{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T09:06:05Z","timestamp":1789549565235,"version":"build-2803163510"},"reference-count":20,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2022,12,14]],"date-time":"2022-12-14T00:00:00Z","timestamp":1670976000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Introduction<\/jats:title>\n<jats:p>Patient referrals to tertiary level of care neurological services are often potentially avoidable and result in inferior clinical outcomes. To decrease transfer burden, stakeholders should acquire a comprehensive perception of specialty referral process dynamics. We identified associations between patient sociodemographic data, disease category and hospital characteristics and avoidable transfers, and differentiated factors underscoring informed decision making as essential care management aspects.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Materials and methods<\/jats:title>\n<jats:p>We completed a retrospective observational study. The inclusion criteria were pediatric and adult patients with neurological diagnosis referred to our tertiary care hospital. The primary outcome was potentially avoidable transfers, which included patients discharged after 24 hours from admission without requiring neurosurgery, neuro-intervention, or specialized diagnostic methodologies and consult in non-neurologic specialties during their hospital stay. Variables included demographics, disease category, health insurance and referring hospital characteristics.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Patient referrals resulted in 1615 potentially avoidable transfers. A direct correlation between increasing referral trends and unwarranted transfers was observed for dementia, spondylosis and trauma conversely, migraine, neuro-ophthalmic disease and seizure disorders showed an increase in unwarranted transfers with decreasing referral trends. The age group over 90 years (OR, 3.71), seizure disorders (OR, 4.16), migraine (OR, 12.50) and neuro-ophthalmic disease (OR, 25.31) significantly associated with higher probability of avoidable transfers. Disparities between pediatric and adult transfer cases were identified for discrete diagnoses. Hospital teaching status but not hospital size showed significant associations with potentially avoidable transfers.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Neurological dysfunctions with overlapping clinical symptomatology in ageing patients have higher probability of unwarranted transfers. In pediatric patients, disease categories with complex symptomatology requiring sophisticated workup show greater likelihood of unwarranted transfers. Future transfer avoidance recommendations include implementation of measures that assist astute disorder assessment at the referring hospital such as specialized diagnostic modalities and teleconsultation. Additional moderators include after-hours specialty expertise provision and advanced directives education.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0279031","type":"journal-article","created":{"date-parts":[[2022,12,14]],"date-time":"2022-12-14T18:29:53Z","timestamp":1671042593000},"page":"e0279031","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":5,"title":["Evaluation of factors associated with interhospital transfers to pediatric and adult tertiary level of care: A study of acute neurological disease cases"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1737-6031","authenticated-orcid":true,"given":"Stanca","family":"Iacob","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yanzhi","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan C.","family":"Peterson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sven","family":"Ivankovic","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Salil","family":"Bhole","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick T.","family":"Tracy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patrick W.","family":"Elwood","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,12,14]]},"reference":[{"issue":"2","key":"pone.0279031.ref001","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1016\/j.jcrc.2012.07.027","article-title":"Reasons underlying interhospital transfers to an academic medical intensive care unit","volume":"28","author":"J Wagner","year":"2013","journal-title":"J Crit Care"},{"key":"pone.0279031.ref002","doi-asserted-by":"crossref","first-page":"e011575","DOI":"10.1161\/JAHA.118.011575","article-title":"Hospital factors associated with interhospital transfer destination for stroke in the Northeast United States","volume":"9","author":"KS Zachrison","year":"2020","journal-title":"J Am Heart Assoc"},{"key":"pone.0279031.ref003","unstructured":"American College of Emergency Physicians. EMTALA Fact Sheet. http:\/\/www.acep.org."},{"issue":"4","key":"pone.0279031.ref004","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1227\/NEU.0000000000001378","article-title":"Identification and cost of potentially avoidable transfers to a tertiary care neurosurgery service: a pilot study","volume":"79","author":"EN Kuhn","year":"2016","journal-title":"Neurosurg"},{"key":"pone.0279031.ref005","doi-asserted-by":"crossref","first-page":"281","DOI":"10.3171\/2018.3.JNS173224","article-title":"Interfacility neurosurgical transfers: an analysis of nontraumatic inpatient and emergency department transfers with implications for improvements in care","volume":"131","author":"MM Safaee","year":"2019","journal-title":"J Neurosurg"},{"issue":"8","key":"pone.0279031.ref006","doi-asserted-by":"crossref","first-page":"763","DOI":"10.1001\/jamasurg.2013.2132","article-title":"Secondary overtriage: the burden of unnecessary interfacility transfers in a rural trauma system","volume":"148","author":"MJ Sorensen","year":"2013","journal-title":"JAMA Surg"},{"key":"pone.0279031.ref007","doi-asserted-by":"crossref","first-page":"375","DOI":"10.3171\/2018.5.PEDS182","article-title":"Secondary overtriage of pediatric neurosurgical trauma at Level I pediatric trauma center","volume":"22","author":"CE Mackel","year":"2018","journal-title":"J Neurosurg Pediatr"},{"issue":"18","key":"pone.0279031.ref008","doi-asserted-by":"crossref","first-page":"e1561","DOI":"10.1212\/WNL.0000000000005419","article-title":"Interfacility transfers for US ischemic stroke and TIA, 2006\u20132014","volume":"90","author":"BP George","year":"2018","journal-title":"Neurology"},{"key":"pone.0279031.ref009","doi-asserted-by":"crossref","unstructured":"Zachrison Sauzer K, Schwamm LH. 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