The region makes the difference: disparities in management of acute myocardial infarction within Switzerland

Insam, Charlène; Paccaud, Fred; Marques‐Vidal, Pedro

doi:10.1177/2047487312469122

Cited by 17 publications

(22 citation statements)

References 22 publications

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“…3–5 The NCDR collected data on each patient’s MI type, hemodynamic status, troponin level, and other covariates allowing for the calculation of mortality risk on admission; thus it extends these prior findings by offering a unique perspective of how illness severity may factor into ICU utilization. While the majority of STEMI patients (80%) are treated in an ICU, 4 hospitals varied substantially in the location of care for older NSTEMI patients.…”

Section: Discussionmentioning

confidence: 98%

“…1 Guidelines recommend that these patients be managed in an intensive care unit (ICU), coronary care unit (CCU) or monitored bed, 2 and recent studies suggest significant variability in ICU utilization. 3–5 Some hospitals routinely admit patients with NSTEMI to the ICU while others may attempt to select patients at risk of clinical deterioration for ICU admission.…”

Section: Introductionmentioning

confidence: 99%

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Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

et al. 2017

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Importance Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Objectives To examine inter-hospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with at low, moderate, or high mortality risk. Design, Settings and Participants Retrospective analysis of 28,018 Medicare patients ≥65 years old admitted with NSTEMI to 346 hospitals participating in ACTION Registry-GWTG between April 1, 2011 and December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Exposure Hospitals with high (>70% NSTEMI patients treated in an ICU during the index hospitalization), intermediate (30–70%), or low (< 30%) ICU utilization rates Main Outcome and Measure 30-day mortality Results Of NSTEMI patients ≥ 65 years old, 11,934 (43%) had an ICU stay. The proportion of NSTEMI patients treated in the ICU varied across hospitals (median 38% [26%, 54%]), but there were no significant differences in hospital characteristics or NSTEMI patient characteristics between hospitals with high, intermediate, or low ICU utilization rates. Compared with high ICU utilization hospitals, hospitals with low or intermediate ICU utilizations rates were only marginally more selective of higher risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs. low: 8.7% vs. 8.7%, adjusted OR 0.91, 95% CI 0.76–1.08; intermediate vs. low: 9.6% vs. 8.7%, adjusted OR 1.06, 95% CI 0.94–1.20). The relationship between hospital ICU utilization and mortality was similar in analyses stratified by low, moderate, or high ACTION risk score categories (adjusted interaction p 0.86). Conclusions and Relevance ICU utilization for older NSTEMI patients varied significantly among hospitals. This variability was not explained by hospital characteristics nor driven by patient risk. Post-MI mortality did not significantly differ among hospitals with high, intermediate, or low ICU utilization.

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Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

et al. 2017

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“…Considerable interhospital variability in intensive care unit (ICU) use has been observed for patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) . ICU use is only minimally correlated with severity of illness, with many low‐risk patients treated in the ICU and many high‐risk patients not treated in the ICU .…”

mentioning

confidence: 99%

“…In one study, 41% of patients with NSTEMI with a predicted risk of in‐hospital mortality <1% were treated in the ICU, and more than half of patients with initial serum troponin elevations >10 times the institution's upper limit of normal were not treated in an ICU . Given non–risk‐driven use patterns, it is perhaps unsurprising that higher hospital‐level ICU use is not associated with lower patient mortality …”

mentioning

confidence: 99%

Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non–ST‐Segment–Elevation Myocardial Infarction

Chen

Thomas

Pieper

et al. 2018

JAHA

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BackgroundIntensive care unit (ICU) use for initially stable patients presenting with non–ST‐segment–elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high‐risk patients with NSTEMI for ICU admission.Methods and ResultsUsing the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high‐grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU‐level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST‐segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C‐statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU.ConclusionsThe ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources.

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“…There is also evidence that socio-demographic determinants have a significant influence on the place of death [20, 21]. Furthermore, there is solid evidence of regional differences in health care use and place of death [7, 22, 23]. However, to our knowledge, evidence on determinants of frequency and length of hospital stay in the time period preceding death is sparse.…”

Section: Introductionmentioning

confidence: 99%

Determinants of aggregate length of hospital stay in the last year of life in Switzerland

Hedinger

Braun

Kaplan

et al. 2016

BMC Health Serv Res

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BackgroundIn contrast to individual preferences, most people in developed countries die in health care institutions, with a considerable impact on health care resource use and costs. However, evidence about determinants of aggregate length of hospital stay in the last year preceding death is scant.MethodsNationwide individual patient data from Swiss hospital discharge statistics were linked with census and mortality records from the Swiss National Cohort. We explored determinants of aggregate length of hospital stay in the last year of life in N = 35,598 inpatients ≥65 years who deceased in 2007 or 2008.ResultsThe average aggregate length of hospital stay in the last year of life was substantially longer in the German speaking region compared to the French (IRR 1.36 [95 % CI 1.32–1.40]) and Italian (IRR 1.22 [95 % CI 1.16–1.29]) speaking region of the country. Increasing age, female sex, multimorbidity, being divorced, foreign nationality, and high educational level prolonged, whereas home ownership shortened the aggregate length of hospital stay. Individuals with complementary private health insurance plans had longer stays than those with compulsory health insurance plans (IRR 1.04 [95 % CI 1.01–1.07]).ConclusionsThe aggregate length of hospital stay during the last year of life was substantially determined by regional and socio-demographic characteristics, and only partially explained by differential health conditions. Therefore, more detailed studies need to evaluate, whether these differences are based on patients’ health care needs and preferences, or whether they are supply-driven.

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The region makes the difference: disparities in management of acute myocardial infarction within Switzerland

Abstract: In Switzerland, significant geographical differences in management and revascularization procedures for AMI were found.

Cited by 17 publications

References 22 publications

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non–ST‐Segment–Elevation Myocardial Infarction

Determinants of aggregate length of hospital stay in the last year of life in Switzerland

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