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Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes.
JAMA 2014; 312(19):1999-2007JAMA

Abstract

IMPORTANCE

Reperfusion times for ST-elevation myocardial infarction (STEMI) occurring in outpatients have improved significantly, but quality improvement efforts have largely ignored STEMI occurring in hospitalized patients (inpatient-onset STEMI).

OBJECTIVE

To define the incidence and variables associated with treatment and outcomes of patients who develop STEMI during hospitalization for conditions other than acute coronary syndromes (ACS).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective observational analysis of STEMIs occurring between 2008 and 2011 as identified in the California State Inpatient Database.

EXPOSURES

STEMIs were classified as inpatient onset or outpatient onset based on present-on-admission codes. Patients who had a STEMI after being hospitalized for ACS were excluded from the analysis.

MAIN OUTCOMES AND MEASURES

Regression models were used to evaluate associations among location of onset of STEMI, resource utilization, and outcomes. Adjustments were made for patient age, sex, comorbidities, and hospital characteristics. The analysis allowed for the location of inpatient STEMI to have a multiplicative rather than an additive effect for resource utilization since these measures were highly skewed.

RESULTS

A total of 62,021 STEMIs were identified in 303 hospitals, of which 3068 (4.9%) occurred in patients hospitalized for non-ACS indications. Patients with inpatient-onset STEMI were older (mean, 71.5 [SD, 13.5] years vs 64.9 [SD, 14.1] years; P < .001) and more frequently female (47.4% vs 32%; P < .001) than those with outpatient-onset STEMI. Patients with inpatient-onset STEMI had higher in-hospital mortality (33.6% vs 9.2%; adjusted odds ratio (AOR), 3.05; 95% CI, 2.76-3.38; P < .001), were less likely to be discharged home (33.7% vs 69.4%; AOR, 0.38; 95% CI, 0.34-0.42; P < .001), and were less likely to undergo cardiac catheterization (33.8% vs 77.8%; AOR, 0.19; 95% CI, 0.16-0.21; P < .001) or percutaneous coronary intervention (21.6% vs 65%; AOR, 0.23; 95% CI, 0.21-0.26; P < .001). Length of stay and inpatient charges were higher for inpatient-onset STEMI (mean length of stay, 13.4 days [95% CI, 12.8-14.0 days] vs 4.7 days [95% CI, 4.6-4.8 days]; adjusted multiplicative effect, 2.51; 95% CI, 2.35-2.69; P < .001; mean inpatient charges, $245,000 [95% CI, $235,300-$254,800] vs $129,000 [95% CI, $127,900-$130,100]; adjusted multiplicative effect, 2.09; 95% CI, 1.93-2.28; P < .001).

CONCLUSIONS AND RELEVANCE

Patients who had a STEMI while hospitalized for a non-ACS condition, compared with those with onset of STEMI as an outpatient, were less likely to undergo invasive testing or intervention and had a higher in-hospital mortality rate.

Authors+Show Affiliations

Division of Cardiology, University of North Carolina, Chapel Hill.Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill3Sheps Center for Health Services Research, University of North Carolina, Chapel Hill.Division of Cardiology, University of North Carolina, Chapel Hill.Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill3Sheps Center for Health Services Research, University of North Carolina, Chapel Hill.Division of Cardiology, University of North Carolina, Chapel Hill.Division of Cardiology, University of North Carolina, Chapel Hill.Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.Department of Health Policy and Management, University of North Carolina Gillings School of Global Public Health, Chapel Hill.Division of Cardiology, University of North Carolina, Chapel Hill.

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

25399275

Citation

Kaul, Prashant, et al. "Association of Inpatient Vs Outpatient Onset of ST-elevation Myocardial Infarction With Treatment and Clinical Outcomes." JAMA, vol. 312, no. 19, 2014, pp. 1999-2007.
Kaul P, Federspiel JJ, Dai X, et al. Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. JAMA. 2014;312(19):1999-2007.
Kaul, P., Federspiel, J. J., Dai, X., Stearns, S. C., Smith, S. C., Yeung, M., ... Stouffer, G. A. (2014). Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. JAMA, 312(19), pp. 1999-2007. doi:10.1001/jama.2014.15236.
Kaul P, et al. Association of Inpatient Vs Outpatient Onset of ST-elevation Myocardial Infarction With Treatment and Clinical Outcomes. JAMA. 2014 Nov 19;312(19):1999-2007. PubMed PMID: 25399275.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. AU - Kaul,Prashant, AU - Federspiel,Jerome J, AU - Dai,Xuming, AU - Stearns,Sally C, AU - Smith,Sidney C,Jr AU - Yeung,Michael, AU - Beyhaghi,Hadi, AU - Zhou,Lei, AU - Stouffer,George A, PY - 2014/11/17/entrez PY - 2014/11/17/pubmed PY - 2014/12/15/medline SP - 1999 EP - 2007 JF - JAMA JO - JAMA VL - 312 IS - 19 N2 - IMPORTANCE: Reperfusion times for ST-elevation myocardial infarction (STEMI) occurring in outpatients have improved significantly, but quality improvement efforts have largely ignored STEMI occurring in hospitalized patients (inpatient-onset STEMI). OBJECTIVE: To define the incidence and variables associated with treatment and outcomes of patients who develop STEMI during hospitalization for conditions other than acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational analysis of STEMIs occurring between 2008 and 2011 as identified in the California State Inpatient Database. EXPOSURES: STEMIs were classified as inpatient onset or outpatient onset based on present-on-admission codes. Patients who had a STEMI after being hospitalized for ACS were excluded from the analysis. MAIN OUTCOMES AND MEASURES: Regression models were used to evaluate associations among location of onset of STEMI, resource utilization, and outcomes. Adjustments were made for patient age, sex, comorbidities, and hospital characteristics. The analysis allowed for the location of inpatient STEMI to have a multiplicative rather than an additive effect for resource utilization since these measures were highly skewed. RESULTS: A total of 62,021 STEMIs were identified in 303 hospitals, of which 3068 (4.9%) occurred in patients hospitalized for non-ACS indications. Patients with inpatient-onset STEMI were older (mean, 71.5 [SD, 13.5] years vs 64.9 [SD, 14.1] years; P < .001) and more frequently female (47.4% vs 32%; P < .001) than those with outpatient-onset STEMI. Patients with inpatient-onset STEMI had higher in-hospital mortality (33.6% vs 9.2%; adjusted odds ratio (AOR), 3.05; 95% CI, 2.76-3.38; P < .001), were less likely to be discharged home (33.7% vs 69.4%; AOR, 0.38; 95% CI, 0.34-0.42; P < .001), and were less likely to undergo cardiac catheterization (33.8% vs 77.8%; AOR, 0.19; 95% CI, 0.16-0.21; P < .001) or percutaneous coronary intervention (21.6% vs 65%; AOR, 0.23; 95% CI, 0.21-0.26; P < .001). Length of stay and inpatient charges were higher for inpatient-onset STEMI (mean length of stay, 13.4 days [95% CI, 12.8-14.0 days] vs 4.7 days [95% CI, 4.6-4.8 days]; adjusted multiplicative effect, 2.51; 95% CI, 2.35-2.69; P < .001; mean inpatient charges, $245,000 [95% CI, $235,300-$254,800] vs $129,000 [95% CI, $127,900-$130,100]; adjusted multiplicative effect, 2.09; 95% CI, 1.93-2.28; P < .001). CONCLUSIONS AND RELEVANCE: Patients who had a STEMI while hospitalized for a non-ACS condition, compared with those with onset of STEMI as an outpatient, were less likely to undergo invasive testing or intervention and had a higher in-hospital mortality rate. SN - 1538-3598 UR - https://www.unboundmedicine.com/medline/citation/25399275/Association_of_inpatient_vs_outpatient_onset_of_ST_elevation_myocardial_infarction_with_treatment_and_clinical_outcomes_ L2 - https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2014.15236 DB - PRIME DP - Unbound Medicine ER -