title: Care Transitions After Acute Myocardial Infarction for Transferred-In Versus Direct-Arrival Patients.
abstract: BACKGROUND
  Many patients in the United States require transfer from one hospital to another for acute myocardial infarction (MI) care. How well these transferred-in patients are transitioned back to their local community is unknown.
  
  
  RESULTS
  We used linked Medicare claims data to examine postdischarge outcomes of 39 136 patients with acute MI aged ≥65 years discharged alive from 451 US hospitals in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines. Multivariable Cox modeling was used to compare the likelihood of outpatient clinic follow-up and risks of all-cause mortality and all-cause or cardiovascular readmission at 30 days post MI between transferred-in and direct-arrival patients. From 2007 to 2010, 14 060 of 39 136 patients (36%) required interhospital transfer for acute MI care, traveling a median of 43 miles (interquartile range, 27-68 miles; 77.6 km [interquartile range, 48.2-122.6 km]). Compared with those arriving directly, transferred-in patients with MI were slightly younger (median age, 73 versus 74; P<0.01) but less likely to have previous MI, heart failure, and previous revascularization than direct-arrival patients. Relative to direct-arrival patients, those transferred-in had a lower likelihood of outpatient follow-up within 30 days post discharge (risk-adjusted incidence, 69.9% versus 78.2%; hazard ratio [HR], 0.90; 95% confidence interval, 0.87-0.92) and higher adjusted 30-day all-cause and cardiovascular readmission risks (14.5% versus 14.0%; HRall-cause, 1.08; 95% confidence interval, 1.01-1.15 and 9.5% versus 9.1%; HRcardiovascular, 1.13; 95% confidence interval, 1.04-1.22). In contrast, risk-adjusted 30-day mortality was similar between transferred-in and direct arrivals (1.6% versus 1.6%; HR, 1.05; 95% confidence interval, 0.86-1.27).
  
  
  CONCLUSIONS
  Transferred-in patients with acute MI are less likely to have outpatient clinic follow-up within 30 days and more likely to be readmitted within the first 30 days post discharge compared with direct-arrival patients. These results indicate room for improvement in the safe and seamless transition of care for transferred patients with MI traveling back to their home environments.
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.). a.vora@duke.edu.
authors.forename: Amit N
authors.initials: AN
authors.lastname: Vora
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.).
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.).
authors.forename: Anne S
authors.initials: AS
authors.lastname: Hellkamp
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.).
authors.forename: Nadia R
authors.initials: NR
authors.lastname: Sutton
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.).
authors.forename: Edward
authors.initials: E
authors.lastname: Panacek
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.).
authors.forename: Laine
authors.initials: L
authors.lastname: Thomas
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.).
authors.forename: James A
authors.initials: JA
authors.lastname: de Lemos
authors.affiliation: From the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (A.N.V., E.D.P., A.S.H., L.T.); Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor (N.R.S.); Department of Emergency Medicine, University of California Davis, Sacramento (E.P.); and Cardiovascular Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (J.A.d.L.).
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D006297:Health Services Accessibility; D006302:Health Services Research; D006801:Humans; D008297:Male; D006278:Medicare; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D010343:Patient Admission; D010351:Patient Discharge; D010359:Patient Readmission; D010360:Patient Transfer; D017064:Process Assessment, Health Care; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D014187:Transportation of Patients; D016896:Treatment Outcome; D014481:United States
keywords: health services accessibility; myocardial infarction; patient readmission; patient transfer; point-of-care systems