Quality of care among elderly patients hospitalized with unstable angina

doi:10.1067/mhj.2001.116477

American Heart Journal

Volume 142, Issue 2, August 2001, Pages 263-270

https://doi.org/10.1067/mhj.2001.116477 Get rights and content

Abstract

Background Guidelines for the management of unstable angina have been published by the United States Agency for Health Care Policy and Research (currently known as the Agency for Healthcare Research and Quality); however, little information is available about the quality of unstable angina care, particularly among elderly patients. Methods We examined 1196 elderly Medicare-insured patients hospitalized with unstable angina (ruled out for acute myocardial infarction) at Connecticut hospitals between August and November 1995 to evaluate quality of care provided during hospitalization. Patients without therapeutic contraindications were evaluated for the use of 5 Agency for Health Care Policy and Research guideline–recommended measures: electrocardiographic examination within 20 minutes of admission, use of aspirin on admission, intravenous heparin on admission, achievement of therapeutic anticoagulation among patients provided heparin, and prescription of aspirin on discharge. Results Less than half (49.6%) of patients underwent electrocardiographic examination within 20 minutes of admission. After excluding patients with contraindications, aspirin was provided to 80.1% of patients and intravenous heparin to 59.2% of indicated patients, of whom only 43.3% achieved therapeutic anticoagulation. Aspirin was prescribed to 82.3% of eligible patients at discharge. Performance on the 5 quality measures varied widely among hospitals. Conclusions Agency for Health Care Policy and Research guideline–recommended risk stratification and therapeutic interventions are underused in elderly patients hospitalized with unstable angina, with quality of care varying widely among hospitals. (Am Heart J 2001;142:263-70)

Section snippets

Study sample

We identified all Medicare-insured patients hospitalized at acute care hospitals in Connecticut between August 1995 and November 1995 with a principal discharge diagnosis indicating acute presentation of coronary artery disease consistent with unstable angina (International Classification of Diseases, Ninth Revision, Clinical Modification code 411.x [intermediate coronary syndrome/acute coronary insufficiency], 413.x [angina decubitus/variant angina], and 414.x [chronic ischemic heart disease

Results

The 1196 patients who met study inclusion criteria were predominantly white and women and had a mean age of 77.5 years. Most patients were admitted with chest pain, and a significant number of patients had associated comorbid conditions, including hypertension, prior myocardial infarction, diabetes mellitus, and prior coronary artery–related procedures (Table II).

. Patient characteristics and unstable angina quality-of-care measures among ideal patients

Empty Cell	Overall	Electrocardiography within 20 minutes		Empty Cell

Discussion

Our evaluation of a community-based cohort of hospitalized Medicare beneficiaries found significant variation in the delivery of care during the diagnosis and management of unstable angina. Although use of aspirin was relatively high, basic procedures such as timely administration of electrocardiography and anticoagulation to therapeutic thresholds were achieved in less than half of patients, with some hospitals performing at markedly lower levels. Hospitals’ performance on each of these

Acknowledgements

We thank Maria Johnson for her outstanding editorial assistance.

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This systematic review with meta-analysis sought to determine the efficacy and safety of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) on clinical outcomes following percutaneous coronary intervention. Medline, Embase, Elsevier, and web of knowledge as well as Google scholar literature were used for selecting appropriate studies with randomized controlled design. After screening 445 studies, a total of 23 trials (including a total of 43,912 patients) were identified that reported outcomes. Pooled analysis revealed that LMWH compared to UFH could significantly increase thrombolysis in myocardial infarction grade 3 flow (p < 0.001), which was associated with similar target vessel revascularization (p = 0.6), similar incidence of stroke (p = 0.7), and significantly lower incidence of re-myocardial infarction (p < 0.001), major bleeding (p = 0.02) and mortality (p < 0.001). Overall, LMWH was shown to be a useful type of heparin for patients with MI undergoing PCI, due to its higher efficacy and lower rate of complication compared to UFH. It is also associated with increased myocardial perfusion, decreased major hemorrhage, and mortality.
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Data on the impact of low molecular weight heparin (LMWH) on bleeding and mortality in elderly patients with acute coronary syndrome (ACS) show conflicting results. Increased efficacy of LMWH in these patients may be accompanied by an increased risk of bleeding related in particular to renal failure that may foster an overdose of LMWH [1–3]. The aim of this study is to assess the impact of LMWH compared with unfractioned heparin (UFH) on bleeding, the need for transfusion and one-year survival in elderly patients (75 years of age or older) with acute myocardial infarction (AMI) from the French registry of Acute ST or non-ST-elevation Myocardial Infarction (FAST-MI) registry of the French Society of Cardiology [4].
There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI).
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963 patients treated with heparin were included (mean age 82 ± 5 years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P = 0.004) and blood transfusions (4.6% vs. 9.7%, P = 0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR = 0.41, 95% CI: 0.20–0.83 and OR = 0.49, 95% CI: 0.28–0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR = 0.66, 95% CI: 0.50–0.85 and OR = 0.71, 95% CI: 0.56–0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH.
The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.
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Data from the Nationwide Inpatient Sample were used to identify admissions for pre-surgical evaluations and surgery. Surgical treatment of epilepsy was identified by the presence of primary ICD-9-CM procedure codes 01.52 (hemispherectomy), 01.53 (lobectomy), or 01.59 (other excision of the brain, including amygdalohippocampectomy). We calculated annual rates of pre-surgical evaluations and surgery based on published estimates of prevalence of epilepsy in the U.S. In addition, we examined variations by region and hospital characteristics, and conducted multivariable analysis to detect temporal trends, adjusting for changes in the population. Sensitivity analysis was also conducted using different algorithms to identify the study population and outcomes.
We detected an increase in the rate of hospitalizations related to intractable epilepsy. Similarly, we noted a significant increase in hospitalizations for VEEG monitoring, but not in IEEG monitoring or in surgery. Multivariable analysis and sensitivity analysis confirmed these results. In addition, there was a significant increase in the proportion of pre-surgical evaluations and surgery performed in non-teaching hospitals.
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Recent clinical studies suggest that low-molecular-weight heparin (LMWH) could be an effective and safe alternative to unfractionated heparin (UFH) for patients with acute myocardial infarction (AMI).
To assess the impact of anticoagulant choice (LMWV vs UFH) on bleeding, the need for blood transfusion and 3-year clinical outcomes in AMI patients from the FAST-MI registry.
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^☆: The analyses upon which this publication is based were performed under Contract Number 500-96-P549, entitled, “Utilization and Quality Control Peer Review Organization for the State of Connecticut, ” sponsored by the Health Care Financing Administration, Department of Health and Human Services. The contents of this publication do not necessarily reflect the views or policies of the U.S. Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this Contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.

^☆☆: Reprints not available from the authors.

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Outcomes, Health Policy, and Managed CareQuality of care among elderly patients hospitalized with unstable angina☆,☆☆

Abstract

Section snippets

Study sample

Results

Discussion

Acknowledgements

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

Quality of care for Medicare patients with acute myocardial infarction: a four-state pilot study from the Cooperative Cardiovascular Project

JAMA

Aspirin in the treatment of acute myocardial infarction in elderly Medicare beneficiaries. Patterns of use and outcomes

Circulation

Quality of care for elderly patients hospitalized with heart failure

Arch Intern Med

Elderly patients receive less aggressive medical and invasive management of unstable angina: potential impact of practice guidelines

Arch Intern Med

Coronary heart disease and related procedures: National Hospital Discharge Survey data

Circulation

Outcomes, Health Policy, and Managed Care
Quality of care among elderly patients hospitalized with unstable angina☆,☆☆