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Age, Sex, Racial Disparities in Heart Attack Hospital Transfer Patterns

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Duke Health News 919-660-1306

DURHAM, N.C. -- Older, female and minority patients rushed
to community hospitals with acute heart attacks are less likely
to be transferred to a larger hospital that offers procedures
to immediately open clogged arteries, Duke University Medical
Center cardiologists have found.

The finding of such disparities is important, the
researchers assert, since research has shown that even with the
added transfer time, patients with an acute heart attack still
fare better with artery-opening procedures -- such as
angioplasty or bypass surgery – than those treated only with
powerful clot-busting drugs.

The researchers said their findings should help give
physicians in smaller community hospitals more confidence about
transferring such patients to larger hospitals. The researchers
also said the reasons for such disparities remain to be
explored, and that they are likely multifactorial.

In their analysis of almost 400,000 U.S. heart attack
patients over the age of 64, the team also found that while
heart attack patients who were not transferred tended to be
sicker than those who were transferred, paradoxically, the
sicker patients were those who would most likely benefit the
most from artery-opening procedures, the researchers said.

"While the medical community is very proficient at treating
complex illnesses like heart disease, there still remain
disparities in the delivery of that care that needs to be
addressed," said Duke cardiology fellow Jeffrey Berger, M.D.,
who presented the results of his analysis March 12, 2006,
during the 55th annual scientific sessions of the American
College of Cardiology in Atlanta.

"Our analysis found that in the U.S., patients over the age
of 64 admitted with an acute heart attack to
non-revascularization hospitals and then transferred were
younger, more frequently male, white and at lower risk and had
improved survival than those who remained at the community
hospital," he continued.

Specifically, the team found that women were 16 percent less
likely to be transferred than men. And, compared to white
patients, African-Americans were 31 percent and Hispanics were
47 percent less likely to be transferred. Also, as age
increased, so did the chances of not being transferred.

For his analysis, Berger consulted Centers for Medicare and
Medicaid Services data from 2001 to 2003. During that time,
399,775 patients over the age of 64 suffering from an acute
heart attack were admitted to hospitals that were unable to
perform angioplasty or bypass surgery. Of those patients, just
over one-third (35 percent) were subsequently transferred to a
larger facility with revascularization capabilities.

In terms of mortality, 8.7 percent of the transferred
patients died; statistical modeling predicted that 8.9 percent
of transferred patients would die. For those patients who were
not transferred, 18.5 percent died; statistical modeling
predicted that 15.2 percent would die.

"There are many disparities in health care, and this
analysis has uncovered another area of concern," Berger said.
"It is crucial that we implement or enhance systems that help
protect against these disparities and improve the quality of
care for all patients."

"Many studies have shown that angioplasty or bypass surgery
is the option of choice over drugs for the vast majority of
patients suffering from an acute heart attack," Berger
continued. "We are now beginning to appreciate that the sickest
of these patients perhaps would do better if they received a
revascularization procedure. These findings suggest that more
patients should be transferred."

Berger said that physicians in smaller community hospitals
may feel that it is too risky to subject heart attack patients
– especially if they are older – to an ambulance ride to
another facility. His said data from this and future studies
should help give confidence to community hospital physicians
about transferring these patients.

"The national guidelines suggest that patients who are
having an acute heart attack should go to the nearest hospital,
and that every hospital is able to provide a pharmacologic
(clot-buster) treatment," Berger continued. "However, there are
a significant number of patients who cannot take these drugs or
do not respond to them."

The main side effect of clot-busting drugs is the potential
for bleeding. According to Berger, many acute heart attack
patients cannot be given these drugs because of the risk of
bleeding within the brain. Also, even after receiving
clot-busters, the arteries do not re-open in every patient,
using up time that could have been better used getting a
procedure, he said.

Berger added that more research is needed to better
understand the root causes of these disparities, since they are
likely to be more logistical or systemic in nature than
medical. The answers likely reside in a combination of factors,
including patient preferences, decisions made by health care
workers, and institutional issues.

Berger began this analysis while at Beth Israel Medical
Center, New York, under senior team member cardiologist David
Brown, M.D., and completed it at Duke. Other colleagues were
Nicholas Wanahita and Samantha Collier, State University of New
York-Stony Brook, N.Y.

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