To assess the impact of exposure to evidence-based medication following hospital discharge for Medicare beneficiaries with acute myocardial infarction (AMI).
A discrete-time hazard model was used to estimate time-to-outcome associated with exposure to four drug classes (angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers (BBs), statins, and clopidogrel) used for post-AMI secondary prevention of cardiovascular events and mortality.
Medicare administrative data for a 5% random sample of beneficiaries.
Medicare beneficiaries (n=9,538) hospitalized for an AMI between 4/1/2006 and 12/31/2007 who survived for at least 30 days after discharge. The cohort was followed until death or 12/31/2008.
Time-varying exposure was measured as proportion of days covered (PDC) for each quarter during the follow-up period. PDC was classified into five categories (0–0.2; >0.2–0.4; >0.4–0.6; >0.6–0.8; >0.8–1.0). Outcomes were mortality and a composite outcome of death or post-AMI hospitalization.
Over a median follow-up of 18 months, mean PDC rates ranged from 0.37 (clopidogrel) to 0.50 (statins). When comparing the highest versus lowest categories of exposure, the hazard of the composite outcome was significantly lower for all drug classes except BBs [statins, adjusted hazard ratio (aHR) = 0.71, ACEIs/ARBs, aHR = 0.81, clopidogrel, aHR = 0.85, BBs, aHR = 0.93]. All four drug classes were significantly associated with reductions in mortality; the magnitude of effect for the mortality outcome was largest for statins and smallest for BBs. Age modified the effect of statins on mortality.
Use of evidence-based medications for secondary prevention post-AMI is suboptimal in the Medicare population and low exposure rates are associated with significantly higher risk for subsequent hospitalization and death.
Myocardial infarction; Medicare; Pharmacotherapy; Medicare Part D; Secondary prevention
Mortality from cardiovascular disease in Estonia is among the highest in Europe. The reasons for this have not been clearly explained. Also, there are no studies available examining outpatient drug utilization patterns in patients who suffered from acute myocardial infarction (AMI) in Estonia. The objective of the present study was to examine drug utilization in different age and gender groups following AMI in Estonia.
Patients admitted to hospital with AMI (ICD code I21-I22) during the period of 01.01.2004-31.12.2005 and who survived more than 30 days were followed 365 days from the index episode. Data about reimbursed prescriptions of beta-blockers (BBs), angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs) and statins for these patients was obtained from the database of the Estonian Health Insurance Fund. Data were mainly analysed using frequency tables and, where appropriate, the Pearson's χ2 test, the Mann-Whitney U-test and the t-test were used. A logistic regression method was used to investigate the relationship between drug allocation and age and gender. We presented drug utilization data as defined daily dosages (DDD) per life day in four age groups and described proportions of different combinations used in men and women.
Four thousand nine hundred patients were hospitalized due to AMI and 3854 of them (78.7%) were treated by BBs, ACE/ARBs and/or statins. Of the 4025 inpatients who survived more than 30 days, 3799 (94.4%) were treated at least by the one of drug groups studied. Median daily dosages differed significantly between men and women in the age group 60-79 years for BBs and ACE/ARBs, respectively. Various combinations of the drugs studied were not allocated in equal proportions for men and women, although the same combinations were the most frequently used for both genders. The logistic regression analysis adjusted to gender and age revealed that some combinations of drugs were not allocated similarly in different age and gender groups.
Most of the patients were prescribed at least one of commonly recommended drugs. Only 40% of them were treated by combinations of beta-blockers, ACE inhibitors/angiotensin II receptor blockers and statins, which is inconsistent with guideline recommendations in Estonia. Standards of training and quality programs in Estonia should be reviewed and updated aiming to improve an adherence to guidelines of management of acute myocardial infarction in all age and gender groups.
As the first nationwide Korean prospective multicenter data collection registry, the Korea Acute Myocardial Infarction Registry (KAMIR) launched in November 2005. Through a number of innovative approaches, KAMIR suggested new horizons about acute myocardial infarction (AMI) which contains unique features of Asian patients from baseline characteristics to treatment strategy. Obesity paradox was existed in Korean AMI patients, whereas no gender differences among them. KAMIR score suggested new risk stratifying method with increased convenience and an enhanced accuracy for the prediction of adverse outcomes. Standard loading dose of clopidogrel was enough for Asian AMI patients. Triple antiplatelet therapy with aspirin, clopidogrel and cilostazol could improve clinical outcomes than dual antiplatelet therapy with aspirin and clopidogrel. Statin improved clinical outcomes even in AMI patients with very low LDL-C levels. The rate of percutaneous coronary intervention was higher and door-to-balloon time was shorter than the previous reports. Zotarolimus eluting stents as the 2nd generation drug-eluting stent (DES) was not superior to the 1st generation DES, in contrast to the western AMI studies. KAMIR made a cornerstone in the study of Korean AMI and expected to be new standards of care for AMI with the renewal of KAMIR design to overcome its pitfalls.
Acute Myocardial Infarction; ST-Elevation Myocardial Infarction; Non-ST-Elevation Myocardial Infarction
Little is known about the association between financial stress and health care outcomes. Our objective was to examine the association between self-reported financial stress during initial hospitalization and long-term outcomes after acute myocardial infarction (AMI).
Materials and Methods
We used Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER) data, an observational, multicenter US study of AMI patients discharged between January 2003 and June 2004. Primary outcomes were disease-specific and generic health status outcomes at 1 year (symptoms, function, and quality of life (QoL)), assessed by the Seattle Angina Questionnaire [SAQ] and Short Form [SF]-12. Secondary outcomes included 1-year rehospitalization and 4-year mortality. Hierarchical regression models accounted for patient socio-demographic, clinical, and quality of care characteristics, and access and barriers to care.
Among 2344 AMI patients, 1241 (52.9%) reported no financial stress, 735 (31.4%) reported low financial stress, and 368 (15.7%) reported high financial stress. When comparing individuals reporting low financial stress to no financial stress, there were no significant differences in post-AMI outcomes. In contrast, individuals reporting high financial stress were more likely to have worse physical health (SF-12 PCS mean difference −3.24, 95% Confidence Interval [CI]: −4.82, −1.66), mental health (SF-12 MCS mean difference: −2.44, 95% CI: −3.83, −1.05), disease-specific QoL (SAQ QoL mean difference: −6.99, 95% CI: −9.59, −4.40), and be experiencing angina (SAQ Angina Relative Risk = 1.66, 95%CI: 1.19, 2.32) at 1 year post-AMI. While 1-year readmission rates were increased (Hazard Ratio = 1.50; 95%CI: 1.20, 1.86), 4-year mortality was no different.
High financial stress is common and an important risk factor for worse long-term outcomes post-AMI, independent of access and barriers to care.
Although medical comorbidities commonly affect clinical outcomes after acute myocardial infarction (AMI), current performance measures of AMI quality focus exclusively on management of the AMI itself. However, AMI patients frequently present with other comorbidities such as diabetes mellitus (DM) that also warrant assessment and management. To date, the quality of DM evaluation among patients presenting with an AMI has not been described. Between 1/2003-6/2004, the PREMIER-QI registry enrolled 3953 AMI patients at 19 U.S. centers. Frequency of glycosylated hemoglobin (A1C) assessment, either during the hospitalization or documented in the chart from the preceding 3 months, was prospectively evaluated. Among 1168 AMI patients with pre-existing DM, only 47% had recent A1C levels available, with marked variability in A1C assessment between hospitals (range 7%–81%). Among those with available A1C, 39% had good control (A1C <7), 36% suboptimal control (A1C 7–9), and 25% poor control (A1C >9). Patients with suboptimal and poor control were more likely to have their DM treatment intensified than those without A1C assessment (RR 1.38 [CI 1.03–1.85] for A1C 7–9; RR 2.20 [CI 1.68–2.88] for A1C >9). Similarly, patients with DM who had A1C measured were more likely to receive instructions on DM disease management prior to discharge. In conclusion, assessment of chronic glycemic control is highly variable among AMI patients with DM. Since much of this variability occurs at the hospital level, evaluation of DM control could represent an additional quality indicator and an opportunity to advance patient-centered AMI care.
Myocardial infarction; diabetes mellitus; glycosylated hemoglobin
Guidelines recommend long-term use of beta-blockers (BB), statins, and angiotensin-converting-enzyme-inhibitors or angiotensin-receptor-blockers (ACEI/ARB) after myocardial infarction (MI), but data on their use after discharge are scarce. From Austrian sickness funds claims, we identified all acute MI patients who were discharged within 30 days and who survived ≥120 days after MI in 2004. We ascertained outpatient use of ACEI/ARBs, BBs, statins, and aspirin from all filled prescriptions between discharge and 120 days post MI. Comorbidities were ascertained from use of indicator drugs during the preceding year. Multivariate logistic regression was used to evaluate the independent determinants of study drug use. We evaluated 4,105 MI patients, whose mean age was 68.8 (±13.2) years; 59.5% were men. Within 120 days after MI, 67% filled prescriptions for ACE/ARBs, 74% for BBs, and 67% for statin. While 41% received all these classes and 34% two, 25% of patients received only one or none of these drugs. Older age and presence of severe mental illness were associated with lower use of all drug classes. Diabetics had greater ACEI/ARB use. Fewer BBs were used in patients with obstructive lung disease. Statin use was lower in patients using treatment for congestive heart failure (all P < 0.001). We conclude that recommended medications were underused in Austrian MI survivors. Quality indicators should be established and interventions be implemented to ensure maximum secondary prevention after MI.
Myocardial infarction; Statins; Beta-blockers; Angiotensin converting enzyme inhibitors; Angiotensin receptor blockers; Secondary prevention
Metabolic changes and smoking are common among HIV patients and may confer increased cardiovascular risk.
The aim of the study was to determine acute myocardial infarction (AMI) rates and cardiovascular risk factors in HIV compared with non-HIV patients in two tertiary care hospitals.
Design, Setting, and Participants
We conducted a health care system-based cohort study using a large data registry with 3,851 HIV and 1,044,589 non-HIV patients. AMI rates were determined among patients receiving longitudinal care between October 1, 1996, and June 30, 2004.
Main Outcome Measures
The primary outcome was myocardial infarction, identified by International Classification of Diseases coding criteria.
AMI was identified in 189 HIV and 26,142 non-HIV patients. AMI rates per 1000 person-years were increased in HIV vs. non-HIV patients [11.13 (95% confidence interval [CI] 9.58–12.68) vs. 6.98 (95% CI 6.89–7.06)]. The HIV cohort had significantly higher proportions of hypertension (21.2 vs. 15.9%), diabetes (11.5 vs. 6.6%), and dyslipidemia (23.3 vs. 17.6%) than the non-HIV cohort (P < 0.0001 for each comparison). The difference in AMI rates between HIV and non-HIV patients was significant, with a relative risk (RR) of 1.75 (95% CI 1.51–2.02; P < 0.0001), adjusting for age, gender, race, hypertension, diabetes, and dyslipidemia. In gender-stratified models, the unadjusted AMI rates per 1000 person-years were higher for HIV patients among women (12.71 vs. 4.88 for HIV compared with non-HIV women), but not among men (10.48 vs. 11.44 for HIV compared with non-HIV men). The RRs (for HIV vs. non-HIV) were 2.98 (95% CI 2.33–3.75; P < 0.0001) for women and 1.40 (95% CI 1.16–1.67; P = 0.0003) for men, adjusting for age, gender, race, hypertension, diabetes, and dyslipidemia. A limitation of this database is that it contains incomplete data on smoking. Smoking could not be included in the overall regression model, and some of the increased risk may be accounted for by differences in smoking rates.
AMI rates and cardiovascular risk factors were increased in HIV compared with non-HIV patients, particularly among women. Cardiac risk modification strategies are important for the long-term care of HIV patients.
Introduction and objectives:
Several registries of acute myocardial infarction (AMI) have been carried out in Spain, but few remain active. This work analyses the evolution of the characteristics and control of patients with AMI during the first 10 years of the PRIMVAC registry, initiated in 1995.
The demographical and clinical characteristics, therapeutic-diagnostic procedures and pharmacological treatment of patients admitted with AMI between January 1995 and December 2004, were analysed in 17 coronary centres in the Autonomous Community of Valencia (South eastern Spain).
The mean age of the 19,719 patients recruited was of 65. The percentage of women, hypertension, hypercholestrolemia and diabetes increased during registry period. The median time of symptoms onset-hospital arrival was 151 minutes, without a decrease over the time, and the delay of thrombolysis fell from 200 to 154 minutes (p<0.01). Percentage of thrombolytic treatment oscillated between 39% and 48%. The mortality in the coronary units decreased (14.1% vs. 8.9%; p<0.001). The number of coronary angiography and percutaneous revascularisation performed increased up to 61% and 32%, respectively, of patients included. On discharge, the use of beta-blockers (29.3% vs. 66.7%), angiotensin-converting enzyme (ACE) inhibitors (41.7% vs. 57.9%) and statins (29.3% vs. 71%) went up.
Overall mortality in the coronary unit decreased, without any variation in the incidence of serious complications. Time to thrombolysis was reduced over the time, with no significant increment in its use. The performance of coronary angiography and percutaneous revascularisation increased, with a low use of primary angioplasty. The use of beta-blockers, ACE inhibitors and statins increased at discharge.
myocardial infarction; registry; treatment; mortality
The optimal treatment of cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains controversial and continues to be associated with a high mortality rate. The present study evaluated the outcomes of all patients having AMI complicated by CS in a single Canadian province.
All consecutive patients diagnosed with AMI and CS from October 1997 to December 2002 in Nova Scotia were included in the present study. The Improving Cardiac Outcomes in Nova Scotia (ICONS) registry was used as the principal source of data. The outcome of interest was in-hospital mortality.
During the study period, a total of 11,300 patients with AMI were identified, with 707 complicated by CS, for an incidence of AMI+CS of 6.3%. The overall mortality rate for patients with AMI+CS was 60.1%. Multivariate regression analysis identified age older than 65 years (OR 2.0; 95% CI 1.4 to 2.9) and renal insufficiency (OR 2.1; 95% CI 1.4 to 3.2) as independent predictors of mortality, while access to invasive cardiac care (defined as admission or transfer to the only cardiac catheterization-capable centre in Halifax, Nova Scotia) was found to be an independent predictor of survival (OR 0.4; 95% CI 0.3 to 0.5). Access to invasive cardiac care was limited to 414 (59%) patients, 250 (35%) of whom actually underwent cardiac catheterization.
Admissions to a tertiary care centre that can provide invasive care was independently associated with improved survival, and older age and renal insufficiency were associated with death among patients with AMI and CS.
Catheterization; Health outcomes; Myocardial infarction; Shock
Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 US centers between 2003-04, to assess the association of living alone with post-AMI outcomes. Outcome measures included 4-year mortality, 1-year readmission, and 1-year health status, using the Seattle Angina Questionnaire (SAQ) and Short Form-12 physical health component (SF-12 PCS) scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs. 14.5%, P<0.001), but comparable rates of 1-year readmission (41.6% vs. 38.3%, p=0.79). Living alone was associated with lower unadjusted quality of life (mean SAQ −2.40 (95% confidence interval [CI] −4.44, −0.35), p=0.02), but had no impact on SF-12 PCS (−0.45 (95% CI −1.65, 0.76), p=0.47) compared with patients who did not live alone. After multivariable adjustment, patients who lived alone had a comparable risk of mortality (hazard ratio [HR] 1.35, 95% CI: 0.94-1.93) and readmission (HR 0.99, 95% CI: 0.76-1.28) as patients who lived with others. Mean quality of life scores remained lower among patients who lived alone (SAQ −2.91 (95% CI −5.56, −0.26), p=0.03). Living alone may be associated with poorer angina-related quality of life one year post-MI, but is not associated with mortality, readmission, or other health status measures after adjusting for other patient and treatment characteristics.
Living alone; acute myocardial infarction; social support
This study was performed to evaluate the effects of diabetes on short- and mid-term clinical outcomes in patients with acute myocardial infarction (AMI). Between October 2005 and December 2009, a total of 22,347 patients with AMI from a nationwide registry was analyzed. At the time point of the day 30 after AMI onset, landmark analyses were performed for the development of major adverse cardiovascular events (MACEs), including death, re-infarction and revascularization. In this cohort, 6,131 patients (27.4%) had diabetes. Short-term MACEs, which occurred within 30 days of AMI onset, were observed in 1,364 patients (6.1%). Among the 30-day survivors (n = 21,604), mid-term MACEs, which occurred between 31 and 365 days after AMI onset, were observed in 1,181 patients (5.4%). After adjustment for potential confounders, diabetes was an independent predictor of mid-term MACEs (HR, 1.25; 95% CI, 1.08-1.45; P = 0.002), but not of short-term MACEs (HR: 1.16; 95% CI: 0.93-1.44; P = 0.167). Diabetes is a poor prognostic factor for mid-term clinical outcomes but not for short-term outcomes in AMI patients. Careful monitoring and intensive care should be considered in diabetic patients, especially following the acute stage of AMI.
Diabetes Mellitus; Myocardial Infarction; Prognosis
Objective: To describe the clinical features, management, and prognosis of patients presenting with clinical markers of spontaneous reperfusion (SR) during acute myocardial infarction (AMI).
Design: Cohort study.
Setting: National registry of 26 coronary care units.
Patients: 2382 consecutive patients with AMI.
Main outcome measures: Patient characteristics, management, and mortality.
Results: The incidence of SR was 4% of patients (n = 98) compared with thrombolytic treatment (n = 1163, 49%), primary angioplasty (n = 102, 4%), and non-reperfusion (n = 1019, 43%). SR patients were more likely to develop less or no myocardial damage as indicated by a higher percentage of non-Q wave AMI (58% v 32%, 47%, and 44%, respectively, p < 0.0001), aborted AMI (25% v 9%, 8%, and 12%, p < 0.001), and lower peak creatine kinase (503 v 1384, 1519, and 751 IU, p < 0.0001). SR patients, however, were more likely to develop recurrent ischaemic events (35% v 17%, 12%, and 16%, respectively; p < 0.001) and subsequently were more likely to be referred to coronary angiography (67%), angioplasty (41%), or bypass surgery (16%, p < 0.001). Mortality at 30 days (1% v 8%, 7%, and 13%, respectively, p < 0.0001) and one year (6% v 11%, 12%, and 19%, p < 0.0001) was significantly lower for SR patients than for the other subgroups. By multivariate analysis, SR remained a strong determinant of 30 day survival (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.01 to 0.74). At one year, the association between SR and survival decreased (OR 0.49, 95% CI 0.18 to 1.13).
Conclusions: Clinical markers of SR are associated with greater myocardial salvage and favourable prognosis. The vulnerability of SR patients to recurrent ischaemic events suggests that they need close surveillance and may benefit from early intervention.
acute myocardial infarction; angina; reperfusion; thrombolysis
Previous studies in North America have shown ethnic variation in the presentation of acute myocardial infarction (AMI), and sex and racial differences in the management and outcome of AMI. In the present study, our aim was to investigate the risk profile of AMI for patients with minority background compared with indigenous Norwegians, at hospital presentation, and to investigate racial differences in hospital care and outcomes.
Patients and methods
A dual-design study was adopted: a cross-sectional study to examine ethnic differences of risk prevalence at hospital presentation and a cohort study to estimate access to angiography, percutaneous coronary intervention (PCI), and hospital and long-term mortality. From a study population of 3105 patients with AMI presenting at Oslo University Hospital between January 1, 2006 and December 31, 2007, we identified 147 cases of AMI in patients with minority background and selected a random sample of 588 indigenous Norwegians with AMI as controls. Prognostic and explanatory strategies were used in the analysis.
Compared with indigenous Norwegians with AMI, AMI patients with minority background suffered their AMI 10 years younger, were generally male, were twice as likely to be smokers, three times as likely to have type 2 diabetes, had lower high-density lipoprotein levels. This group also had 50% less history of hypertension. In terms of hospital care, AMI patients with minority background had shorter times from onset of symptoms to PCI and the same frequency of access to angiography and acute PCI as indigenous Norwegians when adjusting for the confounding effect of age, sex, and nature of myocardial infarction with or without ST elevation.
At presentation to hospital, patients with minority background had a higher risk profile and a shorter time from onset of symptoms to admission to catheterization laboratory than indigenous Norwegians, but the same access to angiography and acute PCI during hospitalization.
ethnicity; myocardial infarction; presentation; management; outcome
To investigate trends in case‐fatality and prognostic impact from recurrent acute myocardial infarction (re‐AMI) during 1985–2002.
Retrospective cohort study using nationwide administrative data from Denmark.
National registries on hospital admissions and causes of death were linked to identify patients with first AMI, re‐AMI and subsequent prognosis.
Patients ⩾30 years old with a discharge diagnosis of AMI during 1985–2002 were tracked for first hospital admission for re‐AMI 1 year after discharge.
Main outcome measures
166 472 patients were identified with a first AMI; 14 123 developed re‐AMI. One‐year crude case‐fatality from first AMI/re‐AMI was 39% versus 43% in 1985–1989 and 25% versus 29% in 2000–2002, respectively. In 1985–89, 35 795 patients survived to discharge (71%); of these 2.5% experienced reinfarction within 30 days (early reinfarction) and an additional 9.0% reinfarction within days 31–365 (late re‐AMI). Re‐AMI carried a poor prognosis in 1985–1989 compared to no re‐AMI with age‐ and sex‐adjusted relative risk of 1‐year case‐fatality of 7.5 (95% CI: 6.9 to 8.5) from early re‐AMI and 11.7 (95% CI: 11.0 to 12.4) from late re‐AMI. In 2000–2002, 23 552 patients (86%) survived to discharge; 4.4% had early re‐AMI and 6.6% late re‐AMI. Adjusted relative risk of 1‐year case‐fatality had declined to 2.1 (95% CI: 1.9 to 2.5) from early re‐AMI and 5.6 (95% CI: 5.1 to 6.2) from late re‐AMI compared to patients without reinfarction.
Prognosis after AMI has improved substantially during the latest two decades and extends to patients with re‐AMI.
acute myocardial infarction; mortality; prognosis; reinfarction; trends
High quality care for acute myocardial infarction (AMI) improves patient outcomes. Still, AMI patients are treated in hospitals with unequal access to percutaneous coronary intervention. The study compares changes in treatment and 30-day and 3-year mortality of AMI patients hospitalized into tertiary and secondary care hospitals in Estonia in 2001 and 2007.
Final analysis included 423 cases in 2001 (210 from tertiary and 213 from secondary care hospitals) and 687 cases in 2007 (327 from tertiary and 360 from secondary care hospitals). The study sample in 2007 was older and had twice more often diabetes mellitus. The patients in the tertiary care hospitals underwent reperfusion for ST-elevation myocardial infarction, cardiac catheterization and revascularisation up to twice as often in 2007 as in 2001. In the secondary care, patient transfer for further invasive treatment into tertiary care hospitals increased (P < 0.001). Prescription rates of evidence-based medications for in-hospital and for outpatient use were higher in 2007 in both types of hospitals. However, better treatment did not improve significantly the short- and long-term mortality within a hospital type in crude and baseline-adjusted analysis. Still, in 2007 a mortality gap between the two hospital types was observed (P < 0.010).
AMI treatment improved in both types of hospitals, while the improvement was more pronounced in tertiary care. Still, better treatment did not result in a significantly lower mortality. Higher age and cardiovascular risk are posing a challenge for AMI treatment.
Acute myocardial infarction; Treatment; Revascularisation; Mortality
In-hospital mortality measures, which are widely used to assess hospital quality, are not based on a standardized follow-up period and may systematically favor hospitals with shorter lengths of stay (LOS).
To assess the agreement between performance measures of U.S. hospitals using risk-standardized in-hospital and 30-day mortality rates.
U.S. acute care non-federal hospitals with at least 30 admissions for acute myocardial infarction (AMI), heart failure (HF) and pneumonia in 2004–2006.
Medicare fee-for-service patients admitted for AMI, HF, and pneumonia from 2004–2006.
The primary outcomes are in-hospital and 30-day risk-standardized mortality rates.
There were 718,508 AMI admissions to 3,135 hospitals, 1,315,845 HF admissions to 4,209 hospitals, and 1,415,237 pneumonia admissions to 4,498 hospitals. The hospital-level mean patient LOS in days varied across hospitals for each condition, ranging (min-max) for AMI, HF and pneumonia from 2–13, 3–11, and 3–14 days, respectively. The mean risk-standardized mortality rate differences (30-day minus inhospital) were 5.3% (SD=1.3) for AMI, 6.0% (SD=1.3) for HF, and 5.7% (SD=1.4) for pneumonia, with wide distributions across hospitals. Hospital performance classifications differed between in-hospital and 30-day models for 257 hospitals (8.2%) for AMI, 456 (10.8%) for HF, and 662 (14.7%) for pneumonia. Hospital mean LOS was positively correlated with in-hospital RSMR for all three conditions.
Our study uses Medicare claims data for risk adjustment.
In-hospital mortality measures provide a different assessment of hospital performance than 30-day mortality and are biased in favor of hospitals with shorter LOS.
Rates of acute myocardial infarction (AMI) hospitalizations for elderly Medicare patients decreased during the last decade. However, trends in population rates of AMI hospitalizations for all adults by subgroups have not been described. Using data from a large, all-payer administrative database of hospitalizations, we calculated annual AMI hospitalization rates from 2001 to 2007. Trend analysis was performed across age, gender and ethnicity categories using survey regression. The overall rate decreased from 314 to 222 AMI hospitalizations per 100,000 persons from 2001 to 2007, representing a 29.2% decline. Significant declines were observed in the AMI hospitalization rate for each group by age categories (p < 0.001) and by gender (p < 0.001). When stratified by ethnicity and gender, the age-adjusted AMI hospitalization rates in white men and women decreased by 30.8% and 31.4% while black men and women had significantly slower rates of decline of 13.6% and 12.6%, respectively. In conclusion, while the overall rate of AMI hospitalizations decreased over the 2001 to 2007 period, the observed decline was smaller for black patients compared with white patients across all age groups studied.
Acute myocardial infarction; hospitalization; disparities
Adherence to evidence-based medications after myocardial infarction is associated with improved outcomes. However, long-term data on factors affecting medication adherence after myocardial infarction are lacking.
Olmsted County residents hospitalized with myocardial infarction from 1997-2006 were identified. Adherence to HMG-CoA reductase inhibitors (statins), beta blockers, angiotensin-converting enzyme inhibitors (ACE Inhibitors), and angiotensin II receptor blockers (ARB), were examined. Cox proportional hazard regression was used to determine the factors associated with medication adherence over time.
Among 292 persons with incident myocardial infarction (63% men, mean age 65 years), patients were followed for an average of 52±31 months. Adherence to guideline-recommended medications declined over time, with 3-year medication continuation rates of 44%, 48%, and 43% for statins, beta blockers, and ACE Inhibitors/ARB, respectively. Enrollment in a cardiac rehabilitation program was associated with an improved likelihood of continuing medications, with adjusted hazard ratio (95% confidence interval) for discontinuation of statins and beta blockers among cardiac rehabilitation participants of 0.66 (0.45-0.92) and 0.70 (0.49-0.98), respectively. Smoking at the time of myocardial infarction was associated with a decreased likelihood of continuing medications, though results did not reach statistical significance. There were no observed associations between demographic characteristics, clinical characteristics of the myocardial infarction and medication adherence.
After myocardial infarction, a large proportion of patients discontinue use of medications over time. Enrollment in cardiac rehabilitation after myocardial infarction is associated with improved medication adherence.
Myocardial infarction; drugs; adherence; cardiac rehabilitation
Recent studies have suggested that there is a positive impact of patient-centered care (PCC) on both the patient–physician relationship and subsequent patient health-related behaviors. One recent prospective study reported a significant relationship between the degree of PCC experienced by patients during their hospitalization for acute myocardial infarction (AMI) and their postdischarge cardiac symptoms. A limitation of this study, however, was a lack of information regarding the technical quality of the AMI care, which might have explained at least part of the differences in outcomes. The present study was undertaken to test the influence of both PCC and technical care quality on outcomes among AMI patients.
We analyzed data from a national sample of 1,858 veterans hospitalized for an initial AMI in a Department of Veterans Affairs medical center during fiscal years 2003 and 2004 for whom data had been compiled on evidence-based treatment and who had also completed a Picker questionnaire assessing perceptions of PCC. Cox proportional hazards models were used to estimate the relationship between PCC and survival 1-year postdischarge, controlling for technical quality of care, patient clinical condition and history, admission process characteristics, and patient sociodemographic characteristics. We hypothesized that better PCC would be associated with a lower probability of death 1-year postdischarge, even after controlling for patient characteristics and the technical quality of care.
Better PCC was associated with a significantly but modestly lower hazard of death over the 1-year study period (hazard ratio 0.992, 95 percent confidence interval 0.986–0.999).
Providing PCC may result in important clinical benefits, in addition to meeting patient needs and expectations.
Patient assessment; satisfaction; patient outcomes; functional status; ADLs; IADLs; quality of care; patient safety (measurement)
The effects of lifestyle changes and evolving treatment practices on coronary disease incidence rates, demographic and clinical profile, as well as the short-term outcomes of patients hospitalized with acute myocardial infarction (AMI) have not been well characterized. The purpose of this study was to examine multi-decade long trends (1975–2005) in the incidence rates, demographic and clinical characteristics, treatment practices, and hospital outcomes of patients hospitalized with an initial AMI from a population-based perspective.
Methods and Results
Residents of the Worcester (MA) metropolitan area (median age = 37 years; 89% Caucasian) hospitalized with an initial AMI (n=8,898) at all greater Worcester medical centers during 15 annual periods between 1975 and 2005 comprised the sample of interest.
The incidence rates of initial AMI were lower in 2005 (209/100,000 population) than in 1975 (277/100,000), though these trends varied inconsistently over time. Patients hospitalized during the most recent study years were significantly older (mean age = 64 years in 1975; 71 years in 2005), more likely to be women (38% in 1975; 48% in 2005), and have a greater prevalence of comorbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventional procedures over the period under investigation. Hospital survival rates improved significantly over time (81% survived in 1975; 91% survived in 2005) while varying trends were observed in the occurrence of clinically important complications.
The results of this community-wide investigation provide insights into the changing magnitude, characteristics, management practices, and outcomes of patients hospitalized with a first MI.
acute myocardial infarction; community-wide trends; surveillance
After acute myocardial infarction (AMI), treatment with beta-blockers and angiotensin-converting enzyme inhibitors (ACEI) is widely recognized as crucial to reduce risk of a subsequent AMI. However, many patients fail to consistently remain on these treatments over time, and long-term adherence has not been well described.
To examine the duration of treatment with beta-blockers and ACEI within the 24 months after an AMI.
A retrospective, observational study using medical and pharmacy claims from a large health plan operating in the Northeastern United States.
Enrollees with an inpatient claim for AMI who initiated beta-blocker (N = 499) or ACEI (N = 526) therapy.
Time from initiation to discontinuation was measured with pharmacy refill records. Associations between therapy discontinuation and potential predictors were estimated using a Cox proportional hazards model.
ACEI discontinuation rates were high: 7% stopped within 1 month, 22% at 6 months, 32% at 1 year and 50% at 2 years. Overall discontinuation rates for beta-blockers were similar, but predictors of discontinuation differed for the two treatment types. For beta-blockers, the risk of discontinuation was highest among males and those from low-income neighborhoods; patients with comorbid hypertension and peripheral vascular disease were less likely to discontinue therapy. These factors were not associated with ACEI discontinuation.
Many patients initiating evidence-based secondary prevention therapies after an AMI fail to consistently remain on these treatments. Adherence is a priority area for development of better-quality measures and quality-improvement interventions. Barriers to beta-blocker adherence for low-income populations need particular attention.
acute myocardial infarction; adherence; beta-blockers; angiotensin converting enzyme inhibitors (ACEI); secondary prevention
Anemia and diabetes are risk factors for short-term mortality following an acute myocardial infarction(AMI). Anemia is more prevalent in patients with diabetes. We performed a retrospective study to assess the impact of the combination of diabetes and anemia on post-myocardial infarction outcomes.
Data relating to all consecutive patients hospitalized with AMI was obtained from a population-based disease-specific registry. Patients were divided into 4 groups: diabetes and anemia (group A, n = 716), diabetes and no anemia (group B, n = 1894), no diabetes and anemia (group C, n = 869), and no diabetes and no anemia (group D, n = 3987). Mortality at 30 days and 31 days to 36 months were the main outcome measures.
30-day mortality was 32.3% in group A, 16.1% in group B, 21.5% in group C, 6.6% in group D (all p < 0.001). 31-day to 36-month mortality was 47.6% in group A, 20.8% in group B, 34.3% in group C, and 10.4% in group D (all p < 0.001). Diabetes and anemia remained independent risk factors for mortality with odds ratios of 1.61 (1.41–1.85, p < 0.001) and 1.59 (1.38–1.85, p < 0.001) respectively at 36 months. Cardiovascular death from 31-days to 36-months was 43.7% of deaths in group A, 54.1% in group B, 47.0% in group C, 50.8% group D (A vs B, p < 0.05).
Patients with both diabetes and anemia have a significantly higher mortality than those with either diabetes or anemia alone. Cardiovascular death remained the most likely cause of mortality in all groups.
It is not clear whether gender is associated with different hospitalization cost and lengths for acute myocardial infarction (AMI). We identified patients hospitalized for primary diagnosis of AMI with (STEMI) or without (NSTEMI) ST elevation from 1999 to 2008 through a national database containing 1,000,000 subjects. As compared to that in 1999~2000, total (0.35‰ versus 0.06‰, P < 0.001) and male (0.59‰ versus 0.07‰, P < 0.001) STEMI hospitalization percentages were decreased in 2007~2008, but female STEMI hospitalization percentages were not different from 1999 to 2008. However, NSTEMI hospitalization percentages were similar over the 10-year period. The hospitalization age for AMI, STEMI, and NSTEMI was increased over the 10-year period by 14, 9, and 7 years in male, and by 18, 18, and 21 years in female. The female and male hospitalization cost and lengths were similar in the period. As compared to nonmedical center, the hospitalization cost for STEMI in medical center was higher in male patients, but not in female patients, and the hospitalization cost for NSTEMI was higher in both male and female gender. We found significant differences between male and female, medical center and non-medical center, or STEMI and NSTEMI on medical care over the 10-year period.
We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75 years, are also observed in the elderly (i.e. ≥75 years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2 %) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55–64, 65–74, 75–84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75–84 year-olds (OR = 1.26; 95 % CI 1.09–1.47) and ≥85 year-olds (OR = 1.26; 1.00–1.58), and a higher 28-day case-fatality in both 75–84 year-olds (OR = 1.26; 1.06–1.50) and ≥85 year-olds (OR = 1.36; 0.99–1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85 year-olds (OR = 1.20; 0.99–1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75 years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.
Myocardial infarction; Short-term mortality; Socioeconomic status; Income; Elderly
The contemporary magnitude and prognostic implications of complete heart block (CHB) in patients with acute myocardial infarction (AMI) are unknown. As part of a community-based study of patients hospitalized with AMI in the Worcester, Massachusetts, metropolitan area, changes over time in the incidence rates of CHB complicating AMI, and the prognostic impact of CHB on short-term survival, were examined.
The study population consisted of 13,663 residents of the Worcester metropolitan area hospitalized with AMI at all greater Worcester medical centers during 15 annual periods between 1975 and 2005.
The average age of the hospitalized study sample was 69 years and 58% were men. The overall proportion of patients with AMI who developed CHB was 4.1%. The incidence rates of CHB complicating AMI declined appreciably over time, with the greatest decline in these incidence rates occurring during the most recent years under study. In 2005, 2.0% of patients hospitalized with AMI developed CHB compared to 5.1 % in the initial study year of 1975. Patients with AMI who developed CHB had higher in-hospital death rates (43.2%) than did those who did not develop CHB (13.0%) (p<.001). The hospital death rates associated with CHB declined appreciably over time, particularly during the most recent years under study. Several patient characteristics were associated with an increased risk for developing CHB during hospitalization for MI.
Our findings indicate recent encouraging declines in the incidence rates of CHB complicating AMI and improving trends in the hospital prognosis of these patients.