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Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project
G T O'Connor1, H B Quinton, N D Traven
1Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH 03755, USA. gerald.t.o'connor@dartmouth.edu
Insights
Treatment for acute myocardial infarction (AMI) varies significantly by location. Evidence-based therapies are underused, leading to poorer patient outcomes despite proven benefits.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Quality indicators for acute myocardial infarction (AMI) treatment include pharmacologic therapy, reperfusion, and smoking cessation advice.
- These essential therapies are not consistently administered to all eligible patients.
Purpose of the Study:
- To evaluate geographic disparities in the adherence to quality indicators for AMI treatment across the United States.
Main Methods:
- Utilized data from the Health Care Financing Administration Cooperative Cardiovascular Project (186,800 Medicare beneficiaries hospitalized for AMI).
- Assessed adherence to quality indicators for pharmacologic therapy, reperfusion, and smoking cessation advice in ideal candidates.
- Compared adherence rates across 306 hospital referral regions, analyzing age- and sex-adjusted rates.
Main Results:
- Aspirin use was high (86.2% during hospitalization, 77.8% at discharge).
- Significant underuse was observed for angiotensin-converting enzyme inhibitors (59.3%), reperfusion (67.2%), beta-blockers (49.5%), and smoking cessation advice (41.9%).
- Calcium channel blockers were withheld from 81.9% of patients with impaired left ventricular function.
Conclusions:
- Considerable geographic variation exists in AMI treatment adherence.
- Gaps between established medical knowledge and clinical practice for AMI care have significant negative consequences.
- Evidence-based therapies for AMI remain underutilized, impacting patient outcomes.
Context:
Quality indicators for the treatment of acute myocardial infarction include pharmacologic therapy, reperfusion, and smoking cessation advice, but these therapies may not be administered to all patients who could benefit from them.
Objective:
To assess geographic variation in adherence to quality indicators for treatment of acute myocardial infarction.
Design:
Inception cohort using data from the Health Care Financing Administration Cooperative Cardiovascular Project.
Setting:
Acute care hospitals in the United States.
Patients:
A total of 186800 Medicare beneficiaries hospitalized for treatment of confirmed acute myocardial infarction from February 1994 through July 1995.
Main Outcome Measures:
Adherence to quality indicators for pharmacologic therapy, reperfusion, and smoking cessation advice for patients judged to be ideal candidates for these therapies. The mean rates of adherence to these quality indicators for the entire United States were determined, and the 20th and 80th percentiles of the age- and sex-adjusted rates for each of 306 hospital referral regions were contrasted (mean rate [20th-80th percentiles]).
Results:
Aspirin was used frequently both during hospitalization (86.2% [82.6%-90.1%]) and at discharge (77.8% [72.5% -83.9%]). Calcium channel blockers were withheld from most patients with impaired left ventricular function (81.9% [73.6%-90.8%]). Lower rates were seen in the use of angiotensin-converting enzyme inhibitors at discharge (59.3% [49.2%-69.2%]); reperfusion, using thrombolytic therapy or coronary angioplasty (67.2% [59.8%-75.1%]); prescription of beta-blockers at discharge (49.5% [35.8%-61.5%]); and for smoking cessation advice (41.9% [32.8%-51.3%]).
Conclusions:
Substantial geographic variation exists in the treatment of patients with acute myocardial infarction, and these gaps between knowledge and practice have important consequences. Therapies with proven benefit for AMI are underused despite strong evidence that their use will result in better patient outcomes.
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