{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T10:17:38Z","timestamp":1788171458113,"version":"build-2803163510"},"reference-count":39,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T00:00:00Z","timestamp":1788134400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background: Pediatric transfers to tertiary hospitals may vary according to geographic origin and referral pathways and may impose substantial healthcare costs. However, data regarding pediatric transfer pathways, tertiary hospital-level care\/admission, and transport-related expenditure in Greece remain limited. Methods: We conducted a retrospective observational study of children aged 0\u201316 years transferred to a tertiary children\u2019s hospital in Athens, Greece, during 2022\u20132023. Transfers were classified as prehospital emergency medical service (EMS) transports or interfacility transfers. Post-transfer outcomes were analysed using a predefined binary endpoint: ED\/short-stay discharge versus tertiary hospital-level care\/admission. Potentially avoidable transfers were identified using conservative predefined resource-utilization criteria. Transport costs were analysed descriptively according to transport modality and geographic region. Results: A total of 423 pediatric transfers were analysed, including 216\/423 (51.1%) prehospital EMS transports and 207\/423 (48.9%) interfacility transfers. Overall, 224\/423 children (53.0%) required tertiary hospital-level care\/admission, whereas 199\/423 (47.0%) were managed as ED\/short-stay discharges. Importantly, only 54\/199 ED\/short-stay discharge cases met the stricter criteria for potential avoidability, representing 54\/423 (12.8%) of all transfers. Ground ambulance accounted for most transfers, whereas air and sea transport accounted for only 12.1% of transfers, but 97.0% of transport-related expenditure. In unadjusted pathway-level analysis, interfacility transfer was associated with higher odds of tertiary hospital-level care\/admission than prehospital EMS transport (OR 3.72, 95% CI 2.49\u20135.57; p &lt; 0.001) and accounted for 93.8% of total transport costs. Conclusions: Most pediatric transfers resulted in tertiary hospital-level care\/admission, and only a minority met the predefined criteria for potential avoidability. A substantially higher proportion of interfacility transfers resulted in tertiary hospital-level care\/admission, and these transfers accounted for a disproportionate share of recorded transport expenditure.<\/jats:p>","DOI":"10.3390\/children13091171","type":"journal-article","created":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T09:21:19Z","timestamp":1788168079000},"page":"1171","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Potentially Avoidable Pediatric Transfers, Tertiary Hospital-Level Care, and Regional Differences in Referral Burden in Greece: A Retrospective Analysis of Transfer Pathways and Costs"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2775-3670","authenticated-orcid":false,"given":"Filippos","family":"Filippatos","sequence":"first","affiliation":[{"name":"First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, \u201cAghia Sophia\u201d Children\u2019s Hospital, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0122-0318","authenticated-orcid":false,"given":"Vasiliki-Maria","family":"Kymioni","sequence":"additional","affiliation":[{"name":"First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, \u201cAghia Sophia\u201d Children\u2019s Hospital, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"software","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Dimitra","family":"Kallitsounaki","sequence":"additional","affiliation":[{"name":"First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, \u201cAghia Sophia\u201d Children\u2019s Hospital, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"validation","vocabulary":"credit"}]},{"given":"Spyridon","family":"Karageorgos","sequence":"additional","affiliation":[{"name":"Pediatric Emergency Department, \u201cAghia Sophia\u201d Children\u2019s Hospital, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3168-050X","authenticated-orcid":false,"given":"Dimitra-Ifigeneia","family":"Matara","sequence":"additional","affiliation":[{"name":"Second Department of Pediatrics, General Children\u2019s Hospital \u201cPanagiotis and Aglaia Kyriakou\u201d, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"methodology","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7622-202X","authenticated-orcid":false,"given":"Marianna","family":"Miliaraki","sequence":"additional","affiliation":[{"name":"Pediatric Intensive Care Unit, University Hospital, 71003 Heraklion, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2258-066X","authenticated-orcid":false,"given":"Stavros","family":"Antonopoulos","sequence":"additional","affiliation":[{"name":"Pediatric Emergency Department, \u201cAghia Sophia\u201d Children\u2019s Hospital, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7993-8418","authenticated-orcid":false,"given":"Konstantinos","family":"Kakleas","sequence":"additional","affiliation":[{"name":"First Department of Pediatrics, Medical School, National and Kapodistrian University of Athens, \u201cAghia Sophia\u201d Children\u2019s Hospital, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,31]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e249","DOI":"10.1016\/S2214-109X(13)70050-0","article-title":"Cost, production, efficiency, or effectiveness: Where should we focus?","volume":"1","author":"Hollingsworth","year":"2013","journal-title":"Lancet Glob. 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