While Cardiologists Attend AHA, ACC Sessions, Hospitalized Cardiac Patients Do Just Fine: Analysis

December 22, 2014

BOSTON, MA — The good news is that no one, it seems, is dying just because US cardiologists head en mass for the American College of Cardiology (ACC) and American Heart Association (AHA) scientific sessions in March and November each year. In fact, a new study suggests that patient care, as assessed by 30-day mortality rates, might actually be better when doctors attend the two major cardiology meetings[1]. For patients admitted with heart failure and cardiac arrest while the AHA and ACC meetings are ongoing, the 30-day mortality rate at major US teaching hospitals is significantly lower than when patients are hospitalized the rest of the year.

For acute-MI patients, the 30-day mortality rate at academic centers was similar when patients were admitted during the meeting dates vs the rest of the year, but the use of PCI was significantly less when doctors were away at the scientific sessions.

"Interventions foregone during meeting dates are more likely to be those for which the risk-benefit tradeoff is less clear and may involve harms that outweigh benefits in high-risk patients," according to Dr Anupam Jena (Harvard Medical School, Boston, MA) and colleagues in a study published online December 22, 2014 in JAMA: Internal Medicine.

"Our finding that substantially lower PCI rates for high-risk patients with acute MI admitted to teaching hospitals during cardiology meetings are not associated with improved survival suggests potential overuse of PCI in this population," they write.

"This interpretation is consistent with evidence that public reporting of PCI outcomes is associated with lower rates of PCI among high-risk patients with acute MI, without any effect on mortality. More broadly, this interpretation may align with other studies of medical care which demonstrate that 'less is more' for intensive-care patients."

In a press release, Jena said the difference in mortality among heart-failure and cardiac-arrest patients hospitalized during the meeting dates vs nonmeeting dates is "tremendous" and "better than most of the medical interventions that exist to treat these conditions."

To Dr Ajay Kirtane (Columbia University, New York), the "less-is-more" hypothesis explaining the "mechanism" for the better mortality rates is simply not known in an observational analysis with many potential confounding variables. He noted that researchers identified just 178 high-risk acute-MI patients admitted to teaching hospitals during the meeting dates over the 10-year sample period. Over nonmeeting dates, 1001 high-risk MI patients were admitted to teaching hospitals.

"To me, that is just too small a sample to make definitive conclusions," he told heartwire . "To take the observation that the rate of PCI was marginally lower with similar outcomes, and then to say maybe we don't need to be doing these procedures, seems like too much of a stretch."

He said the randomized, clinical-trial evidence clearly supports the use of coronary revascularization with PCI or CABG in high-risk acute MI patients. For these high-risk patients, including those treated during meeting and nonmeeting dates with 20% requiring circulatory support, the overall rate of revascularization was just 30%, which is actually far too low. "We don't have a clear sense of who these patients are and what went on with their treatment," Kirtane said.

What the Analysis Shows

With the retrospective analysis, the researchers identified all hospitalizations for acute MI, heart failure, and cardiac arrest between 2002 and 2011. The "exposure" group were those patients hospitalized during dates that coincided with the AHA and ACC scientific sessions, whereas the "controls" included patients hospitalized in the three weeks before and after the meetings.

During the meeting dates, 8570 individuals were hospitalized for acute MI, 19 282 for heart failure, and 1564 for cardiac arrest. In contrast, during nonmeeting dates, 57 471 patients were hospitalized for acute MI, 11 459 were hospitalized for heart failure, and 9580 for cardiac arrest.

The adjusted 30-day mortality rate at teaching hospitals among high-risk heart-failure and cardiac-arrest patients admitted during the meeting dates was 17.5% and 59.1%. During nonmeeting dates, the 30-day mortality rates were 24.8% and 69.4%, respectively. These differences were statistically significant.

For high-risk acute-MI patients, the 30-day mortality rates at teaching hospitals during meeting and nonmeeting dates were 39.2% and 38.5%, respectively. Although this difference was not statistically significant, significantly lower rates of PCI were observed during meetings. When the AHA and ACC were ongoing, the rate of PCI was 20.8%, vs 28.2% during nonmeeting dates.

Among nonteaching hospitals, there was no difference in mortality or utilization rates during the meeting and nonmeeting dates for those hospitalized with these acute cardiovascular conditions. For low-risk patients, there was also no difference in mortality or utilization rates at the academic and nonteaching centers.

Debating the Significance of the Findings

For Dr Rita Redberg (University of California, San Francisco), the editor in chief of JAMA: Internal Medicine, the results suggesting patient care does not suffer during the meetings are "reassuring" despite the a priori hypothesis that it might (and the humorous opposing hypothesis that a meeting might be the safest place to have a heart attack)[2]. As for interpreting the findings, she suggests it's possible more interventions in high-risk patients with heart failure and cardiac arrest might lead to higher mortality.

"Indeed, some high-risk interventions, such as balloon pumps or ventricular assist devices, are being used in populations in which they are not shown to improve outcomes, and recent reports have raised concerns about high rates of fatal complications from pump thrombosis and other problems," writes Redberg.

In their discussion, Jena and colleagues touch on the possibility of unnecessary interventions, noting that cardiologists might be reluctant to intervene in high-risk patients if the primary cardiologist is away at a meeting. A reluctance to intervene might be associated with improved mortality if the usual intervention performed during nonmeeting dates is unnecessary.

To heartwire , Kirtane noted patients are still extremely well cared for even in the absence of their primary cardiologist. In fact, many of the clinicians who are in the trenches, those treating patients every day, remain behind when these meetings occur. If there were times they felt coverage wouldn't be adequate, hospitals, even academic centers, would hold physicians from attending.

"The folks who attend these meetings are not necessarily the same doctors taking care of these patients day in, day out, even when they're back at home," Kirtane told heartwire . "So the reason behind potential differences in outcomes is really hard to explain."

The study was funded by the National Institutes of Health and the National Institute on Aging. Jena reported he had no relevant financial relationships. Disclosures for the coauthors are listed in the article. Redberg reported no relevant financial relationships.


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