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Original Investigation |

Transfer Rates From Nonprocedure Hospitals After Initial Admission and Outcomes Among Elderly Patients With Acute Myocardial Infarction

José Augusto Barreto-Filho, MD, PhD1; Yongfei Wang, MS2,3; Saif S. Rathore, MD, PhD4; Erica S. Spatz, MD, MHS2; Joseph S. Ross, MD, MHS5,6; Jeptha P. Curtis, MD2,3; Brahmajee K. Nallamothu, MD, MPH7,8; Sharon-Lise T. Normand, PhD9,10; Harlan M. Krumholz, MD, SM2,3,5,11
[+] Author Affiliations
1Division of Cardiology, Federal University of Sergipe, Aracaju, Sergipe, Brazil
2Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
3Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
4Department of Medicine, Massachusetts General Hospital, Boston
5Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
6Section of General Internal Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
7Veterans Affairs Ann Arbor Health Services Research and Development Service Center for Clinical Management Research, Ann Arbor, Michigan
8Division of Cardiovascular Medicine, Department of Internal Medicine and Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
9Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts
10Department of Biostatistics, Harvard School of Public Health, Harvard University, Boston, Massachusetts
11Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut
JAMA Intern Med. 2014;174(2):213-222. doi:10.1001/jamainternmed.2013.11944.
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Importance  It is unknown whether hospital transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals (facilities that do not provide catheterization) vary and whether these rates further influence revascularization rates, length of stay, and mortality.

Objectives  To examine hospital differences in transfer rates for elderly patients with acute myocardial infarction across nonprocedure hospitals and to determine whether these rates are associated with revascularization rates, length of stay, and mortality.

Design, Setting, and Participants  We used Medicare claims data from January 1, 2006, to December 31, 2008, to assess transfer rates in nonprocedure hospitals, stratified according to transfer rates as low (≤20%), mid-low (>20%-30%), mid-high (>30%-40%), or high (>40%). Data were analyzed for 55 962 Medicare fee-for-service patients admitted to 901 nonprocedure US hospitals with more than 25 admissions per year for acute myocardial infarction.

Main Outcomes and Measures  We compared rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery during hospitalization and within 60 days, as well as hospital total length of stay, across groups. We measured risk-standardized mortality rates at 30 days and 1 year.

Results  The median transfer rate was 29.4% (interquartile range [25th-75th percentile], 21.8%-37.8%). Higher transfer rates were associated with higher rates of catheterization (P < .001), percutaneous coronary intervention (P < .001), and coronary artery bypass graft surgery (P < .001). Median length of stay was not meaningfully different across the groups. There was no meaningful evidence of associations between transfer rates and risk-standardized mortality at 30 days (mean [SD], 22.3% [2.6%], 22.1% [2.3%], 22.3% [2.4%], and 21.7% [2.1%], respectively; P = .054) or 1 year (43.9% [2.3%], 43.6% [2.2%], 43.5% [2.4%], and 42.8% [2.2%], respectively; P < .001) for low, mid-low, mid-high, and high transfer groups.

Conclusions and Relevance  Nonprocedure hospitals vary substantially in their use of the transfer process for elderly patients admitted with acute myocardial infarction. High-transfer hospitals had greater use of invasive cardiac procedures after admission compared with low-transfer hospitals. However, higher transfer rates were not associated with a significantly lower risk-standardized mortality rate at 30 days. Moreover, at 1 year there was only a 1.1% difference (42.8% vs 43.9%) between hospitals with higher and lower transfer rates. These findings suggest that, as a single intervention, promoting the transfer of patients admitted with acute myocardial infarction may not improve hospital outcomes.

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Figure 1.
Geographic Distribution of Hospitals by Transfer Rates

Geographic distribution of hospitals according to transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals.

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Figure 2.
Distribution of Unadjusted and Risk-Standardized Transfer Rates

Distribution of transfer rates and risk-standardized transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals.

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Figure 3.
Relationship Between Transfer Rate and Risk-Standardized Mortality Rate (RSMR) at 30 Days and 1 Year for Patients with Acute Myocardial Infarction Admitted to Nonprocedure Hospitals

These figures show the association between transfer rate and 30-day or 1-year risk-standardized mortality rate. The line indicates the linear association and the black points show the scatter plot. No linear association was observed for 30-day RSMR and only a modest linear association was found for the 1-year RSMR.

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