Interfacility transfers for US ischemic stroke and TIA, 2006-2014

Objective: To investigate changes in emergency department (ED) transfers for ischemic stroke (IS) and TIA.

Methods: We performed a retrospective observational study using the US Nationwide Emergency Department Sample to identify changes in interfacility ED transfers for IS and TIA from the perspective of the transferring ED (2006-2014). We calculated nationwide transfer rates and individual ED transfer rates for IS/TIA by diagnosis and hospital characteristics. Hospital-level fractional logistic regression examined changes in transfer rates over time.

Results: The population-estimated number of transfers for IS/TIA increased from 22,576 patient visits in 2006 to 54,485 patient visits in 2014 (p trend < 0.001). The rate of IS/TIA transfer increased from 3.4 (95% confidence interval [CI] 3.0-3.8) in 2006 to 7.6 (95% CI 7.2-7.9) in 2014 per 100 ED visits. Among individual EDs, mean transfer rates for IS/TIA increased from 8.2 per 100 ED visits (median 2.0, interquartile range [IQR] 0-10.2) to 19.4 per 100 ED visits (median 8.1, IQR 1.1-33.3) (2006-2014) (p trend < 0.001). Transfers were more common among IS. Transfer rates were greatest among rural (adjusted odds ratio [AOR] 3.05, 95% CI 2.56-3.64) vs urban/teaching and low-volume EDs (AOR 7.49, 95% CI 6.58-8.53, 1st vs 4th quartile). The adjusted odds of transfer for IS/TIA increased threefold (2006-2014).

Conclusions: Interfacility ED transfers for IS/TIA more than doubled from 2006 to 2014. Further work should determine the necessity of IS/TIA transfers and seek to optimize the US stroke care system.