Potentially Avoidable Pediatric Transfers, Tertiary Hospital-Level Care, and Regional Differences in Referral Burden in Greece: A Retrospective Analysis of Transfer Pathways and Costs.

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 0-16 years transferred to a tertiary children's hospital in Athens, Greece, during 2022-2023. 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 2.49-5.57; p < 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.