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(Circulation. 1997;96:1770-1775.)
© 1997 American Heart Association, Inc.
Articles |
Long-term Outcome in Acute Myocardial Infarction Patients Admitted to Hospitals With and Without On-site Cardiac Catheterization Facilities
From the Northwest Health Services Research and Development Field Program, Seattle Veterans Affairs Medical Center (N.R.E., S.D.F.); the Department of Medicine, University of Washington (E.B.L.); and the MITI Coordinating Center, Division of Cardiology, Department of Medicine, University of Washington (L.S.P., C.M., A.P.H., J.S.M.), Seattle, Wash; and the Division of Cardiology, Henry Ford Health Care System, Detroit, Mich (W.D.W.).
Correspondence to Nathan Every, MD, MPH, MITI Coordinating Center, 1910 Fairview Ave E, #205, Seattle WA 98102. E-mail nevery{at}u.washington.edu
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Abstract |
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Background Previous studies have documented the strong association between availability of on-site cardiac catheterization facilities and increased use of coronary angiography in patients with acute myocardial infarction (AMI). Although these studies have shown little influence of the availability of catheterization labs on hospital mortality, no long-term follow-up has been reported.
Methods and Results From a cohort of 12 331 AMI patients admitted to 19 Seattle area hospitals, we compared long-term outcome in 7985 patients admitted to hospitals with and 4346 patients admitted to hospitals without on-site catheterization labs. During the index hospitalization, patients admitted to hospitals with on-site catheterization were more likely to undergo coronary angiography (67.1% versus 39.3%, P<.0001), coronary angioplasty (32.5% versus 13.2%, P<.0001), or coronary bypass surgery (12.5% versus 9.5%, P<.0001). At 3-year follow-up, patients admitted to hospitals with on-site catheterization labs were more likely to undergo postdischarge angiography (19.2% versus 15.2%, P=.0001) and coronary angioplasty (11.6% versus 8.2%, P<.0001). This was associated with approximately $2500.00 per patient in higher cumulative costs. Despite this higher rate of procedure use, there was no association between admission to a hospital with on-site catheterization facilities and lower long-term mortality (multivariate hazard ratio, 1.0; 95% CI, 0.93 to 1.1., the hazard being associated with admission to hospitals with on-site catheterization facilities).
Conclusions In an urban area with unconstrained patient transfer mechanisms and high overall cardiac procedure use rates, AMI patients admitted to hospitals without on-site catheterization facilities were managed with fewer procedures during hospitalization and follow-up. This more conservative treatment approach was not associated with any observed increase in long-term mortality.
Key Words: catheterization • myocardial infarction • cost-benefit analysis • mortality
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Introduction |
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In the present environment of limited healthcare resources, a reduction in the use of procedures is an integral part of most cost reduction strategies. One method for reducing procedure use is to limit the availability of technology, making it less convenient for physicians to perform procedures. This strategy may not be appropriate in conditions such as acute myocardial infarction (AMI), in which the rapid availability of coronary angiography and revascularization may be associated with better patient outcomes. Previous studies in patients with AMI have shown a strong association between the availability of cardiac catheterization facilities and the increased use of cardiac procedures. Whether or not this increased procedure use results in lower hospital mortality may be a function of the system of care. In systems with lower overall procedure use such as the Veterans Administration1 or staff model health maintenance organizations,2 the availability of on-site catheterization is associated with lower mortality rates. Whereas in systems with higher overall procedure use, such as fee-for-service hospitals, it appears that there is no difference in hospital mortality in patients admitted to hospitals with and without catheterization facilities.3 4 5
Although these studies support the concept that not all hospitals need catheterization facilities for optimal management of patients with AMI, they are limited by a lack of long-term patient follow-up. In previous randomized trials of bypass surgery versus medical therapy in patients with coronary disease, improvements in mortality rates were not apparent until after several years of follow-up.6 7 8 Thus it has been argued that longer patient follow-up is required to identify an improvement in mortality rates for hospitals with on-site catheterization facilities and higher rates of revascularization. Other long-term outcomes such as hospital readmission or postdischarge procedure use have also not been evaluated.
To evaluate the long-term consequences of admission to hospitals with and without on-site cardiac catheterization labs, we followed 12 331 Seattle AMI patients (7985 admitted to hospitals with catheterization labs and 4346 admitted to hospitals without catheterization labs) for an average of 2.3 years and determined long-term procedure use, costs, and mortality.
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Methods |
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Patients
Subjects were selected from a population of 12 331 patients with AMI enrolled in the Myocardial Infarction Triage and Intervention (MITI) Project Registry between 1988 and 1994. Characteristics of the registry, data-gathering procedures, and reliability have been described previously.9 Briefly, the MITI Project is a collaborative effort to evaluate new treatment strategies for patients with AMI and includes a registry of all patients admitted for suspected myocardial infarction in the Seattle metropolitan area. For patients transferred to a different institution during the index hospitalization, medical records were abstracted at the second hospital so that each patient had a continuous care record. Patient transfers did not include those patients transferred for diagnostic catheterization who immediately returned to the referring (admitting) facility. The study was approved by the University of Washington Human Subjects Review Committee.
Hospitals participating in the MITI Registry include 2 university hospitals, 2 staff–model health maintenance organization hospitals, 1 Veterans Affairs hospital, and 14 community hospitals. During most of the study period, 10 (53%) of participating hospitals had on-site catheterization labs and 5 (26%) performed bypass surgery. To investigate whether the presence of an on-site cardiac catheterization facility was associated with long-term outcome, patients were divided into two groups according to whether such a facility was available at the admitting hospital. For the purposes of this analysis, all procedures performed on a patient were attributed to the original admitting hospital, even if actually performed after the patient had been transferred to another facility. The admitting hospital was chosen by the patient or the paramedic system and was not assigned or determined by randomization.
Data Collected
Trained abstractors collected detailed demographic, prehospital,
clinical presentation, hospital course, and procedural data
from patient records within 3 months after discharge or death.
Postdischarge deaths, readmissions, and subsequent procedure use were
obtained by linking the MITI Registry to the Washington State
Comprehensive Hospital Abstract Reporting System (CHARS). The CHARS
database includes resource utilization, hospital charge, and vital
status data for every hospital admission in the state of Washington.
Cumulative readmission (primary cardiac ICD-9 diagnosis) and cardiac
procedure utilization rates were calculated at 1 and 3 years after
discharge. Postdischarge procedure utilization rates did not include
those procedures performed during the index admission. All charges were
converted to 1996 dollars, and costs were calculated by multiplying
charges by the Medicare cost-to-charge ratio at the hospital level for
each participating hospital. To adjust for outliers in the cost
comparison, hospital costs greater than the 95th percentile were set to
equal the costs at the 95th percentile of the population.
Statistical Analysis
We used 
2 and Student's t
tests to test for differences in baseline characteristics between
patients admitted to hospitals with and without on-site cardiac
catheterization facilities. Because costs were not
normally distributed, comparisons were made with the
nonparametric Mann-Whitney test. Postdischarge procedure
use and hospital readmission rates were compared at 1 and 3 years and
long-term mortality was compared with the use of Kaplan-Meier plots and
the log rank test. To test whether there was an association between the
type of admitting hospital and long-term mortality independent of
baseline differences, we constructed a series of Cox regression models.
Factors associated with either the use of coronary angiography
during the index hospitalization or long-term mortality in the
univariate comparison were entered stepwise into the model
with type of admitting hospital (with or without on-site
catheterization) forced into the model at the final
step. Because of the high correlation between the availability of
on-site catheterization and the use of angiography and
revascularization, these procedural variables
were not included in the model. Similar statistical methods were used
in subgroup analyses of patients with and without ST-segment
elevation as well as those patients classified as high risk as defined
in the Primary Angioplasty in Myocardial Infarction (PAMI)
Trial10 : those with an anterior infarct location, age >70
years, or heart rate >100 beats per minute.
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Results |
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Baseline and Presentation Characteristics
All 12 331 patients enrolled in the MITI Registry between 1988 and 1994 were included in the analysis and were divided into those patients initially admitted to hospitals with on-site catheterization labs (7985) and those initially admitted to hospitals without on-site catheterization labs (4346). Patients admitted to hospitals with on-site catheterization labs were younger (65.2±13.1 versus 67.8±13.4 years old, P<.0001) and more likely to be male (Table 1
). Past medical
histories were similar between cohorts, although patients admitted to
hospitals with on-site catheterization labs were more
likely to have undergone prior coronary angioplasty and/or
bypass surgery. Patients admitted to hospitals with on-site
catheterization labs were more likely to present
with anterior infarct location (28.8% versus 26.6%,
P<.0001, for hospitals with and without on-site
catheterization labs, respectively) but overall were
less likely to be classified as high risk (58.0% versus 66.1%,
P=.001).
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Patients admitted to hospitals with on-site
catheterization labs were more likely to receive acute
reperfusion therapy (thrombolytic therapy or primary
angioplasty) (34% versus 23%, P<.0001), coronary
angiography (67% versus 39%, P<.0001), coronary
angioplasty (32% versus 13%, P<.0001), or
coronary bypass surgery (12% versus 9%, P<.0001)
(Table 2). Mean and median hospital costs were higher in those patients
admitted to hospitals with on-site catheterization labs
(mean, $16 692±12 495 versus $14 465±12 831, P<.0001;
median, $12 500 versus $9300) (Fig 1). There was no difference in
hospital mortality between cohorts (9.5% versus 10.5%,
P=.09, after multivariate adjustment; odds
ratio, 1.03; 95% CI, 0.94 to 1.12; the odds of hospital mortality
being associated with admission to hospitals with on-site
catheterization facilities).
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Thirty percent of patients admitted to hospitals without on-site
catheterization labs were transferred during the index
hospitalization. Patients who were transferred were younger than those
not transferred (63.4±12.3 versus 69.7±13.5 years old,
P<.0001) and were less likely to have had prior heart
failure, but there was no difference in prior infarct, bypass surgery,
diabetes, or the proportion of patients classified as high risk (Table 3). After transfer, 90%
underwent coronary angiography, 38% coronary
angioplasty, and 32% bypass surgery. Hospital mortality was lower in
patients transferred compared with those who remained in hospitals
without on-site catheterization labs (6.1% versus
12.4%, P<.0001). After multivariate
adjustment for differences in baseline characteristics, patients who
remained in non–catheterization lab hospitals were
significantly more likely to die during hospitalization (odds ratio,
1.44; 95% CI, 1.1 to 1.9).
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Long-term Outcome
Patients were followed for a mean of 2.3 years, with a maximum
follow-up of 6.0 years. Excluding procedures performed as part of the
index hospitalization, patients admitted to hospitals with on-site
catheterization labs were more likely to undergo
postdischarge angiography (19% versus 15%, P=.0001) and
coronary angioplasty (12% versus 8%, P=.0007) at
3-year follow-up. There were no differences in the rates of
postdischarge bypass surgery or hospital readmission (Fig 2). Total cumulative costs at
3 years were higher for patients admitted to hospitals with on-site
catheterization labs (mean costs, $30 507±$23 504
versus $28 030±$22 995, P<.0001; median, $23 800 versus
$20 700) (Fig 1
).
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Unadjusted long-term survival was higher in patients admitted to
hospitals with on-site catheterization labs (74%
versus 71% at 3 years, P=.0001 by log rank) (Fig 3). To evaluate the
association between the availability of on-site
catheterization labs and long-term mortality
independent of differences in baseline characteristics, we performed a
series of Cox regression analyses. Factors associated with
higher long-term mortality in the multivariate
comparison included older age and previous histories of heart failure,
myocardial infarction, or bypass surgery, as well as cardiogenic shock,
heart failure, or stroke during the index hospitalization (Fig 4). The only factor associated
with lower long-term mortality was the use of acute reperfusion
therapy. After adjustment for these factors there was no association
between the availability of on-site catheterization
facilities and long-term mortality (hazard ratio, 1.0; 95% CI, 0.93 to
1.1; the hazard being associated with admission to hospitals with
on-site catheterization facilities).
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Subgroup Analyses
Because there are different treatment strategies in patients with
and without ST-segment elevation on the initial ECG, we examined
characteristics, treatment, and outcome in these subgroups of patients.
In the ST-segment elevation subgroup (n=4412), those admitted to
hospitals with on-site catheterization labs were
younger, more likely to have had prior bypass surgery, and less likely
to be classified as high risk (Table 4). Patients with ST-segment
elevation admitted to hospitals with on-site
catheterization labs underwent more cardiac procedures
(angiography, 81% versus 51%, P<.0001; angioplasty, 49%
versus 22%; rescue angioplasty, 12% versus 4%, P<.0001;
and bypass surgery, 12% versus 10%, P=.09) and had lower
unadjusted hospital mortality (6.8% versus 8.8%, P=.02).
After adjustment for differences in baseline characteristics, there was
no association between admission to hospitals with on-site
catheterization labs and hospital mortality (odds
ratio, 0.97; 95% CI, 0.73 to 1.3). In the subgroup of patients without
ST-segment elevation (n=7918), procedure use was higher in patients
admitted to hospitals with on-site catheterization labs
(angiography, 59% versus 34%, P<.0001; angioplasty, 23%
versus 9%; and bypass surgery, 13% versus 9%, P<.0001),
but there was no difference in hospital mortality
(univariate, 11.1% versus 11.3%, P=.76;
multivariate odds ratio, 1.1; 95% CI, 0.89 to
1.3).
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Because higher-risk patients may particularly benefit from admission to hospitals with on-site catheterization labs, we performed subgroup analyses in 1836 patients classified as high risk (1281 admitted to hospitals with and 555 admitted to hospitals without catheterization labs). In this subgroup, patients admitted to hospitals with on-site catheterization were younger (64.5 versus 66.3 years, P=.007), but there was no difference in prior infarct, heart failure, or bypass surgery. Twenty-four percent of high-risk patients admitted to hospitals without on-site catheterization facilities were transferred during the index admission. As in previous analyses, patients in the high-risk subgroup admitted to hospitals with on-site catheterization underwent more procedures (angiography, 80% versus 50%, P<.0001; angioplasty, 52% versus 24%, P<.0001; and bypass surgery, 12% versus 9%, P<.06). Unadjusted hospital and long-term mortality was lower in patients admitted to hospitals with on-site facilities (8.4% versus 11.9%, P=.02 at discharge and 21.7% versus 29.3%, P=.02 at 3 years). However, there was no difference after multivariate adjustments (odds of hospital mortality, 0.95; 95% CI, 0.65 to 1.4; and hazard of long-term mortality, 0.85; 95% CI, 0.67 to 1.1).
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Clinical indications for the use of invasive cardiac procedures after AMI are controversial. On one hand, multiple trials have shown that the routine use of cardiac catheterization after AMI does not improve hospital or long-term survival.11 12 On the other hand, there does appear to be an association between higher procedure use rates and better patient outcomes including lower mortality in some studies,1 2 improvements in functional status,13 and decreased readmission rates.14 This uncertainty has led to substantial variation in the use of cardiac procedures after AMI.5 15 16 One factor that has been shown to influence the use of cardiac procedures in this setting is simply whether or not a cardiac catheterization facility is available at the admitting hospital. Patients admitted to hospitals with on-site cardiac catheterization labs are more likely to undergo invasive cardiac procedures than patients admitted to hospitals without these facilities.3 4 5 The question remains, however, whether or not this higher rate of angiography is associated with improvements in outcome-most importantly, mortality.
In the present study, we followed a cohort of 12 331 AMI patients admitted to Seattle hospitals with and without cardiac catheterization labs for an average of 2.3 years and evaluated whether the availability of these procedures at the admitting hospital was associated with long-term outcome. In this registry in which all 19 hospitals are either urban or suburban with relatively short transfer times, there was no difference in long-term mortality between patients admitted to hospitals with and without cardiac catheterization labs. In addition, patients admitted to hospitals with on-site catheterization labs were more likely to undergo catheterization and coronary angioplasty after discharge. This higher use of procedures is most likely associated with the approximately $2500.00 in higher cumulative costs incurred per patient.
Although there does not appear to be an overall benefit of on-site catheterization in the Seattle metropolitan area, this study did identify subgroups of patients that may potentially benefit. In univariate comparisons, patients presenting with ST-segment elevation appeared to benefit from the availability of on-site catheterization. This finding may be explained by the timely availability and high rate of rescue or salvage angioplasty performed in those thrombolysis patients admitted to hospitals with on-site catheterization labs (12% versus 4% with and without on-site catheterization, respectively). In addition, unadjusted mortality was lower in high-risk patients admitted to hospitals with on-site catheterization. Whether these findings are a result of the greater and perhaps earlier use of procedures or simply a reflection of the higher-risk status in patients admitted to hospitals without on-site facilities (eg, older age) cannot be completely determined from our analysis. On the other hand, patients without ST-segment elevation as well as lower-risk patients did not appear to benefit from on-site catheterization labs. In these patients, the timing of intervention may be less important than selection of appropriate patients for revascularization. In all likelihood, Seattle physicians were able to identify high-risk patients admitted to hospitals without catheterization labs for transfer and revascularization.
There are three potential scenarios in which the availability of on-site catheterization could improve patient outcome. First, in patients with hemodynamic compromise (eg, unstable for transfer), the rapid availability of revascularization could result in lower mortality. However, any improvement in mortality in these patients should have been observed in hospital mortality data. This was not the case in this modest-sized study as well as several larger cohort studies.4 5 Second, it has been argued that the higher rate of revascularization observed in patients admitted to hospitals with on-site catheterization facilities would result in lower long-term mortality, particularly in higher-risk patients as observed in several reported bypass surgery trials.6 7 8 In this observational study, however, there was no association nor trend toward lower long-term mortality in these patients.
Finally, it has been argued that the higher rates of procedures performed on patients admitted to hospitals with on-site catheterization labs would result in fewer subsequent procedures and readmissions. Although readmission rates were similar between cohorts in this study, patients admitted to hospitals with on-site catheterization labs were more likely to undergo postdischarge procedures and had higher associated long-term costs. Thus it does not appear that performing procedures as part of the index hospital admission results in long-term savings.
Although provocative, the findings of this study should be interpreted cautiously. First, as a cohort study, patients were not randomly assigned to hospitals with and without catheterization labs, and thus, these findings are subject to selection bias. Although we were able to adjust for any differences in measured characteristics between the cohorts, we were not able to adjust for unmeasured factors that may be associated with mortality such as occurrence of arrhythmia, lipid profiles, or socioeconomic status. Second, we did not measure physician specialty in those who practiced in hospitals with and without catheterization facilities. Although it is possible that the association we observed between procedure use and availability of facilities may have been mediated by physician specialty, previous work in this same patient population has shown that these findings were independent of physician specialty.3 Third, our mean follow-up of 2.3 years may have been too short to observe any benefit of admission to hospitals with catheterization labs. However, there was no trend toward lower mortality in patients admitted to hospitals with catheterization labs.
Probably the most important caution in interpretation of these findings is in generalizability. Hospitals participating in the MITI Registry are uniformly urban/suburban with short transfer times (<15 minutes) between hospitals with and without catheterization facilities. In addition, the high rate of both angiography and revascularization in both hospitals with and without on-site catheterization undoubtedly contributes to the low mortality observed in both cohorts. Although the appropriate rate of postinfarction angiography has not been established, previous studies in systems of care with lower overall rates of angiography such as the Department of Veterans Affairs (25% in hospitals without on-site facilities),1 staff-model health maintenance organizations (30%),2 and Canadian hospitals (25% to 35%)17 18 have shown that angiography rates <30% to 35% may be associated with excess mortality. In this study, angiography rates in hospitals without on-site catheterization were 39%, which probably approaches the lowest rate to minimize hospital mortality. Thus these findings are probably not generalizable to hospitals without on-site catheterization that refer for angiography at a lower rate than observed in this study.
We conclude that in an urban area with unconstrained patient transfer mechanisms and high overall cardiac procedure use rates, AMI patients admitted to hospitals without on-site catheterization facilities were managed with fewer procedures during hospitalization and follow-up. This more conservative treatment approach was not associated with any observed increase in long-term mortality.
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Acknowledgments |
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This study was supported by an HSR&D Career Development Award from the Department of Veterans Affairs, grant R01-HL-38454 from the National Heart, Lung, and Blood Institute, Bethesda, Md, and grant HS08362 from the Agency for Health Care Policy and Research, Rockville, Md.
Received March 3, 1997; revision received May 1, 1997; accepted May 5, 1997.
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