Background Current guideline recommend an early invasive strategy for NSTEMI patients (Class IIA)....
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Transcript of Background Current guideline recommend an early invasive strategy for NSTEMI patients (Class IIA)....
Background• Current guideline recommend an early invasive
strategy for NSTEMI patients (Class IIA). However, 67% US hospitals have no catheterization capability.
• Patients transferred for invasive strategy are usually younger with less comorbidities compared with non-transferred patients.
• Thus, hospitals with high proportion of transfer patients should have better outcomes of care.
• However, the association of transfer proportion and outcomes in transfer-out hospitals has not been previously examined.
The association of transfer-out rates from hospitals without revascularization capabilities and mortality risk among older NSTEMI patientsLan Shen, MD, Shuang Li, MS, Laine Thomas, Ph.D, Bimal R. Shah, MD, MBA, Tracy Y. Wang, MD, MHS, Karen Alexander, MD, Eric D. Peterson, MD, MPH, He Ben, MD, Ph.D, Matthew T. Roe, MD, MHS
Duke Clinical Research Institute, Durham, NC, U.S.A; Shanghai Renji Hospital, Cardiology department, Shanghai, China
Methods• 5,678 eligible NSTEMI patients in 65 hospitals
without PCI / CABG capabilities were identified in the CRUSADE registry from 2003 to 2006, were linked to Medicare claims data to assess longitudinal outcomes.
• The distribution of transfer-out rate among all hospitals was examined. Based on the distribution rate, high transfer-out hospitals were defined as having >40% of all eligible patients transferred out, whereas low transfer-out hospitals were defined as having ≤40% of all eligible patients.
• Baseline, presentation features, in-hospital procedures and discharge medications were described by transfer rate status. Wilcoxon-rank rum test was used for comparing continuous variables and chi-square test was used for categorical variables.
• Overall baseline risk profiles were compared using the CRUSADE long-term mortality risk score between patients in the 2 groups of hospitals.
• Multivariable Cox proportional hazard model was used to assess the association between the proportion of transfer out and 30-day, 6-month and 3-year mortality.
Results
.
Conclusions
• Among older patients >65 years old, hospitals with high transfer-out proportions have more low risk patients, with more aggressive acute medication treatment.
• Hospitals with higher transfer-out proportions have lower observed mortality rate of short-term and long-term follow-up. However, such survival advantage disappears after adjustment for baseline characteristics.
• The difference in hospital-level case mix can explain the lack of difference in the adjusted long-term mortality risk between hospital categories.
• Our study support that older patients who are admitted in non-PCI hospitals should undergo early invasive management. Although older patients are usually excluded from clinical trials, no information guide decision making for older patients. Our exploratory study supported older patients to be recommended to aggressive treatment.
Acknowledgments
No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the manuscript, and its final contents.
Contact
Lan Shen, MD, MS.
Shanghai Renji Hospital,
Duke Clinical Research Institute
Tel: 919 -641-9233
Fax: 919-668-7061
Email: [email protected]
Variables
Overall
Patients=5
678
Hospitals=
65
Low
transfer
Patients=2
715
Hospitals
=27
High
transfer
Patients=2
963
Hospitals=
38
Age(Median, IQR)
79 (73, 85) 80 (73, 86) 79 (73,85)
Male sex (%) 48 46 50
Medical history (%)
Smoking 11 11 11
Hypertensio
n
76 76 76
Diabetes mellitus 36 35 37
Renal insufficiency 19 21 18
Dyslipidemia48 44 51
Prior MI 29 27 31
Prior PCI 15 13 17
Prior
CABG21 22 20
Prior CHF 27 30 24
Presentation characteristics (%)
Signs of
CHF36 38 35
Heart rate 88 (74, 106) 89 (75, 106) 87 (73,105)
SBP,
mmHg
143 (120,
164)
141 (119,
162)
145 (122,
166) ST depression 24 22 25
CRUSADE Long-term Mortality Risk Score
36
(25, 47)
37
(26, 48)
34
(24, 46)
Medications within 24 hours (%)
Aspirin 92 91 94 Anticoagula-tion
77 74 79
Clopidogrel 43 44 43
GP IIb/IIIa 28 21 34Diagnostic Cath(%) 31 43 21
Table 2: Impact of transfer-out rate on outcomes
CRUSADE registry
CRUSADE was a national quality improvement initiative designed to promote evidence-based treatment of hospitalized patients with non–ST-segment elevation ACS. Patient data were collected retrospectively via chart review from July, 2001 through December, 2006. More than 500 hospitals in the US participated including more than 200,000 patients.
Limitation
• Given the retrospective nature of the study, unmeasured confounders cannot be excluded, especially comorbidities which prevent patients from being transferred.
• The small number of hospitals in our study did not include all non-revascularization hospitals in U.S, thus it is not representative for hospitals outside of CRUSADE. Our study serves as an exploratory study.
• CRUSADE did not collect long-term medication use, so the impact cannot be measured.
Figure 1: Distribution of transfer-out rate among all hospitals. Figure 2. Percentage of patients in different quartiles of baseline CRUSADE risk score between 2 groups of hospitals.
Table 1. Hospital characteristics
Variables
Overall
(n=65)
Low transfer
Hospitals (n= 27)
High transfer
Hospitals(n= 38)
Region (%)
West 11 11 11
Northeast 35 37 34
Midwest 11 19 5
South 43 33 50
Type of hospital
(%)
No service 40 30 47
Cath Lab Only 60 70 53
Teaching Hospital
(%)
Non-Academic 94 89 97
Academic 6 11 3
Total hospital Beds (median, IQR)
202 (131, 278)
230 (171,300)
167 (110, 260)
Table 3. Impact of transfer out rate on outcomes (high transfer-out vs. low transfer-out).
Outcomes
Observed
mortality
rate
Unadjusted
HR* (95%
CI)
Adjusted
HR* (95%
CI)
MortalityHigh vs. Low
30-day mortality10% vs.
14%0.75
(0.59-0.96)0.92
(0.77-1.10)
6-month mortality
22% vs. 27%
0.80 (0.65-0.97)
0.95 (0.83-1.08)
3-year mortality
46% vs. 52%
0.84(0.73-0.96)
0.99 (0.89-1.09)
*Hazard ratio of the outcomes between high transfer-out
rate hospitals vs. low transfer-out hospitals (reference
group)
CI, confidence interval; HR, hazard ratioAdjusted for: age, male sex, race, weight, dyslipidemia, initial HCT with knot at 35%, initial troponin ratio with two knots (with knots at 5 and 50), prior stroke, diabetes mellitus, signs of heart failure, initial serum creatinine, initial systolic blood pressure, initial heart rate, prior percutaneous coronary intervention (PCI), electrocardiographic changes (ST depression, transient ST elevation, both [vs. neither]), hypertension, prior coronary artery bypass graft (CABG) , PCI, CABG procedures used within 7 days post transfer out.