Quality of Care for Acute Myocardial Infarction in 58 U.S. Emergency Departments

Abstract

Objectives: The objectives of this study were to determine concordance of emergency department (ED) management of acute myocardial infarction (AMI) with guideline recommendations and to identify ED and patient characteristics predictive of higher guideline concordance. Methods:The authors conducted a chart review study of ED AMI care as part of the National Emergency Department Safety Study (NEDSS). Using a primary hospital discharge diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM], codes 410.XX), a random sample of ED visits for AMI in 58 urban EDs across 20 U.S. states between 2003 and 2006 were identified. Concordance with American College of Cardiology ⁄ American Heart Association (ACC ⁄ AHA) guideline recommendations was evaluated using five individual quality measures and a composite concordance score. Concordance scores were calculated as the percentage of eligible patients who received guidelines-recommended care. These percentage scores were rescaled from 0 to 100, with 100 indicating perfect concordance.Results: The cohort consisted of 3,819 subjects; their median age was 65 years, and 62% were men. The mean (± standard deviation [SD]) ED composite concordance score was 61 ± 8), with a broad range of values (42 to 84). Except for aspirin use (mean concordance, 82), ED concordance scores were low (betablocker use, 56; timely electrocardiogram [ECG], 41; timely fibrinolytic therapy, 26; timely ED disposition for primary percutaneous coronary intervention [PCI] candidates, 43). In multivariable analyses, older age (beta-coefficient per 10-year increase, )1.5; 95% confidence interval [CI] = )2.4 to )0.5) and southern EDs (beta-coefficient, )5.2; 95% CI = )9.6 to )0.9) were associated with lower guideline concordance, whereas ST-segment elevation on initial ED ECG was associated with higher guideline concordance (beta-coefficient, 3.6; 95% CI = 1.5 to 5.7).Conclusions: Overall ED concordance with guideline-recommended processes of care was low to moderate. Emergency physicians should continue to work with other stakeholders in AMI care, such as emergency medical services (EMS) and cardiologists, to develop strategies to improve care processes.ACADEMIC EMERGENCY MEDICINE 2010; 17:940-950 ª

Provider practice style and patient health outcomes: The case of heart attacks

“…Tsai et al (2010) ask whether the treatment of AMI is consistent with guidelines from the American Council of Cardiology, and concluded that compliance is “low to moderate” suggesting that there is a great deal of room for improvement. The literature offers many possible reasons for “mistakes” in the choice of procedure to be systematically biased in favor of aggressive and expensive treatment (Chandra et al, 2012).…”

Physician Practice Style and Patient Health Outcomes: The Case of Heart Attacks

“…Results are presented in Section 4, and section 5 concludes. Tsai et al (2010) ask whether the treatment of AMI is consistent with guidelines from the American Council of Cardiology, and concluded that compliance is "low to moderate" suggesting that there is a great deal of room for improvement. The literature offers many possible reasons for "mistakes" in the choice of procedure to be systematically biased in favor of aggressive and expensive treatment (Chandra et al, 2012).…”

Antiplatelet and anticoagulant nonuse for acute myocardial infarction in the emergency department: An analysis from the National Hospital Ambulatory Medical Care Survey, 2002-2010

“…The validity of the results depends on the accuracy of the data abstraction. There is a well-defined procedure for training of local hospital representatives and Census Bureau field representatives involved in the data abstraction (8), although the accuracy of data abstraction, especially reporting on medication use, has been questioned in the past based on divergent results of NHAMCS and local ED-based studies (24). However, the staff at CDC and NHAMCS cited the difference in study methodology and national representation of the NHAMCS sample as the primary reason for the divergent results, although small errors in data abstraction are possible (25).…”