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Differences in Patient Survival After Acute Myocardial Infarction by Hospital Capability of Performing Percutaneous Coronary InterventionImplications for Regionalization
Jersey Chen, MD, MPH;
Harlan M. Krumholz, MD, SM;
Yun Wang, PhD;
Jeptha P. Curtis, MD;
Saif S. Rathore, MPH;
Joseph S. Ross, MD, MHS;
Sharon-Lise T. Normand, PhD;
Geoffrey C. Schreiner, BS;
Gregory Mulvey, BA;
Brahmajee K. Nallamothu, MD, MPH
Arch Intern Med. 2010;170(5):433-439.
Background There are increasing calls for regionalization of acute myocardial infarction (AMI) care in the United States to hospitals with the capacity to perform percutaneous coronary intervention (PCI). Whether regionalization will improve outcomes depends in part on the magnitude of existing differences in outcomes between PCI and non-PCI hospitals within the same health care region.
Methods A 100% sample of claims from Medicare fee-for-service beneficiaries 65 years or older hospitalized for AMI between January 1, 2004, and December 31, 2006, was used to calculate hospital-level, 30-day risk-standardized mortality rates (RSMRs). The RSMRs between PCI and local non-PCI hospitals were compared within local health care regions defined by hospital referral regions (HRRs).
Results A total of 523 119 AMI patients was admitted to 1382 PCI hospitals, and 194 909 AMI patients were admitted to 2491 non-PCI hospitals in 295 HRRs with at least 1 PCI and 1 non-PCI hospital. Although PCI hospitals had lower RSMRs than non-PCI hospitals (mean, 16.1% vs 16.9%; P < .001), considerable overlap was seen in RSMRs between non-PCI and PCI hospitals within the same HRR. In 80 HRRs, the RSMRs at the best-performing PCI hospital were lower than those at local non-PCI hospitals by 3% or more. Among the remaining HRRs, the RSMRs at the best-performing PCI hospital were lower by 1.5% to 3.0% in 104 HRRs and by greater than 0 to 1.5% in 74 HRRs. In 37 HRRs, the RSMRs at the best-performing PCI hospital were no better or were higher than at local non-PCI hospitals.
Conclusions The magnitude of benefit from comprehensively regionalizing AMI care to PCI hospitals appears to vary greatly across HRRs. These findings support a tailored regionalization policy that targets areas with the greatest outcome differences between PCI and local non-PCI hospitals.
Author Affiliations: Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine (Drs Chen, Krumholz, and Curtis and Mr Rathore), and Center for Outcomes Research and Evaluation, Yale–New Haven Hospital (Drs Chen, Krumholz, Wang, and Curtis and Messrs Schreiner and Mulvey), New Haven, Connecticut; Division of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York and Health Services Research and Development Research Enhancement Program and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Administration Medical Center, Bronx, New York (Dr Ross); Department of Health Care Policy, Harvard Medical School, and Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts (Dr Normand); and the Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence, and Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (Dr Nallamothu).
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