PCI Capability Matters More Than Academic Affiliation for STEMI Survival

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When managing patients with ST-segment elevation myocardial infarction (STEMI), a hospital’s capability to perform percutaneous coronary intervention (PCI) matters more than its status as an academic or nonacademic medical center. This finding may stem from the fact that PCI-capable hospitals are more likely to adhere to guideline-based care, according to a study published in the April 2012 issue of the American Journal of Medicine.

José Labarère, MD, of Grenoble University Hospital (Grenoble, France), and colleagues conducted a post-hoc analysis of data from the FAST-MI (French registry of Acute ST elevation or non-ST-elevation Myocardial Infarction) prospective cohort study. The researchers examined 3,059 patients admitted to either academic (n = 39) or nonacademic hospitals (n = 183) for the treatment of STEMI (n = 1,714) or NSTEMI (n = 1,345) in France.

PCI Capability Key

At 1 year, STEMI patients admitted to an academic hospital had lower all-cause mortality (primary endpoint) than those admitted to a nonacademic hospital (10% vs. 15%; P = 0.01). The same pattern was not seen in NSTEMI patients (13% and 14% for academic and nonacademic hospitals, respectively; P = 0.75).

When researchers adjusted for baseline patient and hospital characteristics, such as region and number of beds, the mortality risk associated with nonacademic hospitals in STEMI care was only seen in the absence of PCI capability. Those centers equipped to perform PCI saw no increased risk compared with academic hospitals (table 1).

Table 1. Mortality at 1 Year in STEMI Patients: Nonacademic vs. Academic Hospitals

The place of admission also affected a patient’s likelihood to receive guideline-based therapies. Among STEMI patients, 68% underwent thrombolysis or primary PCI in academic hospitals; 65% in nonacademic hospitals with PCI capability; and 36% in nonacademic hospitals without PCI capability (P < 0.001). Both STEMI and NSTEMI patients admitted to academic hospitals or nonacademic hospitals with PCI capability were more likely to undergo diagnostic catheterization or PCI than those admitted to nonacademic hospitals without PCI capability (P < 0.001).

In addition, these patients were more likely to receive guideline-recommended medications such as aspirin and beta blockers both during hospitalization and at discharge. Multivariable adjustment indicated that the survival advantage seen with admission to academic or PCI-capable nonacademic hospitals was related to the use of acute reperfusion and recommended therapies.

May Not Apply in United States

Although he said the results are interesting, Ajay Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), doubted whether they can be extrapolated to the United States given the differences between the 2 health care systems.

“In the United States, there are actually a lot of nontraditional academic hospitals that do academically oriented work,” Dr. Kirtane told TCTMD in a telephone interview. “Additionally, there a lot of nonacademic hospitals that do primary PCI, and in some cases do a better job of guideline-based care than academic hospitals.”

This assessment was similar to that of the researchers, who acknowledge their results may not be generalizable “because processes of care for patients with acute myocardial infarction have been shown to vary across countries.” The study may also be confounded due to its nonrandomized design, they note.

Lack of Evidence-Based Care

As for why certain facilities did not adopt the use of evidence-based guidelines, Dr. Kirtane and the researchers could only speculate.

“It may reflect higher levels of educational support, implementation of quality improvement tools, and use of standardized protocols in academic or [PCI] hospitals,” the researchers write.

Because PCI in and of itself is a guideline-based practice after MI, it may make sense that hospitals with primary PCI capability—whether academic or nonacademic—are more likely to follow other recommendations, Dr. Kirtane said.

Specifically, primary PCI sites already have a comprehensive approach to treating patients, particularly those with acute coronary syndromes, that encompasses the journey from emergency department to the cath lab. “[E]specially when interventionalists, general cardiologists, and ED attendings are all involved, there is a collaborative decision-making process that allows better guideline-based care,” Dr. Kirtane commented. “If a hospital does not offer all of these things, you could hypothesize that there is less adherence to guideline-based care.”

Study Details

Primary PCI capability was defined by the researchers as the ability to perform emergency PCI 24 hours a day, 7 days a week. Hospitals were defined as being an academic hospital if they were teaching university hospitals with residencies in every subspecialty of medicine and surgery and had medical students, residents, and fellows actively participating in daily patient care.

Patients admitted to academic hospitals were younger and more likely to be men, smokers, and mobile intensive care unit users. In addition, they had lower predicted risk of in-hospital mortality and were more likely to have familial coronary artery disease. More patients admitted to nonacademic hospitals had congestive heart failure.

 

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Source:
Belle L, Labarère J, Fourny M, et al. Quality of care for myocardial infarction at academic and nonacademic hospitals. Am J Med. 2012;Epub ahead of print.

 

 

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• Study Looks at AMI Care in French Universal Coverage System
• Timely PCI Access Not Improved by Increase in PCI-Capable Hospitals

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