Identifying acute myocardial infarction: effects on treatment and mortality, and implications for National Service
R J Sapsford1, R A Lawrance, M F Dorsch
1St James's University Hospital, University of Leeds, Leeds, UK.
Insights
Hospital coding identifies most acute myocardial infarction (AMI) cases for audits, but misses 22.5%. Combining multiple identification methods improves accuracy for National Service Framework audits.
Area of Science:
- Cardiology
- Health Services Research
Background:
- The National Service Framework (NSF) for Coronary Heart Disease mandates annual audits for myocardial infarction patient care.
- There is limited guidance on effective methods for achieving audit standards and monitoring clinical practice.
Purpose of the Study:
- To evaluate the most suitable method for identifying acute myocardial infarction (AMI) cases for NSF audits.
- To determine how different definitions of AMI impact the assessment of care quality.
Main Methods:
- An observational study involving 2153 consecutive patients with confirmed AMI across 20 hospitals in the Yorkshire region over 3 months.
- Compared the sensitivity and positive predictive value of identifying AMI cases using clinical coding, biochemistry records, and coronary care registers against a combined 'gold standard' of all three methods.
Main Results:
- Hospital coding identified 77.5% of AMI cases, showing demographic and secondary preventative measure distributions similar to the total cohort.
- Biochemistry and coronary care registers had substantially lower sensitivity and positive predictive values for patient identification.
- Patients meeting WHO criteria (n=1391) had a 15.9% 30-day mortality, compared to 24.2% for the entire cohort.
Conclusions:
- Despite missing 22.5% of cases, hospital coding offers a representative and robust basis for NSF audits due to a lack of systematic bias.
- Routine use of multiple case identification methods is recommended for comprehensive and accurate audit data.
Background:
The National Service Framework (NSF) for Coronary Heart Disease requires annual clinical audit of the care of patients with myocardial infarction, with little guidance on how to achieve these standards and monitor practice.
Aim:
To assess which method of identification of acute myocardial infarction (AMI) cases is most suitable for NSF audit, and to determine the effect of the definition of AMI on the assessment of quality of care.
Design:
Observational study.
Methods:
Over a 3-month period, 2153 consecutive patients from 20 hospitals across the Yorkshire region, with confirmed AMI, were identified from coronary care registers, biochemistry records and hospital coding systems. The sensitivity and positive predictive value of AMI patient identification using clinical coding, biochemistry and coronary care registers were compared to a 'gold standard' (the combination of all three methods).
Results:
Of 3685 possible cases of AMI singled out by one or more methods, 2153 patients were identified as having a final diagnosis of AMI. Hospital coding revealed 1668 (77.5%) cases, with a demographic profile similar to that of the total cohort. Secondary preventative measures required for inclusion in NSF were also of broadly similar distribution. The sensitivities and positive predictive values for patient identification were substantially less in the cohorts identified through biochemistry and coronary care unit register. Patients fulfilling WHO criteria (n=1391) had a 30-day mortality of 15.9%, vs. 24.2% for the total cohort.
Discussion:
Hospital coding misses a substantial proportion (22.5%) of AMI cases, but without any apparent systematic bias, and thus provides a suitably representative and robust basis for NSF-related audit. Better still would be the routine use of multiple methods of case identification.
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