1. Background Current guideline recommend an early invasive strategy for NSTEMI patients (Class IIA). However, 67% US hospitals have no catheterization capability. Patients transferred for invasive strategy are usually younger with less comorbidities compared with non-transferred patients. Thus, hospitals with high proportion of transfer patients should have better outcomes of care. However, the association of transfer proportion and outcomes in transfer-out hospitals has not been previously examined. The association of transfer-out rates from hospitals without revascularization capabilities and mortality risk among older NSTEMI patients Lan Shen, MD, Shuang Li, MS, Laine Thomas, Ph.D, Bimal R. Shah, MD, MBA, Tracy Y. Wang, MD, MHS, Karen Alexander, MD, Eric D. Peterson, MD, MPH, He Ben, MD, Ph.D, Matthew T. Roe, MD, MHS Duke Clinical Research Institute, Durham, NC, U.S.A; Shanghai Renji Hospital, Cardiology department, Shanghai, China Methods 5,678 eligible NSTEMI patients in 65 hospitals without PCI / CABG capabilities were identified in the CRUSADE registry from 2003 to 2006, were linked to Medicare claims data to assess longitudinal outcomes. The distribution of transfer-out rate among all hospitals was examined. Based on the distribution rate, high transfer-out hospitals were defined as having >40% of all eligible patients transferred out, whereas low transfer-out hospitals were defined as having ≤40% of all eligible patients. Baseline, presentation features, in-hospital procedures and discharge medications were described by transfer rate status. Wilcoxon-rank rum test was used for comparing continuous variables and chi-square test was used for categorical variables. Overall baseline risk profiles were compared using the CRUSADE long-term mortality risk score between patients in the 2 groups of hospitals. Multivariable Cox proportional hazard model was used to assess the association between the proportion of transfer out and 30-day, 6-month and 3-year mortality. Results. Conclusions Among older patients >65 years old, hospitals with high transfer-out proportions have more low risk patients, with more aggressive acute medication treatment. Hospitals with higher transfer-out proportions have lower observed mortality rate of short-term and long-term follow-up. However, such survival advantage disappears after adjustment for baseline characteristics. The difference in hospital-level case mix can explain the lack of difference in the adjusted long- term mortality risk between hospital categories. Our study support that older patients who are admitted in non-PCI hospitals should undergo early invasive management. Although older patients are usually excluded from clinical trials, no information guide decision making for older patients. Our exploratory study supported older patients to be recommended to aggressive treatment. Acknowledgments No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the manuscript, and its final contents. Contact Lan Shen, MD, MS. Shanghai Renji Hospital, Duke Clinical Research Institute Tel: 919 -641-9233 Fax: 919-668-7061 Email: lan.shen@dm.duke.edu Variables Overall Patients=5678 Hospitals=65 Low transfer Patients=2715 Hospitals =27 High transfer Patients=2963 Hospitals=38 Age (Median, IQR) 79 (73, 85)80 (73, 86)79 (73,85) Male sex (%) 484650 Medical history (%) Smoking 11 Hypertension 76 Diabetes mellitus 363537 Renal insufficiency 192118 Dyslipidemia 484451 Prior MI 292731 Prior PCI 151317 Prior CABG 212220 Prior CHF 273024 Presentation characteristics (%) Signs of CHF 363835 Heart rate 88 (74, 106)89 (75, 106)87 (73,105) SBP, mmHg 143 (120, 164)141 (119, 162)145 (122, 166) ST depression 242225 CRUSADE Long-term Mortality Risk Score 36 (25, 47) 37 (26, 48) 34 (24, 46) Medications within 24 hours (%) Aspirin 929194 Anticoagula- tion 777479 Clopidogrel 434443 GP IIb/IIIa 282134 Diagnostic Cath(%) 314321 Table 2: Impact of transfer-out rate on outcomes CRUSADE registry CRUSADE was a national quality improvement initiative designed to promote evidence-based treatment of hospitalized patients with non– ST-segment elevation ACS. Patient data were collected retrospectively via chart review from July, 2001 through December, 2006. More than 500 hospitals in the US participated including more than 200,000 patients. Limitation Given the retrospective nature of the study, unmeasured confounders cannot be excluded, especially comorbidities which prevent patients from being transferred. The small number of hospitals in our study did not include all non-revascularization hospitals in U.S, thus it is not representative for hospitals outside of CRUSADE. Our study serves as an exploratory study. CRUSADE did not collect long-term medication use, so the impact cannot be measured. Figure 1: Distribution of transfer-out rate among all hospitals. Figure 2. Percentage of patients in different quartiles of baseline CRUSADE risk score between 2 groups of hospitals. Table 1. Hospital characteristics Variables Overall (n=65) Low transfer Hospitals (n= 27) High transfer Hospitals (n= 38) Region (%) West11 Northeast353734 Midwest11195 South433350 Type of hospital (%) No service403047 Cath Lab Only607053 Teaching Hospital (%) Non-Academic948997 Academic6113 Total hospital Beds (median, IQR) 202 (131, 278) 230 (171,300) 167 (110, 260) Table 3. Impact of transfer out rate on outcomes (high transfer-out vs. low transfer-out). Outcomes Observed mortality rate Unadjusted HR* (95% CI) Adjusted HR* (95% CI) MortalityHigh vs. Low 30-day mortality10% vs. 14% 0.75 (0.59-0.96) 0.92 (0.77-1.10) 6-month mortality22% vs. 27% 0.80 (0.65-0.97) 0.95 (0.83-1.08) 3-year mortality46% vs. 52% 0.84 (0.73-0.96) 0.99 (0.89-1.09) *Hazard ratio of the outcomes between high transfer-out rate hospitals vs. low transfer-out hospitals (reference group) CI, confidence interval; HR, hazard ratio Adjusted for: age, male sex, race, weight, dyslipidemia, initial HCT with knot at 35%, initial troponin ratio with two knots (with knots at 5 and 50), prior stroke, diabetes mellitus, signs of heart failure, initial serum creatinine, initial systolic blood pressure, initial heart rate, prior percutaneous coronary intervention (PCI), electrocardiographic changes (ST depression, transient ST elevation, both [vs. neither]), hypertension, prior coronary artery bypass graft (CABG), PCI, CABG procedures used within 7 days post transfer out.