Geographic variation in the treatment of acute myocardial infarction - Thecooperative cardiovascular project

Context. Quality indicators for the treatment of acute myocardial infarctio n include pharmacologic therapy, reperfusion, and smoking cessation advice, but these therapies may not be administered to all patients who could bene fit from them. Objective To assess geographic variation in adherence to quality indicators for treatment of acute myocardial infarction, Design Inception cohort using data from the Health Care Financing Administr ation Cooperative Cardiovascular Project. Setting Acute care hospitals in the United States. Patients A total of 186 800 Medicare beneficiaries hospitalized for treatme nt of confirmed acute myocardial infarction from February 1994 through July 1995. Main Outcome Measures Adherence to quality indicators for pharmacologic the rapy, reperfusion, and smoking cessation advice for patients judged to be i deal candidates for these therapies. The mean rates of adherence to these q uality indicators for the entire United States were determined, and the 20t h and 80th percentiles of the age- and sex-adjusted rates for each of 306 h ospital referral regions were contrasted (mean rate [20th-80th percentiles] ), Results Aspirin was used frequently both during hospitalization (86.2% [82. 6% 90.1%]) and at discharge (77.8% [72.5%-83.9%]). Calcium channel blockers were with held from most patients with impaired left Ventricular function (81.9% [73.6%-90.8%]). Lower rates were seen in the use of angiotensin-conv erting enzyme inhibitors at discharge (59.3% [49.2%-69.2%]); reperfusion, u sing thrombolytic therapy or coronary angioplasty. (67.2% [59.8%-75.1%]); p rescription of beta-blockers at discharge (49.5% [35.8%-61.5%]); and for sm oking cessation advice (41.9% [32.8%-51.3%]). Conclusions Substantial geographic Variation exists in the treatment of pat ients with acute myocardial infarction, and these gaps between knowledge an d practice have important consequences. Therapies with proven benefit for A MI are underused despite strong evidence that their use will result in bett er patient outcomes.