Association of Tele-Critical Care Capability With Interhospital Transfers and Potentially Low-Value Transfers Among Critically Ill Medicare Beneficiaries

Objectives: Interhospital transfer is essential for accessing specialized critical care services, yet it poses clinical risk and substantial burden for patients and the healthcare system. Tele-critical care (TCC) programs extend expertise to resource-limited hospitals and may influence transfer decisions by identifying patients requiring escalation or supporting local management. We examined the association between TCC capability at index ICU hospitalizations, interhospital transfer, and post-transfer outcomes. Design: Nationwide retrospective cohort study using 2021–2023 Medicare claims linked to the American Hospital Association Annual Survey Database (AHAASD). Setting: U.S. acute care hospitals. Patients: Medicare fee-for-service beneficiaries with ICU hospitalizations between 2022 and 2023. Interventions: None. Measurements and Main Results: TCC capability was identified by AHAASD reporting and/or the presence of five or more TCC claims annually. The primary outcome was interhospital ICU transfer. Exploratory post-transfer outcomes included receipt of specialty procedures, death or hospice discharge within 1 day of transfer, in-hospital and 30-day mortality, and discharge disposition. Hierarchical logistic regression adjusted for patient demographics, comorbidities, acute organ failures, and transferring/accepting hospital characteristics, with transferring hospitals as random intercepts. Among 2,140,919 ICU hospitalizations, 33.4% occurred at 1,066 TCC-capable hospitals. Absolute transfer rates were similar (2.5% vs. 3.0%), but TCC capability was associated with higher adjusted odds of transfer (adjusted odds ratio [aOR], 1.08; 95% CI, 1.01–1.14). In exploratory post-transfer analyses, transferred patients from TCC hospitals had greater illness severity yet were less likely to die or be discharged to hospice within 1 day of transfer (4.6% vs. 6.6%; aOR, 0.86; 95% CI, 0.76–0.97) and more likely to be discharged home within 2 days (4.7% vs. 3.7%; aOR, 1.17; 95% CI, 1.03–1.33). Conclusions: TCC capability was associated with modestly increased transfer rates, fewer potentially low-value transfers, and improved post-transfer outcomes, suggesting improved transfer selection.