title: Elderly patients at highest risk with acute myocardial infarction are more frequently transferred from community hospitals to tertiary centers: reality or myth?
abstract: BACKGROUND
  The objective of this study was to assess the characteristics of patients with acute myocardial infarction transferred from community hospitals. The study was designed as a retrospective chart review, and the data source was the Cooperative Cardiovascular Project from Michigan.
  
  
  RESULTS
  Included in the study were consecutive Medicare patients with acute myocardial infarction discharged from acute-care hospitals in Michigan between April 1, 1994, and July 31, 1995 (n = 7041): 2866 patients treated at community hospitals, 1241 transferred from community hospitals, 2731 admitted directly to tertiary hospitals, and 203 transferred from an outside emergency room to tertiary hospitals. The outcomes measured were patient characteristics, quality indicators, resource use, and 30-day mortality rates. Compared with patients not transferred, those transferred from community hospitals were younger, more frequently of the male sex, smokers, and were seen earlier after symptom onset. They had fewer cases of diabetes and lower Acute Physiology And Chronic Health Evaluation (APACHE II) scores and Medicare Mortality Prediction System (MMPS) values. Aspirin during hospitalization and at discharge, thrombolytic therapy, and reperfusion therapy were all used more frequently in transferred patients, whereas the other key discharge quality indicators were no different. Mortality rate at 30 days was lower for transferred patients (9.4% vs 25%, P <.0001) when compared with those not transferred.
  
  
  CONCLUSIONS
  Patients who are less ill, those who are seen early, and those who received thrombolytic therapy are more often transferred from community hospitals. On average, patients with greater comorbidity rates are treated at community hospitals and not transferred. Predicted and observed mortality rates were lower for the transferred group. Higher comorbidity rate in patients treated at community hospitals appears to be the major determinant of the observed higher mortality rates in these patients.
authors.affiliation: Center For Health Outcomes, Heart Care Outcomes Assessment Team, Division of Cardiology, University of Michigan, Ann Arbor, USA.
authors.forename: R H
authors.initials: RH
authors.lastname: Mehta
authors.forename: E J
authors.initials: EJ
authors.lastname: Stalhandske
authors.forename: P A
authors.initials: PA
authors.lastname: McCargar
authors.forename: T J
authors.initials: TJ
authors.lastname: Ruane
authors.forename: K A
authors.initials: KA
authors.lastname: Eagle
mesh_terms: D000368:Aged; D015897:Comorbidity; D005260:Female; D006764:Hospitals, Community / Q000706:statistics & numerical data; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D008824:Michigan / Q000453:epidemiology; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000628:therapy; D015425:Myocardial Reperfusion / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data*; D010865:Pilot Projects; D011787:Quality of Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014481:United States