We prospectively studied all transfers from community hospitals to the Zablocki Veterans Administration Medical Center in Milwaukee (Wis) between May 28, 1986, and January 1, 1987. Transfers totaled 4.7% (311/6609) of acute-care admissions during the study period but accounted for 19.1% (39/204) of in-hospital deaths. The mortality rate for transferred patients who required Veterans Administration hospitalization was 12.5% (39/311) compared with 2.6% (165/6298) for all other admissions. At the time of transfer 59 patients (19%) were judged unstable by a modification of the APACHE II classification system, yet only 19 patients were cared for en route by a physician or a nurse. In addition to higher mortality, the transferred patients had a longer median length of stay than nontransferred patients (11 days vs 7 days).