LOS ANGELES -- As reported in a recent issue of the New England Journal of Medicine, researchers studying statistics of elderly heart attack patients found that those treated at "high-volume" hospitals had better odds of survival than those taken to hospitals that treat a relatively low number of heart attacks.
Prediman K. Shah, M.D., Director of the Division of Cardiology at Cedars-Sinai Medical Center -- one of the most respected heart programs in the nation -- says the results provide intriguing observations that, if confirmed by subsequent studies, may lead to a re-examination of paramedic transport policies. Presently, because emergency intervention needs to be started quickly during a heart attack, nearly all jurisdictions require ambulances to take heart attack patients to the nearest hospital.
"The implications of this study are very interesting," according to Dr. Shah. "What it says is that if you are experiencing a heart attack, you will have a somewhat better chance of surviving if the ambulance takes you to the nearest large-volume hospital rather than just the nearest hospital."
The researchers reviewed results of treatment received by 98,898 Medicare patients who were suffering myocardial infarctions (heart attacks) when admitted to hospitals. Those hospitals were divided into four groups, or quartiles, based on volume. Outcomes from the lowest-quartile hospitals were then compared with those in the highest quartile. In assessing the data, adjustments were made to account for differences in severity of illness and other factors.
"The difference in outcome was such that approximately 2.3 extra deaths occurred per 100 patients in the lowest-volume hospitals, compared to the highest," says Dr. Shah. "So the difference in mortality was up nearly 2 deaths per hundred patients."
Access to higher technology equipment at higher volume hospitals did not turn out to be a relevant factor. The principal difference, according to the report that was published in the May 27 issue of the New England Journal of Medicine, appears to be "the availability of an experienced health care team."
"I think that when you do something repeatedly, you get the hang of it and the sense of it, and many things follow automatically," says Dr. Shah. "When a health care team takes care of hundreds of patients, treating them with aspirin and heparin and thrombolytics (clot-dissolving drugs), it becomes second nature. If, on the other hand, you see a patient once every other day, you may be less familiar with the protocol. There is some evidence from other disciplines as well that the more you do, the better the outcomes are."
The study also found that "the patients treated by cardiologists were considerably healthier than the patients treated by other specialists." With this in mind, says Dr. Shah, heart patients might consider establishing a relationship with a cardiologist who practices at a medical center that treats a large number of heart attacks. This may give them several advantages, although, admittedly, they may have no choice in their destination hospital during a medical crisis.
Dr. Shah says he hopes prospective studies will be conducted to test the hypothesis that treatment at large-volume hospitals does make a significant difference in outcomes. The recently published study was retrospective -- analyzing the results of previous outcomes. "In that sense, it remains a provocative sudy but not a conclusive set of observations."
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