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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2004.08.018 Byline: Saif S. Rathore (a)(b), Paul D. Frederick (e), Nathan R. Every (e), Hal V. Barron (f), Harlan M. Krumholz (a)(c)(d) Abstract: Racial differences in reperfusion therapy use among patients hospitalized with myocardial infarction (MI) have been previously reported as national phenomenon. However, it is unclear whether racial differences in treatment vary by region. Author Affiliation: (a) Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn (b) MD/PhD Program, Yale University School of Medicine, New Haven, Conn (c) Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn (d) Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Conn (e) Ovation Research Group, Chicago, Ill (f) Genentech, Incorporated, South San Francisco, Calif Article History: Received 13 January 2004; Accepted 17 August 2004 Article Note: (miscellaneous) The National Registry of Myocardial Infarction-2 and -3 is supported by Genentech, Inc, South San Francisco, Calif. Mr Rathore is supported by National Institutes of Health National Institute of General Medical Sciences Medical Scientist Training Grant GM07205.

Heart attack patients who are treated at hospitals that do many angioplasty procedures have lower mortality rates while they are in the hospital. This was the conclusion of researchers who analyzed mortality rates among heart attack patients treated at 450 hospitals that perform angioplasty and 516 hospitals that use thrombolytic drugs. Both of these treatments are used to open up blocked arteries. The in-hospital mortality rate was 28% lower in hospitals that did the most angioplasties compared to those that did the fewest. This reduction in mortality was not seen in the hospitals that only used thrombolytic drugs.

Young women who have a heart attack have a higher mortality rate than men their age. This was the conclusion of a study of 384,878 heart attack patients between 30 and 89 years old, 155,565 of whom were women. During their hospital stay, the mortality rate in the women less than 50 years old was more than twice the rate in men the same age. Mortality rates in young women were still higher after adjusting for the serious of the heart attack and the care the patients received.

Having to make a copayment may not necessarily reduce the use of emergency medical services. Researchers analyzed the hospital records of 1,331 people in an HMO who came to the emergency room with the signs and symptoms of a heart attack. Of these, 602 were required to make a copayment and 729 were not. A copayment requirement did not cause any significant delays in seeking medical care even after adjusting for other factors that might influence emergency room visits. Some studies have shown that copayment requirements lead to reduced use of emergency medical services.

Treatment of acute heart attack with clot-dissolving drugs or angioplasty appears to be equally effective. Angioplasty and drugs called thrombolytics are both used to open blocked arteries. Researchers studied short-term and long-term mortality in 1,050 heart attack patients treated with angioplasty and 2,095 heart attack patients treated with thrombolytics. There was no difference in mortality between the groups in the short- or long-term. Those who received angioplasty used more resources and incurred higher costs. Thrombolytics are easy to administer and do not require technical skill.

Patients treated in hospitals with cardiac catheterization facilities were three times more likely to have coronary angiography performed after a heart attack than patients admitted to a hospital without those facilities. Coronary angiography is a diagnostic technique that uses X-rays to visualize the heart and blood vessels after the injection of a contrast medium into the veins. A review of the records of 5,867 patients admitted to 19 Seattle, WA, hospitals for treatment of heart attacks evaluated the likelihood that patients would have angiography performed. A further analysis of 614 patients treated by doctors who worked at both hospitals with the catheterization facilities and those without indicated that the doctors performed the procedure on 73% of their patients at hospitals with on-site facilities. The procedure was only performed on 47% of those admitted to hospitals without cardiac catheterization facilities. There was no association between on-site facilities and in-hospital mortality rates.

Abstract Background Cardiac biomarkers are routinely obtained in the setting of suspected myocardial ischemia and infarction. Evidence suggests these markers may correlate with functional and clinical outcomes, but the strength of this correlation is unclear. The relationship between enzyme measures of myocardial necrosis and left ventricular performance and adverse clinical outcomes were explored. Methods Creatine kinase (CK) and CK-MB data were analyzed, as were left ventricular ejection fraction (LVEF) by angiogram, and infarct size by single-photon emission computed tomography (SPECT) imaging in patients in 2 trials: Prompt Reperfusion In Myocardial-infarction Evolution (PRIME), and Efegatran and Streptokinase to Canalize Arteries Like Accelerated Tissue plasminogen activator (ESCALAT). Both trials evaluated efegatran combined with thrombolysis for treating acute ST-segment elevation myocardial infarction (STEMI). Results Peak CK and CK area-under-the-curve (AUC) correlated significantly with SPECT-determined infarct size 5 to 10 days after enrollment. Peak CK had a statistically significant correlation with LVEF, but CK-AUC and LVEF correlation were less robust. Statistically significant correlations exist between SPECT-determined infarct size and peak CK-MB and CK-MB AUC. However, there was no correlation with LVEF for peak CK-MB and CK-MB AUC. The combined outcome of congestive heart failure and death were significantly associated with CK AUC, CK-MB AUC, peak CK, and peak CK-MB measurements. Conclusion Peak CK and CK-MB values and AUC calculations have significant correlation with functional outcomes (LVEF- and SPECT-determined infarct size) and death or CHF outcomes in the setting of STEMI. Cardiac biomarkers provide prognostic information and may serve as valid endpoint measurements for phase II clinical trials.

Abstract Background Few studies report on the effect of organizational factors facilitating transfer between primary and tertiary care hospitals either within an integrated health care system or outside it. In this paper, we report on the relationship between degree of clinical integration of cardiology services and transfer rates of acute coronary syndrome (ACS) patients from primary to tertiary hospitals within and outside the Veterans Health Administration (VHA) system. Methods Prospective cohort study. Transfer rates were obtained for all patients with ACS diagnoses admitted to 12 primary VHA hospitals between 1998 and 1999. Binary variables measuring clinical integration were constructed for each primary VHA hospital reflecting: presence of on-site VHA cardiologist; referral coordinator at the associated tertiary VHA hospital; and/or referral coordinator at the primary VHA hospital. We assessed the association between the integration variables and overall transfer from primary to tertiary hospitals, using random effects logistic regression, controlling for clustering at two levels and adjusting for patient characteristics. Results Three of twelve hospitals had a VHA cardiologist on site, six had a referral coordinator at the tertiary VHA hospital, and four had a referral coordinator at the primary hospital. Presence of a VHA staff cardiologist on site and a referral coordinator at the tertiary VHA hospital decreased the likelihood of any transfer (OR 0.45, 95% CI 0.27–0.77, and 0.46, p = 0.002, CI 0.27–0.78). Conversely, having a referral coordinator at the primary VHA hospital increased the likelihood of transfer (OR 6.28, CI 2.92–13.48). Conclusions Elements of clinical integration are associated with transfer, an important process in the care of ACS patients. In promoting optimal patient care, clinical integration factors should be considered in addition to patient characteristics.