The researchers analyzed six models, each of which explored specific aspects of how hospital transfers relate to a variety of factors, including patient race and ethnicity, patient insurance status, patient medical conditions, referring hospital urbanicity or rurality, and the market of hospitals around the referring hospital.

According to Hsuan, every model was important because each of these factors can affect whether and where a hospital transfers a patient. A rural hospital may be more likely to transfer a patient to a better-equipped regional hub hospital, public or not. A patient with Medicaid may be transferred differently than a patient with private insurance, and both may be transferred differently than a patient with no insurance.

The researchers compared the hospital transfer rates of non-Hispanic Black patients, Hispanic patients and non-Hispanic white patients. Results for Hispanic patients varied based on the specific conditions of the transfer, but Black patients were consistently transferred to public hospitals more often than white patients across all six models. The only times Black patients were not transferred more than white patients were a few specific medical conditions like strokes and heart attacks for which rigorous transfer protocols exist.

The disparity in the transfer rates varied based on which factors were being considered. Overall, 16.6% of Black patients were transferred to a public hospital while only 11.5% of white patients were. Health care system factors like hospital market and urbanicity accounted for most of the disparity. However, when comparing Black and white patients from the same hospital with similar health conditions and the same insurance, there was still an 0.8 percentage point difference in the rate of transfers to public hospitals resulting in more Black patients being transferred than white patients.

No matter how similar the hospitals or patients were that we compared, a difference between transfer rates to public hospitals for Black and white patients persisted, Hsuan said. Even a small percentage difference affects many, many people when your system has millions of transfers.

The researchers described the racial disparity as concerning in their publication. Hsuan said the reason for the disparity needs to be investigated, but addressing the problem is more important than immediately understanding the root cause.

Our data do not allow us to identify why Black people are transferred to public hospitals more often, but whatever the cause, there is inequality in the system that should be examined and corrected, Hsuan said. We need to address this inequality so that a person of any background can enter any emergency department and receive the best possible care to treat their condition and if needed potentially save their life.

Co-authors of this research include David Vanness, Department of Health Policy and Administration at Penn State; Yinan Wang, Department of Health Policy and Administration at Penn State; Douglas Leslie, Department of Public Health Sciences at Penn State; Eleanor Dunham, Department of Emergency Medicine at Penn State; Jeannette Rogowski, Department of Health Policy and Administration at Penn State; Alexis Zebrowski, Department of Emergency Medicine and Department of Population Health Science and Policy at Icahn School of Medicine at Mount Sinai; Brendan Carr, Department of Emergency Medicine and Department of Population Health Science and Policy at Icahn School of Medicine at Mount Sinai; David Buckler, Department of Emergency Medicine at Icahn School of Medicine at Mount Sinai; and Edward Norton, Department of Health Management and Policy and Department of Economics at University of Michigan.

The National Institute on Minority Health and Health Disparities, the Penn State Clinical and Translational Science Institute and the Penn State Social Science Research Institute supported this research.

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Race and ethnicity may affect whether and where hospitals transfer patients - Pennsylvania State University