Transfer rates from nonprocedure hospitals after initial admission and outcomes among elderly patients with acute myocardial infarction

JAMA Intern Med. 2014 Feb 1;174(2):213-22. doi: 10.1001/jamainternmed.2013.11944.


Importance: 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.

Objectives: 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.

Design, setting, and participants: 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.

Main outcomes and measures: 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 and relevance: 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.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Fee-for-Service Plans / economics
  • Female
  • Hospital Mortality / trends
  • Hospitals, Special / economics
  • Hospitals, Special / statistics & numerical data*
  • Humans
  • Male
  • Medicare / economics
  • Myocardial Infarction / economics
  • Myocardial Infarction / mortality
  • Myocardial Infarction / therapy*
  • Myocardial Revascularization / economics
  • Myocardial Revascularization / methods*
  • Patient Admission*
  • Patient Transfer / economics
  • Patient Transfer / statistics & numerical data*
  • Survival Rate / trends
  • United States / epidemiology