Health disparities in heart attack hospital transfer patterns

Older, female and minority patients rushed to community hospitals with acute heart attacks are less likely to be transferred to a larger hospital that offers procedures to immediately open clogged arteries, Duke University Medical Center cardiologists have found.

The finding of such disparities is important, the researchers assert, since research has shown that even with the added transfer time, patients with an acute heart attack still fare better with artery-opening procedures -- such as angioplasty or bypass surgery - than those treated only with powerful clot-busting drugs.

The researchers said their findings should help give physicians in smaller community hospitals more confidence about transferring such patients to larger hospitals. The researchers also said the reasons for such disparities remain to be explored, and that they are likely multifactorial.

In their analysis of almost 400,000 U.S. heart attack patients over the age of 64, the team also found that while heart attack patients who were not transferred tended to be sicker than those who were transferred, paradoxically, the sicker patients were those who would most likely benefit the most from artery-opening procedures, the researchers said.

"While the medical community is very proficient at treating complex illnesses like heart disease, there still remain disparities in the delivery of that care that needs to be addressed," said Duke cardiology fellow Jeffrey Berger, M.D., who presented the results of his analysis March 12, 2006, during the 55th annual scientific sessions of the American College of Cardiology in Atlanta.

"Our analysis found that in the U.S., patients over the age of 64 admitted with an acute heart attack to non-revascularization hospitals and then transferred were younger, more frequently male, white and at lower risk and had improved survival than those who remained at the community hospital," he continued.

Specifically, the team found that women were16 percent less likely to be transferred than men. And, compared to white patients, African-Americans were 31 percent and Hispanics were 47 percent less likely to be transferred. Also, as age increased, so did the chances of not being transferred.

For his analysis, Berger consulted Centers for Medicare and Medicaid Services data from 2001 to 2003. During that time, 399,775 patients over the age of 64 suffering from an acute heart attack were admitted to hospitals that were unable to perform angioplasty or bypass surgery. Of those patients, just over one-third (35 percent) were subsequently transferred to a larger facility with revascularization capabilities.

In terms of mortality, 8.7 percent of the transferred patients died; statistical modeling predicted that 8.9 percent of transferred patients would die. For those patients who were not transferred, 18.5 percent died; statistical modeling predicted that 15.2 percent would die.

"There are many disparities in health care, and this analysis has uncovered another area of concern," Berger said. "It is crucial that we implement or enhance systems that help protect against these disparities and improve the quality of care for all patients."

"Many studies have shown that angioplasty or bypass surgery is the option of choice over drugs for the vast majority of patients suffering from an acute heart attack," Berger continued. "We are now beginning to appreciate that the sickest of these patients perhaps would do better if they received a revascularization procedure. These findings suggest that more patients should be transferred."

Berger said that physicians in smaller community hospitals may feel that it is too risky to subject heart attack patients - especially if they are older - to an ambulance ride to another facility. His said data from this and future studies should help give confidence to community hospital physicians about transferring these patients.

"The national guidelines suggest that patients who are having an acute heart attack should go to the nearest hospital, and that every hospital is able to provide a pharmacologic (clot-buster) treatment," Berger continued. "However, there are a significant number of patients who cannot take these drugs or do not respond to them."

The main side effect of clot-busting drugs is the potential for bleeding. According to Berger, many acute heart attack patients cannot be given these drugs because of the risk of bleeding within the brain. Also, even after receiving clot-busters, the arteries do not re-open in every patient, using up time that could have been better used getting a procedure, he said.

Berger added that more research is needed to better understand the root causes of these disparities, since they are likely to be more logistical or systemic in nature than medical. The answers likely reside in a combination of factors, including patient preferences, decisions made by health care workers, and institutional issues.