Community Hospitals Do Not Transfer High-Risk Heart Patients For Aggressive Therapy
NEW ORLEANS -- In an analysis of the transfer patterns from more than 100 U.S. community hospitals, Duke University Medical Center researchers have found that fewer than one of five high-risk patients presenting with unstable angina or non-ST-segment elevation myocardial infarction (UA/NSTEMI) were quickly transferred to tertiary facilities with the ability to reopen clogged arteries with an angioplasty or coronary bypass surgery procedure, as recommended by the leading U.S. heart organizations.
The results of this analysis, the first such comprehensive look at this issue at community hospitals, highlights a crucial weakness in the delivery of cardiac care that should be addressed to improve the outcomes of patients with heart attacks, the researchers said. They cited recommendations of the American College of Cardiology (ACC) and the American Heart Association (AHA) that certain high-risk patients should be treated invasively within the first 48 hours of arriving at the hospital.
According to their analysis, only 18.7 percent of these high-risk patients with UA/NSTEMI were transferred to a tertiary hospital within 48 hours of presenting to a community hospital with symptoms of a heart attack. An additional 27.2 percent were transferred more than 48 hours after presentation.
Ironically, mortality rates for the patients not transferred are higher, mainly because the younger, healthier heart patients tend to be quickly transferred to tertiary care institutions while the sickest patients remain at community hospitals, the researchers said.
The results of the current analysis were presented today (March 7, 2004) by Duke cardiologist Matthew Roe, MD, at the annual scientific sessions of the ACC.
"Paradoxically, we found that those high-risk patients who would stand to benefit the most from early invasive care were the least likely to be transferred to a facility capable of performing angioplasty or bypass surgery procedures," Roe said. "These findings support the creation of new initiatives designed enhance the triage strategies for these patients by using a 'hub-and-spoke' system of regionalized tertiary referral for high-risk patients."
Roe's analysis is a part of the national effort to improve the outcomes for heart patients through the use of therapies -- whether drug or procedural -- that have been proven effective by large-scale clinical trials. The effort is known as CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA Guidelines). CRUSADE is coordinated by the Duke Clinical Research Institute.
CRUSADE focuses on heart patients with UA/NSTEMI. These patients typically arrive at emergency rooms with chest pain (angina), but often will not have telltale signs of a heart attack on the initial electrocardiogram and may only be diagnosed with a heart attack when the results of initial blood testing are reported a few hours later.
While patients with acute ST-segment elevation myocardial infarction are at higher risk of dying within 30 days of their hospital stay, patients with UA/NSTEMI actually have a higher risk of dying six months and one year after initial hospital presentation. It is estimated that about 1.3 million Americans are hospitalized each year with UA/NSTEMI
Roe and colleagues examined the clinical characteristics of 11,645 patients seen in 106 community hospitals participating in CRUSADE, which maintains a national registry of data collected from more than 400 hospitals nationwide. Forty-five of the hospitals did not have cardiac catheterization laboratories, while 61 had only diagnostic catheterization laboratories. None of the community hospitals had facilities to perform angioplasty or coronary bypass surgery.
Of the 11,645 patients seen in community hospitals, 54.1 percent (6,296) were not transferred. These patients were on average 75 years old, compared to an average age of 63 for those who were transferred in less than 48 hours. They were also more likely to have other conditions, such as diabetes, renal insufficiency and past heart problems.
Those patients who were not transferred also tended not to receive guidelines-recommended medications that have been proven in trials to improve outcomes.
"This is very concerning, because if you're not going to transfer a high-risk patient for a procedure, these drugs should be used because medical therapies are the only options for such patients" Roe said. Specifically, agents such platelet glycoprotein IIb/IIIa inhibitors were used in only 19.2 percent of the non-transferred patients, compared to 46.4 percent for those transferred.
While the current analysis did not follow patients after they were transferred, the in-hospital mortality rates by hospital capabilities for the 57,039 patients currently in the CRUSADE registry are as follows: hospital without catheterization laboratory -- 9.6 percent; hospital with diagnostic catheterization laboratory only -- 9.2 percent; hospital with angioplasty capabilities -- 6.3 percent; hospital with angioplasty and bypass surgery capabilities -- 4.2 percent.
These findings indicate that patients at the highest risk for early mortality are unlikely to be transferred from community hospitals for angioplasty or coronary bypass surgery. Since these patients are also less likely to receive beneficial medications for UA/NSTEMI, the high mortality rates may be due to poor adherence to the ACC/AHA practice guidelines recommendations.
"The patients in the CRUSADE registry are from "real world" practice that physicians see every day in all types of hospitals," Roe said. "While CRUSADE points out weaknesses in the health-care system, it also can help in showing us where to improve the system. We hope these findings will stimulate community hospitals to re-evaluate their care processes for patients with UA/NSTEMI."
CRUSADE is funded by Millennium Pharmaceuticals, Cambridge, MA, and Schering Corp, Kenilworth, NJ. Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, NY, provided an unrestricted grant in support of CRUSADE.