Shen Lan, Shah Bimal R, Li Shuang, Thomas Laine, Wang Tracy Y, Alexander Karen P, Peterson Eric D, He Ben, Roe Matthew T
Department of Cardiology, Shanghai Renji Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China.
Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina.
Clin Cardiol. 2015 Dec;38(12):733-9. doi: 10.1002/clc.22480. Epub 2015 Oct 29.
Interhospital transfer invasive management patterns and implications for older non-ST-segment elevation myocardial infarction (NSTEMI) patients initially presenting to non-revascularization-capable hospitals have not been explored.
Patients admitted to hospitals with a higher transfer proportion have lower risk of long-term mortality.
We linked CRUSADE Registry data on 5678 patients age ≥65 years from 65 United States non-revascularization-capable hospitals (2003-2006) with inpatient Medicare longitudinal claims. Hospitals were categorized according to hospital-level patient transfer-out rates, low (≤40%) vs high (>40%). The associations between transfer-out rates and 30-day, 6-month, and 3-year mortality risk were evaluated using Cox proportional hazard models.
Hospital-level transfer-out rates varied widely (median, 43%; interquartile range, 31%-54%). Compared with patients from low-transfer-out hospitals (n = 2715), patients from high-transfer-out hospitals (n = 2963) were more likely to be male, less likely to have renal insufficiency and prior heart failure, and had lower long-term CRUSADE mortality risk scores. These patients also more commonly received evidence-based acute medications before transfer and underwent subsequent revascularization after transfer. The adjusted risks of mortality at various time intervals were similar for those from high- vs low-transfer-out hospitals: 30 days (hazard ratio: 0.95, 95% confidence interval: 0.79-1.14), 6 months (0.97, 0.84-1.12), and 3 years (1.01, 0.91-1.11).
Transfer rates for older NSTEMI patients vary widely among non-revascularization-capable hospitals. Despite lower predicted mortality risk and higher rates of post-transfer revascularization, patients from high-transfer-out hospitals had a similar risk for short- and long-term mortality compared with those from low-transfer-out hospitals.
院间转运的侵入性管理模式以及对最初就诊于无血运重建能力医院的老年非ST段抬高型心肌梗死（NSTEMI）患者的影响尚未得到探究。
转入比例较高的医院收治的患者长期死亡风险较低。
我们将美国65家无血运重建能力医院（2003 - 2006年）5678例年龄≥65岁患者的CRUSADE注册数据与医疗保险住院纵向索赔数据相链接。医院根据医院层面的患者转出率进行分类，低（≤40%）与高（>40%）。使用Cox比例风险模型评估转出率与30天、6个月和3年死亡风险之间的关联。
医院层面的转出率差异很大（中位数为43%；四分位间距为31% - 54%）。与转出率低的医院的患者（n = 2715）相比，转出率高的医院的患者（n = 2963）更可能为男性，肾功能不全和既往心力衰竭的可能性更小，且CRUSADE长期死亡风险评分更低。这些患者在转运前也更常接受循证急性药物治疗，并在转运后接受血运重建。转出率高与转出率低的医院的患者在不同时间间隔的校正死亡风险相似：30天（风险比：0.95，95%置信区间：0.79 - 1.14），6个月（0.97，0.84 - 1.12），3年（1.01，0.91 - 1.11）。
在无血运重建能力的医院中，老年NSTEMI患者的转出率差异很大。尽管预测的死亡风险较低且转运后血运重建率较高，但转出率高的医院的患者与转出率低的医院的患者相比，短期和长期死亡风险相似。
