Changes in myocardial infarction guideline adherence as a function of patient risk: an end to paradoxical care?
Apurva A Motivala1, Christopher P Cannon, Vankeepuram S Srinivas
1Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA.
Insights
Patients with myocardial infarction (MI) at higher risk paradoxically receive less guideline-based care, but adherence is improving across all risk groups. The gap in care between low- and high-risk patients is narrowing over time.
Area of Science:
- Cardiology
- Health Services Research
- Clinical Quality Improvement
Background:
- Guideline-based care for myocardial infarction (MI) improves patient outcomes, particularly for high-risk individuals.
- Previous research indicates a potential mismatch where high-risk patients receive guideline-recommended therapies less frequently.
- This study investigates adherence to MI care guidelines based on patient risk stratification.
Purpose of the Study:
- To assess if guideline-based care for myocardial infarction (MI) varies with patient baseline risk.
- To determine if improvements in guideline adherence over time are consistent across different risk groups.
Main Methods:
- Analysis of 112,848 patients with MI from 279 hospitals (August 2000 - December 2008) enrolled in the Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) registry.
- Development and validation of an in-hospital mortality model to categorize patients into low, intermediate, and high-risk tertiles.
- Examination of guideline-based care utilization and temporal trends in adherence.
Main Results:
- High-risk MI patients were significantly less likely to receive key therapies (aspirin, beta-blockers, ACE inhibitors/ARBs, statins) and discharge recommendations (smoking cessation, cardiac rehab referral) compared to lower-risk patients.
- Guideline-recommended therapy use increased significantly per year across all risk groups (low-risk OR: 1.33, intermediate-risk OR: 1.30, high-risk OR: 1.30).
- A statistically significant narrowing of the guideline adherence gap between low- and high-risk patients was observed over the study period (p = 0.0002).
Conclusions:
- Despite persistent lower adherence in high-risk myocardial infarction (MI) patients, guideline-based care is improving for all risk categories.
- The disparity in care between low- and high-risk MI patients appears to be decreasing over time.
- These findings highlight progress in MI care quality but underscore the need for continued efforts to ensure equitable guideline adherence.
Objectives:
The goals of this analysis were to determine: 1) whether guideline-based care during hospitalization for a myocardial infarction (MI) varied as a function of patients' baseline risk; and 2) whether temporal improvements in guideline adherence occurred in all risk groups.
Background:
Guideline-based care of patients with MI improves outcomes, especially among those at higher risk. Previous studies suggest that this group is paradoxically less likely to receive guideline-based care (risk-treatment mismatch).
Methods:
A total of 112,848 patients with MI were enrolled at 279 hospitals participating in Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) between August 2000 and December 2008. We developed and validated an in-hospital mortality model (C-statistic: 0.75) to stratify patients into risk tertiles: low (0% to 3%), intermediate (3% to 6.5%), and high (>6.5%). Use of guideline-based care and temporal trends were examined.
Results:
High-risk patients were significantly less likely to receive aspirin, beta-blockers, angiotensin-converting inhibitors/angiotensin receptor blockers, statins, diabetic treatment, smoking cessation advice, or cardiac rehabilitation referral at discharge compared with those at lower risk (all p < 0.0001). However, use of guideline-recommended therapies increased significantly in all risk groups per year (low-risk odds ratio: 1.33 [95% confidence interval (CI): 1.22 to 1.45]; intermediate-risk odds ratio: 1.30 [95% CI: 1.21 to 1.38]; and high-risk odds ratio: 1.30 [95% confidence interval: 1.23 to 1.37]). Also, there was a narrowing in the guideline adherence gap between low- and high-risk patients over time (p = 0.0002).
Conclusions:
Although adherence to guideline-based care remains paradoxically lower in those MI patients at higher risk of mortality and most likely to benefit from treatment, care is improving for eligible patients within all risk categories, and the gaps between low- and high-risk groups seem to be narrowing.
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