Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Objective: Over 40% of the 2.4 million emergency department (ED) visits to Veterans Health Administration (VHA) hospitals are from veterans who live in rural areas, a population at increased risk of interfacility transfer. Veterans may undergo interfacility transfer to obtain emergent or urgent access to specialized health services, particularly mental health care. However, such transfers raise questions regarding appropriate use of resources, travel burdens for patients and families, and logistical challenges for ED staff and providers that may delay timely care. We sought to describe ED-based, interfacility transfer rates within the VHA and to estimate the proportion of potentially avoidable transfers (PAT) of patients with mental health conditions relative to other diseases. Methods: This observational cohort included all patients who were transferred from a VHA ED to another VHA hospital between 2012 and 2014. We extracted data from Clinical Data Warehouse administrative data. PAT was defined as discharge from the receiving ED without a procedure, or hospital length of stay at the receiving hospital ≤ 1 day without having a procedure performed. We conducted facility-level and diagnosis-level analysis to identify conditions for which an alternative to transfer, such as telehealth access to specialty care, could be developed and implemented in low-volume or rural EDs. Results: Of 6,131,734 ED visits during the three-year study period, 18,875 (0.3%) were transferred from one VHA ED to another VHA facility. Rural residents were transferred three times as often as urban residents (0.6% vs. 0.2%, p<0.001), and 23.6% of all VHA-to-VHA transfers met the PAT definition. Mental health conditions were the most common reason for interfacility transfer (34% of all interfacility transfers), followed by heart disease (12%). Of transfers that met PAT criteria, 11% were for mental health diagnoses whereas 21% were for heart disease. Geographic analysis suggested that overall PAT proportion ranged across regions from 8-53% with mental health PATs between 2-42%. Conclusion: VHA interfacility transfer is commonly performed for mental health diagnoses, and there is substantial regional variation in potentially avoidable transfers in a national sample of transfers. A significant proportion of these transfers may be potentially avoidable. Future work should focus on improving capabilities to provide specialty evaluation locally for these conditions, possibly using telehealth solutions. Additional work should also focus on measuring the timeliness of these transfers.