Background Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied.

Objective To evaluate the association between IHT and healthcare utilisation and clinical outcomes.

Design Retrospective cohort.

Setting CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

Participants Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories.

Main outcome measures Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients.

Results The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease).

Conclusions In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients’ disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.