle-income country with universal healthcare coverage. The findings might be helpful to inform decision-making dealing with the inter-hospital transfer of ER patients in resource-poor rural settings with similar case-mix.