The Cooperative Cardiovascular Project - CCP

Description:

Quality of care indicators in patients with acute MI.

Hypothesis:

Appropriate treatment may not be dispensed to all Medicare patients with AMI.

Study Design

Study Design:

Patients Screened: Not given
Patients Enrolled: 115,015
Mean Follow Up: Not given
Mean Patient Age: 74.9
Female: 46

Patient Populations:

Pilot: All hospitalizations for Medicare patients discharged with a principal diagnosis of AMI (ICD-9-CM principal diagnosis code of 410) between June 1, 1992 and February 28, 1993 in Alabama, Connecticut, Iowa, and Wisconsin

Main: Eligible patients aged 65 years or older who survived hospitalization with a confirmed AMI in 1994 or 1995 in all acute care nongovernmental hospitals in the United States.

Exclusions:

Fifth digit of the ICD-9-CM code was 2 (indicates hospital admissions that were not related to the acute care of AMI).

Primary Endpoints:

Not given

Secondary Endpoints:

not given

Drug/Procedures Used:

Aspirin; beta-blocker; ACE inhibitor; calcium channel blocker; heparin; thrombolytics; IV nitroglycerin; counseling on smoking cessation

Principal Findings:

Potential exclusions to the use of standard treatments in AMI care were common with 90% and 70% of patients having potential exclusions for thrombolytics and beta-blockers, respectively.

In cohorts of "ideal candidates" for specific interventions, 83% received aspirin, 69% received thrombolytics, and 70% received heparin during the initial hospitalization; 77% received aspirin and 45% received beta-blockers at discharge.

The quality of care for Medicare patients with acute myocardial infarction has improved in the Cooperative Cardiovascular Project pilot states. Performance on the defined quality indicators appeared to be better in the pilot states than in the rest of the nation in 1995 and was associated with reduced mortality.

Among the 45308 patients without contraindications to beta-blockers, 22665 (50.0%) had a beta-blocker as a discharge medication. There was significant variation by state, ranging from 30.3% to 77.1%. Of the 36795 patients who were not receiving beta-blocker therapy on admission, 16006 (43.5%) had therapy initiated on or before discharge.

Interpretation:

These data demonstrate that many Medicare patients may not be ideal candidates for standard AMI therapies, but these treatments are underused, even in the absence of discernible contraindications. Between 1991 and 1995, use of therapies with proven benefit appeared to improve over time.

References:

1. JAMA 1995;273:1509-1514. Pilot study
2. JAMA 1996;275:1322-8. Short-term mortality predictors
3. JAMA 1998;279:1351-7. Final results
4. JAMA 1998;280:623-9. Use of beta-blockade

Clinical Topics: Anticoagulation Management

Keywords: Myocardial Infarction, Connecticut, Wisconsin, Heparin, Patient Discharge, Calcium Channel Blockers, Iowa, Hospitalization, United States, Smoking Cessation, Nitroglycerin


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