This article is more than 5 years old. Information may no longer be current.
Transfer rates vary after admission for acute MI at nonprocedure hospitals
Click Here to Manage Email Alerts
Stand-alone patient-transfer interventions to improve MI outcomes for patients initially admitted to nonprocedure hospitals yield no benefit in terms of revascularization rates, length of stay or mortality, study findings indicate.
Among 55,962 Medicare fee-for-service patients admitted to 901 US hospitals that did not perform catheterization on site, mortality differed only 1.1% at 1-year follow-up between hospitals with the highest and lowest transfer rates (42.8% vs. 43.9%).
“Overall, these findings fail to provide strong evidence that hospitals with high transfer rates achieve better clinical outcomes,” Harlan M. Krumholz, MD, of the Yale Center for Outcomes Research and Evaluation in New Haven, Conn., and colleagues reported in JAMA Internal Medicine.
Previous studies have shown that fewer than half of patients with acute MI who are admitted to nonprocedure hospitals are transferred and that these decisions are not always evidence-based, in fact, patients at lower risk are more likely to be transferred for invasive cardiac procedures.
To better understand how transfer rates affect outcomes in patients with acute MI aged at least 65 years, Krumholz and colleagues analyzed Medicare claims data collected from 2006 to 2008, including:
- 10,767 patients admitted at 189 low-transfer hospitals;
- 18,870 patients at 277 mid-low–transfer hospitals;
- 16,829 patients at 263 mid-high–transfer hospitals;
- 9,496 patients at 172 high-transfer hospitals.
Catheterization, PCI and CABG rates were compared across groups during hospitalization and within 60 days. Risk-standardized mortality at 30 days and 1 year, as well as total length of hospital stay, also were measured.
The median transfer rate was 29.4% (interquartile range [25th-75th percentile], 21.8%-37.8%). Patients with higher transfer rates tended to be younger, were more likely to be male and less likely than those admitted to low-transfer hospitals to have had conditions such as previous acute MI, valvular or rheumatic heart disease, HF, stroke, renal failure, dementia/senility and chronic obstructive pulmonary disease.
Overall, higher transfer rates were significantly associated with higher rates of catheterization, PCI and CABG (P<.001 for all), the researchers found.
However, there was no association between transfer rates and risk-standardized mortality at 30 days (P=.054) or 1 year (P<.001) for patients in the low, mid-low, mid-high and high transfer groups. Median length of stay was not meaningfully different across the groups.
These findings indicate the potential for a “risk paradox practice” in patient selection, the researchers said.
“We anticipated that hospitals with higher rates of both transfer and invasive procedures should have notably better risk-standardized mortality rates. However, this was not the case,” they said. “It may be that interhospital transfer of patients with acute [MI] is a complex process that depends on other key processes, including the proper selection of patients at the right time, to be translated into a net benefit.”
The study did not include patients transferred directly from EDs. Additional limitations included reliance on administrative codes from Medicare claims data, which did not specify MI subtype and severity, or physical and cognitive function, all of which may influence outcomes.
Disclosure: Krumholz and another researcher report receiving a Medtronic research grant to develop clinical trial data-sharing methods.
Perspective
Back to Top
William H. Matthai, Jr., MD, FACC
The fascinating article in JAMA Internal Medicine by Barreto-Filho et al may well be a demonstration of appropriate medical care. At the outset, it is important to recognize that this study excluded transfers from the ED, and so it is likely that many patients with STEMI, for whom prompt reperfusion is recommended, were excluded from this population, leaving mostly non-STEMI ACS patients to be studied.
The ACCF/AHA Treatment Guidelines for Unstable Angina/Non-ST Elevation Myocardial Infarction recommend early transfer for patients with refractory symptoms, hemodynamic instability or electrical instability – the highest-risk patients. For other patients who are initially stabilized, risk stratification is recommended. The TIMI or GRACE risk calculators are suggested.
An early invasive strategy is recommended for those with a high risk score, and a selective invasive strategy is reasonable for those with lower risk. In addition, the guidelines suggest that older adults should be treated in the same manner as younger people, but management should be “patient-centered, with consideration given to general health, functional and cognitive status, comorbidities, life expectancy, and patient preferences and goals.”
While local practice, personal experience and other factors are certainly playing a role, one can hope that appropriate patient management is also playing a large part in the findings of this study. There is no question that uniform transfer of MI patients from non-procedure hospitals to procedure hospitals is inappropriate. For those of us who aspire to practice evidence-based medicine with appropriate use of invasive procedures, I recommend to “Get With the Guidelines.”
Click Here to Manage Email Alerts