title: Transfer rates from nonprocedure hospitals after initial admission and outcomes among elderly patients with acute myocardial infarction.
abstract: OBJECTIVE
  It is unknown whether hospital transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals (facilities that do not provide catheterization) vary and whether these rates further influence revascularization rates, length of stay, and mortality.
  
  
  OBJECTIVE
  To examine hospital differences in transfer rates for elderly patients with acute myocardial infarction across nonprocedure hospitals and to determine whether these rates are associated with revascularization rates, length of stay, and mortality.
  
  
  METHODS
  We used Medicare claims data from January 1, 2006, to December 31, 2008, to assess transfer rates in nonprocedure hospitals, stratified according to transfer rates as low (≤ 20%), mid-low (>20%-30%), mid-high (>30%-40%), or high (>40%). Data were analyzed for 55,962 Medicare fee-for-service patients admitted to 901 nonprocedure US hospitals with more than 25 admissions per year for acute myocardial infarction.
  
  
  METHODS
  We compared rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery during hospitalization and within 60 days, as well as hospital total length of stay, across groups. We measured risk-standardized mortality rates at 30 days and 1 year. RESULTS The median transfer rate was 29.4% (interquartile range [25th-75th percentile], 21.8%-37.8%). Higher transfer rates were associated with higher rates of catheterization (P < .001), percutaneous coronary intervention (P < .001), and coronary artery bypass graft surgery (P < .001). Median length of stay was not meaningfully different across the groups. There was no meaningful evidence of associations between transfer rates and risk-standardized mortality at 30 days (mean [SD], 22.3% [2.6%], 22.1% [2.3%], 22.3% [2.4%], and 21.7% [2.1%], respectively; P = .054) or 1 year (43.9% [2.3%], 43.6% [2.2%], 43.5% [2.4%], and 42.8% [2.2%], respectively; P < .001) for low, mid-low, mid-high, and high transfer groups.
  
  
  CONCLUSIONS
  Nonprocedure hospitals vary substantially in their use of the transfer process for elderly patients admitted with acute myocardial infarction. High-transfer hospitals had greater use of invasive cardiac procedures after admission compared with low-transfer hospitals. However, higher transfer rates were not associated with a significantly lower risk-standardized mortality rate at 30 days. Moreover, at 1 year there was only a 1.1% difference (42.8% vs 43.9%) between hospitals with higher and lower transfer rates. These findings suggest that, as a single intervention, promoting the transfer of patients admitted with acute myocardial infarction may not improve hospital outcomes.
authors.affiliation: Division of Cardiology, Federal University of Sergipe, Aracaju, Sergipe, Brazil.
authors.forename: José Augusto
authors.initials: JA
authors.lastname: Barreto-Filho
authors.affiliation: Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut3Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Yongfei
authors.initials: Y
authors.lastname: Wang
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Boston.
authors.forename: Saif S
authors.initials: SS
authors.lastname: Rathore
authors.affiliation: Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Erica S
authors.initials: ES
authors.lastname: Spatz
authors.affiliation: Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut6Section of General Internal Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Hav.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Ross
authors.affiliation: Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut3Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
authors.forename: Jeptha P
authors.initials: JP
authors.lastname: Curtis
authors.affiliation: Veterans Affairs Ann Arbor Health Services Research and Development Service Center for Clinical Management Research, Ann Arbor, Michigan8Division of Cardiovascular Medicine, Department of Internal Medicine and Center for Healthcare Outcomes and Policy, In.
authors.forename: Brahmajee K
authors.initials: BK
authors.lastname: Nallamothu
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Harvard University, Boston, Massachusetts10Department of Biostatistics, Harvard School of Public Health, Harvard University, Boston, Massachusetts.
authors.forename: Sharon-Lise T
authors.initials: SL
authors.lastname: Normand
authors.affiliation: Section of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut3Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut5Robert Wood Johnson Clinical Scho.
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
mesh_terms: D000368:Aged; D018588:Fee-for-Service Plans / Q000191:economics; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006782:Hospitals, Special / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare / Q000191:economics; D009203:Myocardial Infarction / Q000191:economics / Q000401:mortality / Q000628:therapy*; D009204:Myocardial Revascularization / Q000191:economics / Q000379:methods*; D010343:Patient Admission; D010360:Patient Transfer / Q000191:economics / Q000706:statistics & numerical data*; D015996:Survival Rate / Q000639:trends; D014481:United States / Q000453:epidemiology