ELDERLY PATIENTS RECEIVE LESS AGGRESSIVE MEDICAL AND INVASIVE MANAGEMENT OF UNSTABLE ANGINA - POTENTIAL IMPACT OF PRACTICE GUIDELINES

Background: The Agency for Health Care Policy and Research (AHCPR) rel eased a practice guideline on the diagnosis and management of unstable angina in 1994.Objective: To examine practice variation across the ag e spectrum in the management of patients hospitalized with unstable an gina 2 years before release of the AHCPR guideline. Design: Retrospect ive cohort. Setting: Urban academic hospital. Patients: All nonreferra l patients diagnosed as having unstable angina who were hospitalized d irectly from the emergency department to the intensive care or telemet ry unit between October 1, 1991, and September 30, 1992. Measurements: Percentage of eligible patients receiving medical treatment concordan t with 8 important AHCPR guideline recommendations. Results: Half of t he 280 patients were older than 66 years; women were older than men on average (70 vs 64 years; P<.001). After excluding those with contrain dications to therapy, patients in the oldest quartile (age, 75.20-93.3 7 years) were less likely than younger patients to receive aspirin (P< .009), P-blockers (P<.04), and referral for cardiac catheterization (P <.001). Overall guideline concordance weighted for the number of eligi ble patients declined with increasing age (87.4%, 87.4%, 84.0%, and 74 .9% for age quartiles 1 to 4, respectively; chi(2), P<.001). Increasin g age, the presence of congestive heart failure at presentation, a his tory of congestive heart failure, previous myocardial infarction, incr easing comorbidity, and elevated creatinine concentration were associa ted with care that was less concordant with AHCPR guideline recommenda tions; only age and congestive heart failure at presentation remained significant in the multivariate analysis (odds ratios, 1.28 per decade [95% confidence interval, 1.02-1.61] and 3.16 [95% confidence interva l, 1.57-6.36], respectively). Conclusions: Older patients were less li kely to receive standard therapies for unstable angina before release of the 1994 AHCPR guideline. Patients presenting with congestive heart failure also received care that was more discordant with guideline re commendations. The AHCPR guideline allows identification of patients w ho receive nonstandard care and, if applied to those patients with the greatest likelihood to benefit, could lead to improved health care de livery.