Elderly patients at highest risk with acute myocardial infarction are more frequently transferred from community hospitals to tertiary centers: Reality or myth?

doi:10.1016/S0002-8703(99)70184-5

American Heart Journal

Volume 138, Issue 4, October 1999, Pages 688-695

https://doi.org/10.1016/S0002-8703(99)70184-5 Get rights and content

Abstract

Background The objective of this study was to assess the characteristics of patients with acute myocardial infarction transferred from community hospitals. The study was designed as a retrospective chart review, and the data source was the Cooperative Cardiovascular Project from Michigan. Methods and Results Included in the study were consecutive Medicare patients with acute myocardial infarction discharged from acute-care hospitals in Michigan between April 1, 1994, and July 31, 1995 (n = 7041): 2866 patients treated at community hospitals, 1241 transferred from community hospitals, 2731 admitted directly to tertiary hospitals, and 203 transferred from an outside emergency room to tertiary hospitals. The outcomes measured were patient characteristics, quality indicators, resource use, and 30-day mortality rates. Compared with patients not transferred, those transferred from community hospitals were younger, more frequently of the male sex, smokers, and were seen earlier after symptom onset. They had fewer cases of diabetes and lower Acute Physiology And Chronic Health Evaluation (APACHE II) scores and Medicare Mortality Prediction System (MMPS) values. Aspirin during hospitalization and at discharge, thrombolytic therapy, and reperfusion therapy were all used more frequently in transferred patients, whereas the other key discharge quality indicators were no different. Mortality rate at 30 days was lower for transferred patients (9.4% vs 25%, P < .0001) when compared with those not transferred. Conclusions Patients who are less ill, those who are seen early, and those who received thrombolytic therapy are more often transferred from community hospitals. On average, patients with greater comorbidity rates are treated at community hospitals and not transferred. Predicted and observed mortality rates were lower for the transferred group. Higher comorbidity rate in patients treated at community hospitals appears to be the major determinant of the observed higher mortality rates in these patients. (Am Heart J 1999;138:688-95.)

Section snippets

Patient selection and data collection

Data for this study were collected as a part of the pilot phase of the Cooperative Cardiovascular Project (CCP) sponsored by the Health Care Financing Administration (HCFA) to improve the quality of care of patients with AMI in the Medicare population in the United States. This study cohort consisted of all patients discharged from a hospital in Michigan with a principal diagnosis of AMI (ICD-9-CM principal diagnosis code of 410) over a consecutive 8-month period. To facilitate the process of

Results

First, we compared the patients treated solely at community hospitals (2866 patients, group A) with those transferred from the community hospitals (1241 patients, group B) (Table I).

. Care of Medicare patients with AMI at community hospitals in Michigan

Empty Cell	Treated at community hospitals (group A)	Transferred from community hospitals (group B)	P value
No. of patients	2866	1241
Median age (y)	77.2	71.5	<.0001
% Age >75 y	59.6	28.4	<.0001
% Male	46.7	53.4	<.0001
% White	89.3	90.9	.12
% Diabetic	34.1	29.7	<.01
% Cigarette smokers

Discussion

Rapid advances in the field of interventional cardiology and in heart surgery, along with the soaring cost of medical treatment, have led to the regionalization of specialized health care services. Only 15.2% of hospitals in the United States offer CABG, and 17.8% have capabilities of performing PTCA.¹⁷ Thus many patients with AMI are admitted to a community hospital, where such advanced diagnostic and therapeutic options are unavailable. Some of these patients are subsequently transferred to a

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Many academic medical centers (AMC) transfer patients who require admission but not tertiary care to partner community hospitals from their emergency departments (ED). These transfers alleviate ED boarding but may worsen existing healthcare disparities. We assessed whether disparities exist in the transfer of patients from one AMC ED to a community hospital General Medical Service.
We performed a retrospective cohort study on all patients screened for transfer between April 1 and December 31, 2021. During the screening process, the treating ED physician determines whether the patient meets standardized clinical criteria and a patient coordinator requests patient consent. We collected patient demographics data from the electronic health record and performed logistic regression at each stage of the transfer process to analyze how individual characteristics impact the odds of proceeding with transfer.
5558 patients were screened and 596 (11%) ultimately transferred. 1999 (36%) patients were Black or Hispanic, 698 (12%) had a preferred language other than English, and 956 (17%) were on Medicaid or uninsured. A greater proportion of Black and Hispanic patients were deemed eligible for interhospital transfer compared to White patients and a greater proportion of Hispanic patients completed transfer to the community hospital (p < 0.017 after Bonferroni correction). After accounting for other demographic variables, patients older than 50 (OR 1.21, 95% CI 1.04–1.40), with a preferred language other than English (OR 1.27, 95% CI 1.00–1.62), and from a priority neighborhood (OR 1.38, 95% CI 1.18–1.61) were more likely to be eligible for transfer, while patients who were male (OR 1.50, 95% CI 1.10–2.05) and younger than 50 (OR 1.85, 95% CI 1.20–2.78) were more likely to consent to transfer (p < 0.05).
Health disparities exist in the screening process for our interfacility transfer program. Further investigation into why these disparities exist and mitigation strategies should be undertaken.
Repatriation of Transferred Patients: A Solution for Hospital Capacity Concerns?
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Optimizing Safety for Surgical Patients Undergoing Interhospital Transfer
2021, Surgical Clinics of North America
Citation Excerpt :
Comparing the rate of interhospital transfers using the American College of Surgeons National Surgery Quality Improvement Program database, transfers of patients who underwent surgery increased from 3.2% between 2005 and 2008 to 4.5% between 2009 and 2012.11 The application of standardized processes for interhospital transfer is best described in the care of patients suffering trauma, acute myocardial infarction, and stroke.12–17 Regionalization of trauma care began in the 1970s.18
The effect of high-risk ST elevation myocardial infarction transfer patients on risk-adjusted in-hospital mortality: A report from the American Heart Association Mission: Lifeline program
2016, American Heart Journal
Citation Excerpt :
Differences in reported mortality among studies are likely in part related to varying definitions of cardiac arrest, as well as inclusion criteria. Most,24,25 but not all,26 prior studies investigating the effect of MI transfer patients on PCI-receiving hospital mortality found that MI transfer patients tended to be at lower risk24,25 with a corresponding lower mortality24,25,27,28 than those MI patients directly presenting to the PCI-receiving hospital. However, most studies were performed more than 5 years ago24,25,27 when primary PCI was infrequently used, included only admitted patients24,25 rather than those transferred from the ED, or combined outcomes of NSTEMI and STEMI populations.24,25
Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected.
The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry—Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry—Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile.
Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, −0.04%; middle, −0.05%; and high, 0.03%).
Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.
A systematic review of the volume-outcome relationship for radical prostatectomy
2013, European Urology
Citation Excerpt :
For example, senior clinicians may delegate more junior staff to deal with the difficult cases most likely to have poor outcomes, leading to high-volume providers caring for patients at lower risk and obtaining apparently superior results [69]. There is some evidence in cardiology of a patient selection phenomenon (eg, that patients with a favorable prognosis for survival are selectively referred to high-volume hospitals) [70]. In other instances, it is plausible that high-risk patients may be selectively referred on to high-volume centers.
Due to the complexity and challenging nature of radical prostatectomy (RP), it is likely that both short- and long-term outcomes strongly depend on the cumulative number of cases performed by the surgeon as well as by the hospital.
To review systematically the association between hospital and surgeon volume and perioperative, oncologic, and functional outcomes after RP.
A systematic review of the literature was performed, searching PubMed, Embase, and Scopus databases for original and review articles between January 1, 1995, and December 31, 2011. Inclusion and exclusion criteria comprised RP, hospital and/or surgeon volume reported as a predictor variable, a measurable end point, and a description of multiple hospitals or surgeons.
Overall 45 publications fulfilled the inclusion criteria, where most data originated from retrospective institutional or population-based cohorts. Studies generally focused on hospital or surgeon volume separately. Although most of these analyses corroborated the impact of increasing volume with better outcomes, some failed to find any significant effect. Studies also differed with respect to the proposed volume cut-off for improved outcomes, as well as the statistical means of evaluating the volume–outcome relationship. Five studies simultaneously compared hospital and surgeon volume, where results suggest that the importance of either hospital or surgeon volume largely depends on the end point of interest.
Undeniable evidence suggests that increasing volume improves outcomes. Although it would seem reasonable to refer RP patients to high-volume centers, such regionalization may not be entirely practical. As such, the implications of such a shift in practice have yet to be fully determined and warrant further exploration.
Influence of transfer-in rates on quality of care and outcomes at receiving hospitals in patients with non-ST-segment elevation myocardial infarction
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Patients with non–ST-segment elevation myocardial infarction (NSTEMI) are frequently transferred to tertiary hospitals for angiography and/or revascularization from hospitals lacking such capabilities. Given that patients who undergo invasive cardiac procedures are younger and have fewer comorbidities compared with those managed medically, the relative proportion of transfer-in patients at tertiary hospitals may influence comparisons of quality and guidelines adherence.
We evaluated 142,092 NSTEMI patients treated at 396 revascularization-capable sites in the CRUSADE National Quality Improvement Initiative from 2001 to 2006. Transfer-in patients were included if they arrived at the receiving hospital after their first presentation to a different hospital. Hospitals were categorized into tertiles based upon their transfer-in rates (low, intermediate, and high) and adherence to practice guidelines recommendations for NSTEMI. In-hospital clinical outcomes were compared across hospital tertiles.
Acute and discharge composite guidelines adherence scores improved at hospitals with an increasing proportion of transfer-in patients, both for transferred as well as for directly admitted patients. These better adherence scores were inversely associated with overall mortality, with the lowest mortality observed in patients at hospitals with the highest transfer-in rates. However, once adjusted for baseline confounders, the mortality rates for patients in the hospitals in the highest transfer-in tertile did not differ significantly compared with the sites in the lowest transfer-in tertile (odds ratio 1.02, 95% CI 0.90-1.16).
Our findings show that the proportion of NSTEMI patients transferred into revascularization-capable hospitals varies significantly. Hospitals with a higher proportion of transfer-in patients tend to provide higher overall quality of NSTE acute coronary syndrome care; they also have lower overall in-hospital mortality, which may, in part, be related to the lower-risk baseline characteristics of patients at these hospitals.

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^☆: Reprint requests: Kim A. Eagle, MD, FACC, B1F245 University Hospital, 1500 E Medical Center Dr, Ann Arbor, MI-48109. E-mail: [email protected]

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Elderly patients at highest risk with acute myocardial infarction are more frequently transferred from community hospitals to tertiary centers: Reality or myth?☆,☆☆

Abstract

Section snippets

Patient selection and data collection

Results

Discussion

Am J Cardiol

Am J Med

Am J Cardiol

J Am Coll Cardiol

Chest

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Lancet

J Am Coll Cardiol

Am J Cardiol

1988 Summary: National Hospital Discharge Survey: advance data from vital and statistics

Morbidity and mortality: chartbook on cardiovascular, lung and blood diseases

Delay time in suspected acute myocardial infarction and the importance of its modification

Clin Cardiol

GISSI-2. A factorial randomized trial of alteplase versus streptokinase and heparin versus no heparin among 12490 patients with acute myocardial infarction

Lancet

ISIS-3: a randomized comparison of streptokinase versus tissue plasminogen activator versus anistreplase and of aspirin plus heparin versus aspirin alone among 41299 cases of suspected acute myocardial infarction

Lancet

An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction

N Engl J Med

HCFA’s Cooperative Cardiovascular Project: a nationwide quality assessment of acute myocardial infarction

Clin Cardiol

The Cooperative Cardiovascular Project in Missouri

Mo Med

Quality of care for Medicare patients with acute myocardial infarction: a 4-state pilot study from the Cooperative Cardiovascular Project

JAMA

Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction

J Gen Intern Med

Hospital Statistics