Due to an editing error, an article yesterday said that patients transferred to Cook County Hospital from private Chicago-area hospitals were found to have a higher death rate than others at the hospital. The increased death rate was found among patients transferred to the hospital's medical service, but not among surgical patients.
The transfer of poor, uninsured patients from private to public hospitals for financial reasons -- a practice known as "dumping" -- has increased dramatically in many parts of the country, and may be contributing to the deaths of some critically ill patients, according to a study and editorial in today's New England Journal of Medicine.
The study of 467 patients sent from emergency rooms of private Chicago-area hospitals to Cook County Hospital found that 24 percent were medically unstable when transferred, and that most were transferred without their written informed consent.
The death rate for transferred patients was significantly higher than for patients already in the hospital, a difference that the authors suggested might have been due to delays in treatment.
The Cook County study reflects a trend found in many areas, including Washington, where transfers of uninsured patients from private hospitals to D.C. General increased 450 percent between 1981 and 1985.
"It's a growing problem. It occurs all over the country," said Dr. Arnold Relman, the journal's editor, who called for tighter state laws to control dumping. He said, "It's dangerous and it can result in loss of life. And it's frankly discriminatory . . . . "
Relman said transferring of uninsured patients has increased since 1980 for several reasons, including changes in hospital reimbursment by insurance companies, a rise in the number of Americans lacking health insurance, and the growth of for-profit hospital chains.
Relman said "dumping" is particularly prevalent in states where many hospitals are operated for profit, such as Texas, Florida, Tennessee and Kentucky. For-profit hospitals frequently refuse to treat uninsured patients, at the same time "skimming off" patients with good insurance coverage, he said. This heightens competition among private, non-profit hospitals, which are having difficulty covering the cost of caring for uninsured patients because of tighter insurance company rules on reimbursement.
Relman applauded regulations in Texas, effective April 1, that will make it illegal for hospitals to transfer emergency patients except for medical reasons. Offending hospitals will face fines and possible license revocation.
Of the patients studied at Cook County Hospital, 87 percent had been transferred there because they lacked insurance that would pay for private hospitalization. Eighty-nine percent were black or Hispanic and 81 percent were unemployed.
Many were critically ill when transferred, with 22 percent requiring admission to intensive care the first day. Most significantly, 9.4 percent of these patients died, compared to 3.8 percent of the patients already there.
"We had not expected that degree of increased mortality," said Dr. Robert L. Schiff, an attending physician in the hospital's department of medicine and a co-author of the study. He said the delay in treatment averaged five hours, and might have been a factor in the increased death rate.
"The most striking thing was that definitive treatment was not done" at the private hospitals first, he said. Such treatment might included surgery or antibiotics to fight infection.
Schiff said that Illinois is one of 22 states with laws prohibiting hospitals from denying care to emergency patients, but that the law does not appear to deter transfers. Transfers to Cook County Hospital from other hospitals increased from 1,295 in 1980 to 6,769 in 1983.
A similar pattern prevails in others areas. Transfers to D.C. General Hospital from private Washington hospitals rose from 169 in 1981 to 930 in 1985, according to Penelope G. Anderson, director of public affairs and marketing.
However, it is not viewed as a problem, she said, because private hospitals are adhering to policy guidelines that prohibit the transfer of medically unstable patients. "They're being very responsible," she said. "We have not had any serious vilations of the policy."