In-hospital Outcomes and Cost Associated With Treatments for Non-ST-elevation Myocardial Infarction
Fabio V Lima1, Kevin F Kennedy2, Marwan Saad1
1Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
Insights
Outcomes for non-ST-elevation myocardial infarction (NSTEMI) vary significantly by hospital and treatment strategy. This study found considerable differences in patient outcomes, length of stay, and costs, even after accounting for patient and hospital factors.
Area of Science:
- Cardiology
- Health Services Research
- Outcomes Research
Background:
- Management of non-ST-elevation myocardial infarction (NSTEMI) varies widely across US hospitals.
- Limited data exist on outcome variations linked to specific NSTEMI management strategies.
Purpose of the Study:
- To characterize variations in clinical outcomes, length of stay (LOS), and costs associated with different NSTEMI treatment strategies.
- To analyze hospital-level variations in outcomes following medical therapy, angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG).
Main Methods:
- Analysis of 140,194 NSTEMI hospitalizations from the National Inpatient Sample (2016-2018).
- Patients categorized by treatment: medical therapy alone, angiography without revascularization, PCI, or CABG.
- Primary endpoint: composite of in-hospital death, postprocedure myocardial infarction, or stroke; secondary endpoints: LOS and cost.
- Variation characterized by median odds ratio, adjusting for patient and hospital factors.
Main Results:
- Significant variation in the composite outcome was observed: patients undergoing PCI were 25% more likely, and those undergoing CABG were 45% more likely, to experience adverse events at some hospitals compared to others.
- Hospital-level variations in LOS and cost were also significant across all treatment modalities.
- Treatment distribution: 25.5% medical therapy, 20.5% angiography only, 41.6% PCI, 12.4% CABG.
Conclusions:
- Substantial hospital-level variation exists in clinical outcomes, LOS, and costs for NSTEMI patients, irrespective of the treatment strategy.
- These variations persist even after adjusting for patient and hospital characteristics, highlighting potential areas for quality improvement.
Background:
Although variation in the management of patients with non-ST-elevation myocardial infarction (NSTEMI) is well documented across US hospitals, few data exist characterizing variation in outcomes following specific management strategies.
Methods:
Admissions for NSTEMI to hospitals performing coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery between 2016 and 2018 were identified from the National Inpatient Sample. Patients were categorized according to treatment rendered (medical therapy alone, angiography without revascularization, PCI, or CABG). The primary end point was variation in the incidence of composite in-hospital death, postprocedure myocardial infarction, or stroke, stratified by treatment rendered. Secondary outcomes included variation in length of stay (LOS), cost, and use of each treatment modality. Variation was characterized by the median odds ratio.
Results:
Among 140,194 hospitalizations for NSTEMI, 35,748 (25.5%) patients received medical therapy alone, 28,678 (20.5%) underwent angiography without revascularization, 58,383 (41.6%) underwent PCI, and 17,385 (12.4%) underwent CABG. Despite adjusting for patient- and hospital-related factors, 2 similar patients were 25% more likely to experience the composite primary outcome following PCI and 45% more likely following CABG at 1 randomly selected hospital than at another. Significant hospital-level variations in LOS and cost were also apparent following each treatment modality.
Conclusions:
In a large national analysis of hospitalizations for NSTEMI, significant variation was observed in clinical outcome, LOS, and cost associated with each treatment modality, despite adjustment for patient- and hospital-related factors.
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