Dr. Padma Kaul

Discharge rates after heart attack vary between Europe/North America

Europeans are keeping low-risk heart attack patients in hospital too long despite research saying there’s little risk, says researcher Padma Kaul

Despite a decade of research suggesting that low-risk patients can be discharged from hospital after four days, many countries—especially in Europe—could be keeping patients in hospital for an unnecessary length of time.

The latest research, led by University of Alberta researcher Padma Kaul and published in a recent issue of the prestigious medical journal, The Lancet, explored the inconsistencies in the time patients spend in hospital after heart attack. Previous research has outlined how early discharge of low-risk patients with acute heart attack (myocardial infarction) is feasible after four days hospital stay, and can be achieved at no additional risk of adverse events. Dr. Kaul and her colleagues assessed the extent to which different countries have taken advantage of the opportunity for early discharge.

The investigators analyzed the hospital discharge data of over 50,000 people who took part in previous randomized trials, GUSTO-I, GUSTOIII, and ASSENT-2 covering the years 1990-98; these studies enrolled patients with heart attack in the United States, Canada, Australia, New Zealand, Belgium, France, Germany, Spain and Poland.

What they found was that the rate of early discharge of eligible patients was consistently low—less than two percent—in Belgium, France, Germany, Spain, and Poland, although the number of eligible patients discharged on or before day four increased in the United States, Canada, Australia and New Zealand. Despite this increase, no more than 40 percent of patients who were eligible for early discharge were actually discharged early, Dr. Kaul points out. “In the most recent trial, called ASSENT-2, the number of potentially unnecessary hospital days (per 100 patients enrolled) ranged from 65 in New Zealand to 839 in Germany.”

“Despite more than a decade of research, there is still a lot of variation between countries,” says Dr. Kaul. “The potential for more efficient discharge of low-risk patients exists in all countries investigated, but was especially evident in the European countries.”

So why is this happening? In an accompanying editorial on the subject, Adam Timmis, of the London Chest Hospital, says: “At present resources in the United Kingdom, in terms of catheter laboratories and trained interventional staff, are insufficient to meet this standard of care, with the result that many high-risk patients stay in hospital even longer than those reported on by Dr. Kaul and her colleagues, while they wait for catheter laboratory access.”

“With adequate resources, however, primary angioplasty and stenting, which will unify hospital management under a cardiology team, could improve the cost effectiveness of early discharge for acute myocardial infarction.”

Dr. Kaul points out that in this modern era of cost-conscious medicine, clinical management decisions must account not only for risks and benefits but also consider resource consumption. These inter-country comparisons can often serve as natural “experiments” to draw inferences about the return on national investment in medical care and identify opportunities for more efficient use of medical resources, says the researcher who is associated with the Virtual Coordinating Center for Global Collaborative Cardiovascular Research (VIGOUR).

Dr. Kaul and her VIGOUR colleagues are also exploring the differences in delivery of cardiovascular care in the United States and Canada. Historically, Canadian rates of cardiac catheterization and revascularization have been significantly lower than those in the US, especially among elderly patients.

Recently, the Canadian Institutes of Health Research (CIHR) provided funding of $223,480 over three years to fund research on the impact of these differences have on patient care, focusing on the differences in treatment and long-term mortality and quality of life outcomes of elderly heart attack patients. This will complement Dr. Kaul’s recent CIHR-funded work on gender differences in the identification, treatment and outcomes of acute coronary syndromes.

For further information, please contact Dr. Padma Kaul using the Email contact form or by phone at 780 407-8680