The use of angiotensin-converting enzyme inhibitors in patients with acute myocardial infarction in community hospitals. Michigan State University Inter-Institutional Collaborative Heart (MICH) Study Group

Factors associated with the use of evidence-based therapies after discharge among elderly patients with myocardial infarction

BACKGROUND

In an accompanying article, we report moderate between-hospital variation in the postdischarge use of beta-blockers, angiotensin-modifying drugs and statins by elderly patients who had been admitted to hospital with acute myocardial infarction. Our objective was to identify the characteristics of patients, physicians, hospitals and communities associated with differences in the use of these medications after discharge.

METHODS

For this retrospective, population-based cohort study, we used linked administrative databases. We examined data for all patients aged 65 years or older who were discharged from hospital in 2005/06 with a diagnosis of myocardial infarction. We determined the effect of patient, physician, hospital and community characteristics on the rate of postdischarge medication use.

RESULTS

Increasing patient age was associated with lower postdischarge use of medications. The odds ratios (ORs) for a 1-year increase in age were 0.98 (95% confidence interval [CI] 0.97-0.99) for beta-blockers, 0.97 (95% CI 0.97-0.98) for angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers and 0.94 (95% CI 0.93-0.95) for statins. Having a general or family practitioner, a general internist or a physician of another specialty as the attending physician, relative to having a cardiologist, was associated with lower postdischarge use of beta-blockers, angiotensin-modifying agents and statins (ORs ranging from 0.46 to 0.82). Having an attending physician with 29 or more years experience, relative to having a physician who had graduated within the past 15 years, was associated with lower use of beta-blockers (OR 0.71, 95% CI 0.60-0.84) and statins (OR 0.81, 95% CI 0.67-0.97).

INTERPRETATION

Patients who received care from noncardiologists and physicians with at least 29 years of experience had substantially lower use of evidence-based drug therapies after discharge. Dissemination strategies should be devised to improve the prescribing of evidence-based medications by these physicians.

Use of evidence-based therapies after discharge among elderly patients with acute myocardial infarction

BACKGROUND

Postdischarge use of evidence-based drug therapies has been proposed as a measure of quality of care for myocardial infarction patients. We examined trends in the use of evidence-based drug therapies after discharge among elderly patients with myocardial infarction.

METHODS

We performed a cross-sectional study in a retrospective population-based cohort that was created using linked administrative databases. We included patients aged 65 years and older who were discharged from hospital with a diagnosis of myocardial infarction between Apr. 1, 1992, and Mar. 31, 2005. We determined the annual percentage of patients who filled a prescription for statins, beta-blockers and angiotensin-modifying drugs within 90 days after discharge.

RESULTS

The percentage of patients who filled a prescription for a beta-blocker increased from 42.6% in 1992 to 78.1% in 2005. The percentage of patients who filled a prescription for an angiotensin-modifying drug increased from 42.0% in 1992 to 78.4% in 2005. The percentage of patients who filled a prescription for a statin increased from 4.2% in 1992 to 79.2% in 2005. In 2005, about half of the hospitals had rates of use for each of these therapies that were less than 80%. The temporal rate of increase in statin use after discharge was slower among noncardiologists than among cardiologists (3.5%-2.8% slower). The rate of increase was 4.8% slower for among physicians with low volumes of myocardial infarction patients than among those with high volumes of such patients and was 5.7% greater at teaching hospitals compared with nonteaching hospitals.

INTERPRETATION

Use of statins, beta-blockers and angiotensin-modifying drugs increased from 1992 to 2005. The rate of increase in the use of these medications after discharge varied across physician and hospital characteristics.

Comparing clinical and administrative data for profiling hospitals on postdischarge medication use by patients with acute myocardial infarction

BACKGROUND

Postdischarge medication use is frequently used as a measure of hospital performance, with many reports produced using clinical data obtained from chart reviews. The introduction of a drug benefit program administered by the Centers for Medicare and Medicaid Services presents an opportunity to use administrative data for routine reporting on hospital performance. We determined the concordance between hospital-specific prescribing rates of evidence-based medical therapies obtained from clinical and administrative data in Ontario, Canada.

METHODS

This was a retrospective cohort study using data on patients discharged from 102 hospitals in Ontario, Canada with acute myocardial infarction (AMI) between April 1, 1999, and March 31, 2001. We compared hospital-specific rates of discharge prescribing in AMI patients, determined using clinical data obtained using retrospective chart review with hospital-specific rates of prescriptions filled within 30 days of hospital discharge in elderly patients using administrative data.

RESULTS

There was a moderate agreement between hospital-specific rates of discharge prescriptions written for AMI patients in clinical data with hospital-specific rates of prescriptions filled using administrative data. Although differences in rates were, on average, small between the 2 data sources, there was moderate variation in the differences between these 2 rates across hospitals. There was very strong agreement between rates of discharge prescribing in all patients and in ideal patients with no contraindications, both determined using clinical data.

CONCLUSIONS

Post-AMI discharge prescribing in all patients determined using clinical data is an excellent proxy for prescribing in ideal patients using clinical data. However, there is weaker agreement between administrative and clinical data.

Does outpatient telephone coaching add to hospital quality improvement following hospitalization for acute coronary syndrome?

BACKGROUND

Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care.

OBJECTIVE

To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge.

DESIGN

Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus).

DATA

medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization).

ANALYSIS

pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis.

PARTICIPANTS

Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys.

MEASUREMENTS

We measured secondary prevention behaviors, physical functioning, and quality of life.

RESULTS

QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months.

CONCLUSIONS

Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.

Changes in practice patterns affecting in-hospital and post-discharge survival among ACS patients

Background

Adherence to clinical practice guidelines for the treatment of specific illnesses may result in unexpected outcomes, given that multiple therapies must often be given to patients with diverse medical conditions. Yet, few studies have presented empirical evidence that quality improvement (QI) programs both change practice by improving adherence to guidelines and improve patient outcomes under the conditions of actual practice. Thus, we focus on patient survival, following hospitalization for acute coronary syndrome in three successive patient cohorts from the same community hospitals, with a quality improvement intervention occurring between cohorts two and three.

Methods

This study is a comparison of three historical cohorts of Acute Coronary Syndrome (ACS) patients in the same five community hospitals in 1994–5, 1997, 2002–3. A quality improvement project, the Guidelines Applied to Practice (GAP), was implemented in these hospitals in 2001.

Study participants were recruited from community hospitals located in two Michigan communities during three separate time periods. The cohorts comprise (1) patients enrolled between December 1993 and April 1995 (N = 814), (2) patients enrolled between February 1997 and September 1997 (N = 452), and (3) patients enrolled between January 14, 2002 and April 13, 2003 (N = 710).

Mortality data were obtained from Michigan's Bureau of Vital Statistics for all three patient cohorts. Predictor variables, obtained from medical record reviews, included demographic information, indicators of disease severity (ejection fraction), co-morbid conditions, hospital treatment information concerning most invasive procedures and the use of ace-inhibitors, beta-blockers and aspirin in the hospital and as discharge recommendations.

Results

Adjusted in-hospital mortality showed a marked improvement with a HR = 0.16 (p < 0.001) comparing 2003 patients in the same hospitals to those 10 years earlier. Large gains in the in-hospital mortality were maintained based on 1-year mortality rates after hospital discharge.

Conclusion

Changes in practice patterns that follow recommended guidelines can significantly improve care for ACS patients. In-hospital mortality gains were maintained in the year following discharge.

Low utilization and wide interhospital variation in investigation of patients after acute myocardial infarction: inadequate resources or insufficient evidence?

BACKGROUND

Guidelines for the management of patients with acute myocardial infarction are available, but implementation may be difficult when resources are limited.

OBJECTIVE

The aim of this study was to investigate whether resources, manpower or access to specialist facilities affect care following myocardial infarction.

PATIENTS AND METHODS

A representative sample of 1595 patients in all 19 district general hospitals in Wales was analysed for differences in use of investigations and prescription of secondary prevention and how these factors were related to provision of cardiologists and coronary care beds and distance from specialist cardiac services.

RESULTS

Inpatient investigation rates were low and there were wide interhospital variations for exercise testing [mean 42%; interquartile range (IQR) 27-59%] and echocardiography (mean 46%; IQR 33-66%). In comparison, prescription of secondary prevention was similar to European standards and showed less interhospital variation (beta blockers mean 48%; IQR 44-54%; angiotensin-converting enzyme inhibitors mean 59%; IQR 43-63%). There was little association between investigation or secondary prevention rates and cardiac services, but overall rates and provision were low.

CONCLUSION

Delivery of care after acute myocardial infarction for stratifying risk and preventing recurrence was unrelated to relative provision or distance from specialist centres. Low use of investigations and high interhospital variability could imply limited access to resources such as echocardiography. Higher rates of prescription of drugs, with less variation between hospitals, argues against low utilization because of insufficient evidence.

Changes in rates of beta-blocker use in community hospital patients with acute myocardial infarction

OBJECTIVE

To examine changes in the rate of beta-blocker (BB) use at admission, in hospital, and at discharge between 1994 and 1995 (MICH I) and 1997 (MICH II) in patients with acute myocardial infarction (AMI).

DESIGN

Comparison of two prospectively enrolled cohorts.

SETTING

Five mid-Michigan community hospitals.

PATIENTS

We studied 287 MICH I patients and 121 MICH II patients with AMI who had no contraindications to BB use from cohorts of consecutively admitted cases of AMI (814 in MICH I; 500 in MICH II).

RESULTS

Prescription of BBs to ideal patients with AMI increased in patients with previous history of myocardial infarction on arrival at the hospital (12.5% vs 36.0%; P= .01), in hospital (47.0% vs 76%; P < .01), and at discharge (34.0% vs 61.9%; P < .01). Neither race nor gender was a predictor of BB use. Younger age predicted BB prescription at discharge (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.32 to 3.23). Later study cohort was the most important predictor of BB use in hospital (OR, 3.4; 95% CI, 2.09 to 5.25).

CONCLUSION

BB use improved dramatically over the study period, but additional work is needed to improve use of BB after discharge and among elderly patients with AMI.

Quality of care for secondary prevention for patients with coronary heart disease: results of the Hastening the Effective Application of Research through Technology (HEART) trial

BACKGROUND

Effective therapies for reducing mortality rates in persons with coronary heart disease (CHD) remain underused. We report the results of an effectiveness trial of a quality improvement effort to increase the use of 3-hydroxy-3methylglutaryl coenzyme A (HMG CoA) reductase inhibitors, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors in patients with CHD in a network-model managed-care setting.

METHODS

Patients with CHD were identified by searching a claims database. The use of therapies was assessed by linkage with a pharmacy database. An intervention, consisting of a guideline summary, peer comparison performance feedback, and patient specific chart reminders was evaluated in a randomized, practice-based effectiveness trial.

RESULTS

Data were available for >700 patients per year (1999-2002) in 131 practices. At baseline (1999), 55% of patients were receiving HMG CoA reductase inhibitors, 39% of patients were receiving beta-blockers, and 24% of patients were receiving ACE inhibitors. The use of all 3 types of medications increased steadily with time, with the exception of a decrease in the use of HMG CoA reductase inhibitors in the final year (2002). No difference in medication use was observed between randomized groups.

CONCLUSIONS

The observed pattern of care supports the contention that the quality of outpatient care for secondary prevention of CHD improved from 1999 to 2002 in this setting. The basis for the inconsistent pattern of use of HMG CoA reductase inhibitors is not certain, but may relate to concerns about toxicity. Centralized mailings of guideline summaries, performance feedback reports, and chart reminders had no observable impact on quality of care in this setting. More intensive intervention may be required to improve the quality of outpatient care for the secondary prevention of CHD.