In-Hospital Mortality Among Rural Medicare Patients With Acute Myocardial Infarction: The Influence of Demographics, Transfer, and Health Factors
ABSTRACT CONTEXT/PURPOSE: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients.
Cross-sectional retrospective analyses on 2003-2005 Medicare hospital inpatient data from 5 states were conducted to compare predictors of in-hospital AMI mortality between rural hospital transferred and nontransferred patients. A total of 9,690 rural hospital AMI patients were identified: 3,087 were transferred to receiving hospitals and 6,603 were not transferred. Separate logistic regressions were conducted for transferred and nontransferred patient cohorts and results were compared.
Transfer patients were younger, more likely male, had fewer comorbidities/complications, and were less likely to expire (5.3% vs 16.7%) in the hospital. Congestive heart failure and cardiac dysrhythmia were the most common comorbidities/complications among transfer and no-transfer AMI patients, but shock (OR = 9.44) and acute renal failure (OR = 3.67) had the strongest associations with in-hospital mortality for both cohorts. Undergoing a percutaneous coronary intervention (PCI) was associated with a 42% reduction in hospital mortality risk for transfer patients.
Transfer was associated with a greater likelihood of in-hospital AMI survival, largely but not fully explained by transfer patients being younger with fewer comorbidities/complications who are receiving advanced cardiac care. Additional studies are needed to clarify other factors that explain higher in-hospital mortality among nontransfers, such as patients' health care decision-making.
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ABSTRACT: To compare 2 strategies, stage-matched nursing and community intervention (SMN+CI) and community intervention (CI) alone in changing cardiovascular risk factors in up to 3 behavioral areas: diet, physical activity, and/or smoking among rural women. A 14-month, multisite randomized controlled trial of 117 rural women was conducted. Transtheoretical model was used in identification of stage of change and development of the SMN+CI nursing interventions. A social-ecological model was used to address issues of rurality in the development of interventions. The SMN + CI group was superior on 4 outcomes. There were significant increases in 2 measures of dietary intake; improvement in dietary stage of change for fruits and vegetables; and reduced diastolic blood pressure (DBP) in the SMN + CI group. After log transformation DBP significance was lost. The CI group had a significant reduction in change in total cholesterol; however, significance was lost after control for the initiation of lipid lowering medications. There was a significant reduction in Framingham risk scores pre- to postintervention, regardless of group. There continues to be a need to improve cardiovascular risk factors in rural women. There should be an exploration of whether intensified dose and fidelity of the intervention strategies of diet and physical activity are effective in improving anthropometric and laboratory values. Further investigation is warranted into factors influencing the pre- to postreduction in Framingham risk scores.The Journal of Rural Health 06/2013; 29(3):248-257. DOI:10.1111/j.1748-0361.2012.00442.x · 1.77 Impact Factor