Patterns of hospital bypass and interhospital transfer among patients with heart failure: Brief Title: Hospital bypass and transfer for heart failure.

Abstract Objectives We describe how patient characteristics influence hospital bypass, interhospital transfer, and in-hospital mortality in patients with heart failure (HF) in Washington. Background Rural HF patients may bypass their nearest hospital or be transferred for appropriate therapies. The frequency, determinants, and outcomes of these practices remain uncharacterized. Methods Mean excess travel times based on hospital and patient residence ZIP codes were calculated using published methods. Hospitals and servicing areas were coded based on bed size and ZIP code, respectively. Transfer patterns were analyzed using bootstrap inference for clusters. Analysis of mortality and transfer-associated factors was performed using logistic regression with generalized estimating equations. Results 48,163 patients, representing 1,106 instances of transfer, were studied. Mean excess travel time increased 7.14 minutes per decrease in population density (metropolitan, micropolitan, small town, rural; p Conclusion Rural hospital bypass is prevalent among HF patients, though its clinical significance is unclear. Female and older patients were found to have a lower likelihood of transfer adjusted for other factors. Interhospital transfer is associated with increased mortality when adjusted for comorbidities.