title: Outcomes after acute coronary syndrome admission to primary versus tertiary Veterans Affairs medical centers: the Veterans Affairs Access to Cardiology study.
abstract: BACKGROUND
  There is a concern that patients with acute coronary syndrome (ACS) admitted to primary care hospitals (without on-site cardiac procedures) may be at risk for worse outcomes compared with patients admitted to tertiary care hospitals. In addition to mortality, one way to assess patient outcomes is via health status and rehospitalization rates. We compared the health status and rehospitalization of patients with ACS admitted to primary versus tertiary care Veterans Affairs hospitals.
  
  
  METHODS
  This was a cohort study of 2132 patients with ACS admitted to 21 Veterans Affairs hospitals (12 primary care and 9 tertiary care) from 1998 to 1999. Primary outcomes were 7-month health status as measured by the Seattle Angina Questionnaire and rehospitalization. Hierarchical multivariable regression was used to evaluate the association between admission to a primary (vs tertiary) care hospital and these outcomes. Discharge medications and 7-month cardiac procedure rates were also compared.
  
  
  RESULTS
  There were no significant differences in discharge medication rates between primary and tertiary hospital patients. Forty-two percent of the patients admitted to a primary care hospital was transferred to a tertiary care hospital during index admission. Primary hospital patients had significantly lower 7-month rates of cardiac catheterization (36% vs 51%, P < .001) and percutaneous coronary intervention (11% vs 20%, P < .001), but there were no differences in coronary artery bypass graft surgery rates. After risk adjustment, there were no significant differences in 7-month angina frequency (odds ratio [OR] 0.98, 95% CI 0.78-1.22), physical limitation (OR 0.97, 95% CI 0.77-1.23), quality of life (OR 1.12, 95% CI 0.89-1.40), or rehospitalization (OR 1.07, 95% CI 0.54-2.14) between the 2 groups.
  
  
  CONCLUSIONS
  These results suggest that an integrated health care system can achieve similar intermediate-term health status and rehospitalization outcomes for patients with ACS irrespective of the site of admission despite the lower rates of cardiac procedures for the primary care hospital patients.
authors.affiliation: Cardiology and Health Services Research, Denver VA Medical Center, Denver, CO 80220, USA. john.rumsfeld@med.va.gov
authors.forename: John S
authors.initials: JS
authors.lastname: Rumsfeld
authors.forename: David J
authors.initials: DJ
authors.lastname: Magid
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Mary E
authors.initials: ME
authors.lastname: Plomondon
authors.forename: Laura A
authors.initials: LA
authors.lastname: Petersen
authors.forename: Gary K
authors.initials: GK
authors.lastname: Grunwald
authors.forename: Nathan R
authors.initials: NR
authors.lastname: Every
authors.forename: Anne E
authors.initials: AE
authors.lastname: Sales
mesh_terms: D000208:Acute Disease; D000368:Aged; D000789:Angina, Unstable / Q000628:therapy*; D002300:Cardiac Care Facilities; D015331:Cohort Studies; D005260:Female; D006304:Health Status; D006760:Hospitalization / Q000706:statistics & numerical data*; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000628:therapy*; D011320:Primary Health Care; D013577:Syndrome; D016896:Treatment Outcome