Canadian Strategy of Transferring STEMI Patients to Non-PCI Hospitals Postprocedure Has Global Implications
In regions where PCI centers are sparse, repatriating STEMI patients to non-PCI hospitals following their procedure may be beneficial for hospitals and patients alike, according to a Canadian study.
Researchers found that the majority of STEMI patients treated at PCI-capable hospitals were transferred to non-PCI hospitals within 24 hours, with just over 1% returning to the PCI hospital for complications and few in-hospital deaths.
According to senior author Akshay Bagai, MD (St. Michael’s Hospital, Toronto, Canada), parts of Europe and Australia also practice this strategy of repatriating primary PCI patients back to non-PCI centers, and the model has implications for many other areas where PCI care is challenging.
“This has certain advantages,” he told TCTMD. “For one, the care of the MI patient is shared between the PCI and non-PCI hospitals, so nobody feels that they have been left out of [the treatment process].” Without this strategy, he added, there is a disincentive for non-PCI hospitals to participate in regional systems of care. Other reasons are to free up needed beds in PCI hospitals, and to allow patients to be closer to their home and family as well as to the local cardiologist with whom they will follow-up after discharge.
Low Rates of Mortality, Return to PCI Center
The study, led by Bagai’s colleague Rudee Ting, MBBS, and published online April 29, 2016, in the American Heart Journal, included 979 consecutive STEMI patients who were transported for primary PCI from the emergency department and catchment area of two non-PCI hospitals in Ontario between 2008 and 2014. The goal was to repatriate patients back to those hospitals within 24 hours of the primary PCI.
The average time to repatriation was 21.8 hours, with 65.2% of all patients moved to the non-PCI hospital within 24 hours and 89.8% by 48 hours. Compared with patients who were repatriated within 24 hours, those who were not were older and more likely to have prior heart failure. Independent predictors of delayed repatriation beyond 24 hours included low systolic blood pressure, requirement for mechanical ventilation, ventricular arrhythmia, infarct of the LAD or bypass graft, TIMI 1 or 0 in the infarct-related artery, and procedural vascular access site complications.
Among those who were repatriated, 1.3% had to be transferred back to the PCI hospital for urgent care that included recurrent chest pain and ventricular arrhythmia. The rate of mortality among repatriated patients was 2.0%, with no increase in index-admission mortality attributed to repatriation to a non-PCI hospital compared with not being repatriated (adjusted OR 0.46; 95% CI 0.16-1.32).
US Adoption Unlikely
In an interview with TCTMD, Harold L. Dauerman, MD (University of Vermont, Burlington, VT), who was not affiliated with the study, said while the strategy has implications in countries that have a low density of PCI centers, it is unlikely to ever be adopted in the United States where 80% of STEMI patients live within 60 minutes of a PCI center, making both the utilization of transfer and the coordination with non-PCI hospitals much less common. While the hospitals in the study average 160 to 180 STEMI patients transferred per year, Dauerman said the US average is less than 20 per year.
More importantly, the difference in healthcare systems between the United States and Canada could not be more striking.
“The US is a DRG [diagnosis-related group] system, and it’s not clear to me that we have a system that allows payments to non-PCI and PCI hospitals to be spread appropriately by repatriating patients,” Dauerman said. “So unless that financial barrier were to be solved, there would be a financial disincentive to not keep patients until discharge.”
Another issue, he noted, is that the average total length of stay for STEMI patients after PCI in the US, including all comers, is about 4.0 days; 3.0 days for uncomplicated STEMI.
“So transferring someone back [to a non-PCI hospital] any time after 24 hours makes no sense for the patient or the family, because by the time they’re transferred and get settled into the new hospital they will be there less than 24 hours before they’re discharged home,” he said. “Ten to 15 years ago, when length of stay for STEMI was 7 days, there might have been a stronger argument that it would improve patient and family satisfaction to transfer patients back to a non-PCI center closer to their home. But, in the last 15 years there have been so many new PCI centers that the distance from peoples’ homes to the center is no longer a giant barrier in almost all regions of the country.” Furthermore, he said transferring patients back to non-PCI hospitals may even add hours to length of stay.
Bagai said the study did not look at whether repatriation added to total stay, but noted it will be important to look at in future studies of this model.
“We do believe that regional healthcare systems are important and there are data to support that, and we do believe that non-PCI hospitals should have incentive to participate,” he said. “If it turns out that doing this is best practice, then the compensation should evolve accordingly rather than say we can’t do this because of the compensation [issues].”
But Dauerman also noted that the 2.0% mortality rate of repatriated patients “would be unacceptable in the US system, where public reporting would then ascribe the AMI deaths to the non-PCI centers.”
Bagai noted that while Canada does have public reporting, “We are about 5 years behind in regards to figuring out how best to use that data to motivate hospitals or penalize hospitals for the care that they provide.”
- Ting R, Tejpal A, Finken L, et al. Repatriation to referral hospital after reperfusion of STEMI patients transferred for primary percutaneous coronary intervention: insights of a Canadian regional STEMI care system. Am Heart J. 2016;Epub ahead of print.
- Ting and Bagai report no relevant conflicts of interest.
- Dauerman reports consulting for and receiving research grants from Medtronic and Boston Scientific.