Heart-attack patients treated at New Jersey hospitals with low hospital performance scores have a higher chance of having another heart attack — or worse, dying of cardiovascular causes — than those treated at hospital with high performance scores, a Rutgers University study shows.
In the study published in May in the American Journal of Cardiology, researchers from Rutgers medical school, department of economics and college of pharmacy compared so-called care scores obtained from New Jersey Hospital Performance Reports with one-month and one-year rates of readmission for heart attack or death due to cardiovascular causes, for the period of 2004 to 2013. They found that at low-scoring hospitals, 3 percent of heart attack patients returned to the hospital due to a new heart attack within 30 days. At one year, 13 percent had been readmitted and about 8 percent had died from cardiovascular causes.
Those who were admitted to a teaching hospital fared better. Their chances of being readmitted after a month were 25 percent lower than patients initially admitted to a non-teaching hospital. And their chances of suffering cardiovascular death after a year were 10 percent lower.
Researchers looked at four elements of care scores: prescription of aspirin, b blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker used for left ventricular systolic dysfunction, and an overall composite score for acute myocardial infarction, or AMI, reported annually in the Hospital Performance Reports. Some 80 hospitals, 36 of which were teaching hospitals, were included in the study. Researchers then looked at the association of those scores with 30-day and one-year rates of readmission for AMI and CV-related deaths. The result was that hospitals with low performance scores for AMI were associated with increased CV death and readmission for AMI.
“You have to define ‘quality,’ and the way we defined it was, if you go there and you die, that’s not good quality,” said Dr. John Kostis, director of the Cardiovascular Institute of New Jersey and Associate Dean for Cardiovascular Research at Rutgers Robert Wood Johnson Medical School. Nor is it good quality if you go there and die the day they send you home, or within a year, or even 30 days. And it isn’t good quality if you go to a hospital, they take care of you, you go home and a month later, you wind up back there for another heart attack, he said.
The aspirin connection
This study indicates that a hospital’s overall composite score and the score it receives for “aspirin prescribed at discharge” were positively — and significantly — associated with outcomes after 30 days, the authors wrote. When looking at how patients fared a year out, hospitals with high performance scores on any of the heart-related tasks reduced the patient’s risk of dying from cardiovascular causes.
Previous studies on the correlation between a hospital’s quality and its patient outcomes have been mixed. While some studies have found an association of higher scores with better clinical outcomes, others observed no relation, and some have even reported that higher scores were associated with worse outcomes. But most of those studies involved older patients, had a short duration of follow-up, and were published more than five years ago, this study’s authors said. Rutgers researchers used a unique database, known as the Myocardial Infarction Data Acquisition System or MIDAS, which tracks all heart-related admissions to acute-care hospitals in New Jersey from 1986 until now. By using MIDAS, they could track what happened to patients for long periods after their initial visit.
“If someone got admitted for a heart attack in ’86 or ’87, and then had bypass surgery in ’89, and then has a stroke in 2020, 2010, and then had a cardiac arrest, all that data is available,” said Kostis.
It’s one of the few, if not the only, healthcare database in the United States with such longitudinal data, Kostis said. In Europe, health authorities are required to keep such information; not so in the U.S. Only the Medicare system tracks visits and follow-ups over years, but anyone below Medicare age who has a heart attack would not be in there, he said.
By taking MIDAS data and cross-referencing it with how a hospital was rated on its cardiovascular care, researchers were able to detect a relationship between the two.
Questions without answers
The problem with the study, Kostis acknowledged, is that it doesn’t take into account what actually happens: Did the nurse or doctor tell the patient to take a cholesterol-lowering statin or an aspirin? And if they did, did the patient comply? Some patients don’t even get their prescriptions filled, Kostis said.
“The only thing we know is what was written in the chart: that the patient was told to get statins, or aspirin,” Kostis said. The researchers can’t be sure the patient was truly told what to take, or that once told, the patient took it.
“We don’t think there is a strong bias in people not taking the medication that is prescribed,” Kostis said. “But we know there may be a little bit.”
Sheryl Mount, a cardiac nurse in South Jersey, said she’s not surprised to hear of different patient outcomes, depending on the hospital where they are treated, but said that probably wasn’t for the most severe cases. If the patient is having a classic heart attack, known technically as an ST elevation myocardial infarction or STEMI — which can be life-threatening — the treatment is standardized, she said. If someone goes into an emergency room complaining of chest pain, they’re immediately given an EKG, and if it indicates a STEMI, they are immediately given care in a catheterization laboratory, or cath lab, with specialized diagnostic imaging equipment. It’s with the less severe cases, or the non-STEMI (non-ST-elevation myocardial infarction) patients, that there may be different levels of care, she said.
“To me, that’s the person who is going to fall through the cracks, the one who needs to keep on taking their medication, to be told what the medication is for, to even have access to a pharmacy to get that medication,” Mount said. “And if the pain is gone, they may not think they even have to take the medicine anymore.”
What happens at teaching hospitals?
She adds that at a teaching hospital, there are so many people checking in on the patient, the idea that they have to take their meds is repeatedly reinforced. That repetition and attention is probably not happening at a non-teaching hospital, she said.
“It is the education that makes the biggest difference, especially with cardiac patients. I believe that in these teaching hospitals and hospitals with high care scores, they have made education a priority,” Mount said. “Some cardiac medication, if not taken as prescribed or not taken at all, can lead to another heart attack.”
That’s especially true for patients who had coronary angioplasty as a treatment for a heart attack, she said.
“They must take antiplatelet medication and follow up with a cardiologist, or chances are very high that the angioplasty will close over and cause another heart attack,” she said.
The study’s authors concluded that healthcare providers should allocate more resources toward improving hospital performance in order to decrease AMI case fatalities and AMI readmissions.
While the state Department of Health monitors cardiac surgery outcomes and the performance of cardiac cath services, such as elective angioplasty, emergency angioplasty and diagnostic catheterizations, by hospital and by surgeon, officials there said they would be in favor of such efforts.
“The Department encourages any additional efforts to reduce acute myocardial infarction, unplanned readmissions and fatalities by healthcare providers,” said Janelle Fleming, a health department spokesperson.