Fa. Mcalister et al., The treatment and prevention of coronary heart disease in Canada: Do olderpatients receive efficacious therapies?, J AM GER SO, 47(7), 1999, pp. 811-818
Citations number
74
Categorie Soggetti
Public Health & Health Care Science","General & Internal Medicine
OBJECTIVES: To review the evidence for clinical efficacy and cost-effective
ness of proven medications in the treatment and prevention of myocardial in
farction (MI) in older patients; to summarize Canadian data on treatment pa
tterns and clinical outcomes for younger and older patients with coronary h
eart disease; to explore the reasons for gaps between best care, based on t
he evidence of efficacy from trials, and usual care, based on the populatio
n effectiveness audits; and to explore potential approaches to closing the
care gaps.
DESIGN: Review of the recent clinical trial literature on the management of
MI, highlighting results in older patients. Review of medication utilizati
on and outcomes data from a series of large, consecutively enrolled patient
cohorts with acute MI (N = 7070) in a variety of cardiac care settings (10
centers in five Canadian provinces, including university-based teaching ho
spitals, community hospitals, cardiologist and family physician out-patient
clinics) from 1987 to 1996.
RESULTS: There is no qualitative interaction of cardiac therapies: thrombol
ytics, beta-blockers, acetylsalicylic acid (ASA), and statins are efficacio
us in all clinically relevant patient subgroups, including older people. Ho
wever, there are consistent gaps between usual care and best care, particul
arly among older patients (in whom there is also a concomitantly higher mor
tality risk). Repeated multivariate analyses confirm older age to be an ind
ependent contributor to increased risk. Use of efficacious medications is,
in contrast, consistently associated with increased survival. Analysis of t
emporal trends suggests beneficial changes in practice patterns and outcome
s are possible to achieve. However, "best care" has not been rapidly or com
pletely achieved. Review of strategies to close these care gaps suggests th
at audit and feedback, critical pathways, and multifactorial interventions
involving patients and other members of the healthcare team as well as phys
icians may be the most efficacious strategies for change.
CONCLUSIONS: Despite equal or enhanced efficacy, there is consistently less
prescription of proven drugs among older cardiac patients. These care patt
erns may contribute to their enhanced risk. The causes underlying these pra
ctice patterns are complex, and their population impact may be undervalued
by clinicians and managers. Improvement of these patterns is difficult, but
ultimately it would be beneficial for this presently disadvantaged, readil
y identified, high risk patient population.