Tuesday, August 9, 2005

Quality of Care for Heart Attack Patients Needs Improvement
By Julie McKeel

Despite published care guidelines for the treatment of heart attack patients, the use of evidence-based drugs for patients diagnosed with acute and non-acute heart attacks fell below the recommended guidelines, according to an analysis using the U.S. National Registry of Myocardial Infarction 4 (NRMI-4) database.

[The NRMI is an observational registry that analyzes in-hospital treatment patterns for patients with the confirmed diagnosis of acute myocardial infarction (AMI, or heart attack) based on the diagnosis code for MI defined in the International Classification of Diseases, Ninth Revision.]

The report is published in the July 25, 2005 issue of the Archives of Internal Medicine.

The analysis shows that recommended treatments were provided less often for the non-acute heart attack patients, though the use of the recommended medications for both groups fell below the published guidelines.

Matthew Roe, MD, MHS

"We used the NRMI database, which collects information on both types of MI patients, to understand how evidence-based therapies are utilized in separate populations," added Roe.

AMI treatment has improved over the two decades based on new guidelines for the use of evidence-based drugs and therapies designed to reduce death rates. Most studies have focused on improving quality of care for patients with acute ST-segment elevation MI (STEMI)*. However, AMI treatments are not applied as often for patients with non-STEMI (NSTEMI) despite the fact that the number of NSTEMI (compared with STEMI) patients has consistently increased during the past 10 years.

Treatment differences between heart attack categories have not been well described. In this analysis, the researchers compared the use of recommended medications and prevention interventions with the practice guidelines for 53,417 STEMI patients and 132,551 non-STEMI patients from 1247 U.S. hospitals.

"The main findings were that therapies that we know have benefit in those populations aspirin, beta blockers, ACE inhibitors were used less commonly in non-ST-segment-elevation MI but, [in] both populations, there was still much lower use of these therapies, overall, than we'd like to see," Roe told theheart.org. "Between 12% and 15% of patients didn't receive aspirin within 24 hours, about 20% didn't receive a beta blocker, and many patients didn't undergo basic procedures like catheterization typically in the non-ST-segment-elevation population."

"So that led to much higher mortality rates than seen in previous studies," Roe added. Unadjusted in-hospital death rates were 12.5% for non-STEMI patients and 14.3% for STEMI patients.

When discharged, STEMI patients were less likely than non-STEMI patients to receive recommended discharge medications (aspirin, beta blockers, ACE inhibitors, and lipid-lowering drugs) as well as cardiac-rehabilitation referrals and smoking-cessation counseling.

"We're seeing lower-than-expected use of therapies even lower in the non-STEMI population with very high mortality rates," Roe told theheart.org. "This is a surprising finding, given how much we know about the benefits of these different therapies, and [it] raises the question of what can we do to try to improve care processes for all MI patients."

According to the study, quality improvement interventions designed to narrow the gaps in care between NSTEMI and STEMI patients may reduce the high mortality rates associated with acute heart attack.

"All hospitals should be participating in some form of an ongoing quality-improvement program for patients with acute MI," continues Roe.

"This study highlights the need to comprehensively work with all healthcare providers to try to make sure they understand what the benefits of therapies are for patients with acute MI and [to see] that they are utilized in all appropriate patients."

This study was supported by an unrestricted grant from Genentech Inc. The NRMI is funded by Genentech Inc.

Study authors include the DCRI's Dr. Matthew Roe and Dr. Eric Peterson; Lori S. Parsons (Ovation Research Group, Seattle, Wash); Dr. Charles Pollack (Department of Emergency Medicine, University of Pennsylvania, Philadelphia), Drs. John Canto and William Rogers (Division of Cardiology, University of Alabama); Dr. Hal Barron (Genentech Inc, San Francisco, Calif); and Dr. Nathan Every (Department of Cardiology, Veterans Affairs Medical Center, Seattle) for the National Registry of Myocardial Infarction Investigators.

* STEMI (ST-segment elevation MI) and NSTEMI (non-ST-segment elevation MI). Sometimes called Q-wave and non-Q-wave MIs (myocardial infarction or heart attack). Refers to the portion of the ECG-the ST segment- used to diagnose the MI.