Dataset Information

The Association of Transfer Rate From Hospitals Without Revascularization Capabilities and Mortality Risk for Older Non-ST-Segment Elevation Myocardial Infarction Patients.

ABSTRACT:

Background

Interhospital transfer invasive management patterns and implications for older non-ST-segment elevation myocardial infarction (NSTEMI) patients initially presenting to non-revascularization-capable hospitals have not been explored.

Hypothesis

Patients admitted to hospitals with a higher transfer proportion have lower risk of long-term mortality.

Methods

We linked CRUSADE Registry data on 5678 patients age ≥65 years from 65 United States non-revascularization-capable hospitals (2003-2006) with inpatient Medicare longitudinal claims. Hospitals were categorized according to hospital-level patient transfer-out rates, low (≤40%) vs high (>40%). The associations between transfer-out rates and 30-day, 6-month, and 3-year mortality risk were evaluated using Cox proportional hazard models.

Results

Hospital-level transfer-out rates varied widely (median, 43%; interquartile range, 31%-54%). Compared with patients from low-transfer-out hospitals (n = 2715), patients from high-transfer-out hospitals (n = 2963) were more likely to be male, less likely to have renal insufficiency and prior heart failure, and had lower long-term CRUSADE mortality risk scores. These patients also more commonly received evidence-based acute medications before transfer and underwent subsequent revascularization after transfer. The adjusted risks of mortality at various time intervals were similar for those from high- vs low-transfer-out hospitals: 30 days (hazard ratio: 0.95, 95% confidence interval: 0.79-1.14), 6 months (0.97, 0.84-1.12), and 3 years (1.01, 0.91-1.11).

Conclusions

Transfer rates for older NSTEMI patients vary widely among non-revascularization-capable hospitals. Despite lower predicted mortality risk and higher rates of post-transfer revascularization, patients from high-transfer-out hospitals had a similar risk for short- and long-term mortality compared with those from low-transfer-out hospitals.

SUBMITTER: Shen L

PROVIDER: S-EPMC6490845 | biostudies-literature | 2015 Dec

REPOSITORIES: biostudies-literature

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Publications

The Association of Transfer Rate From Hospitals Without Revascularization Capabilities and Mortality Risk for Older Non-ST-Segment Elevation Myocardial Infarction Patients.

Shen Lan L Shah Bimal R BR Li Shuang S Thomas Laine L Wang Tracy Y TY Alexander Karen P KP Peterson Eric D ED He Ben B Roe Matthew T MT

Clinical cardiology 20151029 12

<h4>Background</h4>Interhospital transfer invasive management patterns and implications for older non-ST-segment elevation myocardial infarction (NSTEMI) patients initially presenting to non-revascularization-capable hospitals have not been explored.<h4>Hypothesis</h4>Patients admitted to hospitals with a higher transfer proportion have lower risk of long-term mortality.<h4>Methods</h4>We linked CRUSADE Registry data on 5678 patients age ≥65 years from 65 United States non-revascularization-capa ...[more]

PMID: 26511331

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Project description:ImportanceChallenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors.ObjectiveTo examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model.Design, setting, and participantsThis multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period.ExposuresCreation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology.Main outcomes and measuresPrimary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.ResultsA total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04).Conclusions and relevanceA hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.

Project description:Background and aimsThe long-term outcomes of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease remain debated.MethodsThe Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry was used to analyse 57 097 revascularized patients with NSTEMI with multivessel disease in Sweden from January 2005 to June 2022. The primary endpoint was all-cause mortality, encompassing both in-hospital and long-term mortality; the secondary endpoints included myocardial infarction (MI), stroke, new revascularization, and heart failure. Multilevel logistic regression with follow-up time as a log-transformed offset variable and double-robust adjustment with the instrumental variable method were applied to control for known and unknown confounders.ResultsPercutaneous coronary intervention was the primary therapy in 42 190 (73.9%) patients, while 14 907 (26.1%) received CABG. Percutaneous coronary intervention patients were generally older with more prior cardiovascular events, whereas CABG patients had higher incidences of diabetes, hypertension, left main and three-vessel disease, and reduced ejection fraction. Over a median follow-up of 7.1 years, PCI was associated with higher risks of death [adjusted odds ratio (aOR) 1.67; 95% confidence interval (CI) 1.54-1.81] and MI (aOR 1.51; 95% CI 1.41-1.62) but there was no significant difference in stroke. Repeat revascularization was three times more likely to PCI (aOR 3.01; 95% CI 2.57-3.51), while heart failure risk was 15% higher (aOR 1.15; 95% CI 1.07-1.25). Coronary artery bypass grafting provided longer survival within 15 years, especially in patients under 70 years of age, with left main disease or left ventricular dysfunction, though this benefit diminished over shorter time horizons.ConclusionsCoronary artery bypass grafting is associated with lower risks of mortality, MI, repeat revascularization, and heart failure in patients with NSTEMI, particularly in high-risk subgroups. However, its survival benefit lessens with shorter life expectancy.

Dataset Information

The Association of Transfer Rate From Hospitals Without Revascularization Capabilities and Mortality Risk for Older Non-ST-Segment Elevation Myocardial Infarction Patients.

Background

Hypothesis

Methods

Results

Conclusions

Publications

The Association of Transfer Rate From Hospitals Without Revascularization Capabilities and Mortality Risk for Older Non-ST-Segment Elevation Myocardial Infarction Patients.

Similar Datasets

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