Background

1. The Association of Transfer-out Rates From Hospitals Without Revascularization Capabilities and Mortality Risk Among Older NSTEMI Patients Lan Shen, MD1,2; Shuang Li, MS1; Laine Thomas, PhD1; Bimal R. Shah, MD, MBA1; Tracy Y. Wang, MD, MHS, MSc1; Karen Alexander, MD1; Eric D. Peterson, MD, MPH1; He Ben, MD, PhD2; Matthew T. Roe, MD, MHS1 From the 1Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, U.S.A; 2Shanghai Renji Hospital, Cardiology Department, Shanghai, China • Background • Current guidelines recommend an early invasive strategy for NSTEMI patients (Class IIA); however, 67% of United States (U.S.) hospitals have no catheterization capabilities. • Patients transferred for invasive strategy are usually younger with less comorbidities compared with non-transferred patients. • Therefore, hospitals with a high proportion of transfer patients should have better care outcomes. • Nevertheless, the association of transfer proportion and outcomes in transfer-out hospitals has not been previously examined. Results . Table 2. Impact of transfer-out rate on outcomes • 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 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. • Limitations • 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 the U.S; therefore, our study is not representative for hospitals outside of CRUSADE, but serves as an exploratory study. • CRUSADE did not collect long-term medication use, so the impact cannot be measured. • Methods • 5,678 eligible NSTEMI patients in 65 hospitals without PCI/CABG capabilities were identified in the CRUSADE registry from 2003 to 2006, and were linked to Medicare claims data to assess longitudinal outcomes. • The distribution of transfer-out rates 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. A Wilcoxon rank-sum test was used for comparing continuous variables and a 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. • A multivariable Cox proportional hazard model was used to assess the association between the proportion of transfer-out patients and 30-day, 6-month, and 3-year mortality. • Table 1. Hospital characteristics • Table 3. Impact of transfer-out rate on outcomes (high transfer-out vs. low transfer-out) • 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. • No information from clinical trials guides decision making for older patients. Our exploratory study supports the need for further research in fully delineating patient profiles that contribute to transfer decisions and how to accurate fairly implement care practice for these type of hospitals. Contact Lan Shen, MD, MS Shanghai Renji Hospital and Duke Clinical Research Institute Tel: 919 -641-9233 Fax: 919-668-7061 Email: lan.shen@dm.duke.edu • The CRUSADE registry 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 and more than 200,000 patients in the U.S. participated in CRUSADE. Adjusted 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) surgery, PCI, CABG procedures used within 7 days post transfer-out.