The Impact of For-Profit The Impact of For-Profit Hospital Status on the Care and Hospital Status on the Care and

Outcomes of Patients with Outcomes of Patients with NSTEMI: Results From NSTEMI: Results From

CRUSADECRUSADE

Bimal R. Shah, MD, Seth W. Glickman, MD, MBA, Li Liang, PhD, W. Brian Gibler, MD, E. Magnus Ohman, MD, Charles V. Pollack Jr., MA,

MD, Matthew T. Roe, MD, MHS, Eric D. Peterson, MD, MPH

J J Am Coll Cardiol 2007;50:1462-68Am Coll Cardiol 2007;50:1462-68

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

BACKGROUNDBACKGROUND

• Background: We sought to determine whether for-profit status influenced hospitals’ care or outcomes among non-ST-segment elevation myocardial infarction (NSTEMI) patients.

• Objectives: While for-profit hospitals potentially have financial incentives to selectively care for younger, healthier patients, perform highly reimbursed procedures, reduce costs by limiting access to expensive medications, and encourage shorter inpatient length of stay, there are limited data available to investigate these issues objectively.

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

METHODSMETHODS

• Using data from the CRUSADE initiative, we investigated whether for-profit status influenced hospitals’ patient case mix, care, or outcomes among 145,357 patients with NSTEMI treated between January 1, 2001 and December 31, 2005 at 532 U.S. hospitals.

• Impact of for-profit status on care and outcomes was analyzed overall and after adjustment for clinical and facility factors using generalized estimating equations regression modeling.

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

RESULTS:RESULTS: Comparison of Comparison of Patient CharacteristicsPatient Characteristics

Characteristics Overall (n = 145,357)

For-profit (n = 11,658)

Non-profit (n = 133,699)

p value

Age, yrs* 67.3±14.2 67.6±14.3 67.3±14.2 0.0166 Women 39.3 38.9 39.3 0.4213 Race <0.0001

White 80.6 74.8 81.1 Black 10.5 14.0 10.2

Insurance <0.0001 HMO/private 43.8 45.8 43.6 Medicare 42.2 40.5 42.3

Hypertension 69.3 70.9 69.2 <0.0001 Diabetes mellitus 33.0 33.8 32.9 0.0123 Prior MI 29.4 27.9 29.6 0.0021 Prior PCI 20.2 20.1 20.3 0.8482 Prior CABG 19.1 19.7 19.0 0.0274 Prior CHF 17.9 19.5 17.8 <0.0001 Prior stroke 10.5 11.2 10.5 0.0045 Renal insufficiency   13.9 15.4 13.7 <0.0001 Data are presented as percentages except as indicated.

*Presented as mean±standard deviation.†Known serum creatinine >2.0 mg/dL, calculated creatinine clearance <30 mL/min, or need for renal dialysis.BMI = body mass index; HMO = health maintenance organization; VAMC = Veterans Administration Medical Center; CAD = coronary artery disease; MI = myocardial infarction; PCI = percutaneous coronary intervention; CABG = coronary artery bypass graft; CHF = congestive heart failure.

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

RESULTS:RESULTS: Comparison of Comparison of Hospital CharacteristicsHospital Characteristics

Characteristics Overall (n = 532)

For-profit (n = 58)

Non-profit (n = 474)

p value

Region West 12.2 13.5 12.1 <0.0001 Northeast 22.2 4.3 23.7 Midwest 32.8 6.6 35.1 South 32.8 75.6 29.1

Type of hospital No services 5.64 0.03 6.12 <0.0001 Cath lab only 9.09 10.7 8.95 PCI, no surgery

6.12 9.84 5.80

Surgery 79.2 79.4 79.1 Teaching hospital*

Academic 28.3 10.7 29.8 <0.0001 Total hospital beds 

404 ± 219 298 ± 112 414 ± 223 <0.0001

Data are presented as percentages except as indicated. *Membership in Council of Teaching Hospitals. †Presented as mean±standard deviation. PCI = percutaneous coronary intervention

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

RESULTS:RESULTS: Comparison of Guideline-Comparison of Guideline-Based In-Hospital Therapy UseBased In-Hospital Therapy Use

Data are presented as percentages except as indicated. OR = odds ratio; UFH = unfractionated heparin; LMWH = low molecular weight heparin; GP = glycoprotein; PCI = percutaneous coronary intervention; CABG = coronary artery bypass graft.

Outcome For-profit (n = 11,658)

Non-profit (n = 133,699)

p value (adjusted

OR) Acute aspirin 93.2 93.8 0.46 Acute beta-blocker 81.4 85.3 0.08 Acute clopidogrel 49.1 46.7 0.15 Acute heparin (UFH or LMWH)

86.3 86.7 0.43

Acute GP IIb/IIIa 41.3 43.2 0.29 Catheterization (overall) 72.3 72.0 0.71 Catheterization within 48 hr of arrival

51.3 51.9 0.34

PCI 44.5 44.0 0.17 PCI within 48 hr of arrival

33.8 32.8 0.10

CABG 11.9 12.1 0.27

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

RESULTS:RESULTS: Comparison of Guideline-Comparison of Guideline-Based Discharge Therapy UseBased Discharge Therapy Use

Data are presented as percentages except as indicated. ACE = angiotensin converting enzyme.

Discharge Therapies

For-profit (n = 11,658)

Non-profit (n = 133,699)

p value (adjusted OR)

Aspirin 91.9 92.3 0.8437 Beta-blocker 84.6 88.5 0.0392 ACE inhibitor 59.9 63.7 0.1171 Clopidogrel 64.0 63.3 0.1749 Lipid-lowering agent

81.5 84.4 0.4949

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

RESULTS:RESULTS: Comparison of Comparison of In-Hospital OutcomesIn-Hospital Outcomes

Data are presented as percentages except as indicated. OR = odds ratio; MI = myocardial infarction; RBC = red blood cell; LOS = length of stay.

*In patients not receiving coronary artery bypass graft surgery. †Major Bleeding is as defined as: 1) absolute hematocrit (HCT) drop of ≥12% (baseline HCT - nadir HCT ≥12%); 2) intracranial hemorrhage stroke; 3) retroperitoneal witnessed bleeding event; 4) baseline HCT ≥28% and RBC transfusion; 5) baseline HCT <28% and RBC transfusion and witnessed bleeding event. ‡Log transformation of adjusted LOS reported.

Outcome For-profit (n = 11,658)

Non-profit (n = 133,699)

p value (adjusted OR)

Death 5.13 4.74 0.9934 Death or MI 7.41 6.93 0.4178 Cardiogenic shock

2.54 2.76 0.3951

RBC transfusion* 9.21 9.64 0.7600 Major bleeding*  9.95 9.90 0.6023 LOS, daysą 5.81 5.73 0.6821

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.

J Am Coll Cardiol 2007;50:1462-68

CONCLUSION

• We found that adjusted in-hospital outcomes for patients at for-profit hospitals were identical to non-profit hospitals.

• Despite organizational differences that may exist in fiscal strategy and resource allocations, no differences were found in process measures, in-hospital outcomes, or procedure utilization.