Do Orders Limiting Aggressive Treatment Impact Care for Acute Myocardial Infarction?
Objectives
Little is known about whether advance directives impact inpatient care for a condition with clear treatment guidelines. The goal of this research was to determine the association between limitation of aggressive treatment (LAT) orders and guideline adherence for acute myocardial infarction (AMI).
Design
Secondary examination of data from the national Cooperative Cardiovascular Project (CCP) baseline data. We used seemingly unrelated regression to correct for potential selection bias between patients with and without LAT orders and to determine whether such orders predict guideline adherence for several treatments related to acute myocardial infarction.
Setting
The setting included 4111 short-term non-federal acute care hospitals in the United States.
Participants
Participants were 147,475 AMI cases with complete data abstracted from inpatient hospital charts, representing most fee-for-service Medicare patients who were hospitalized with AMI between February 1994 and July 1995.
Measurements
Adherence to guidelines for treating acute myocardial infarction, including aspirin, Beta blockers, and reperfusion via thrombolytics or PTCA.
Results
Patients with LAT orders are less likely to receive care in accordance with guidelines when controlling for other factors that may explain a lower likelihood of guideline adherence. After adjustment for selection effects, we found a lower predicted probability that patients received more invasive treatments.
Conclusion
Patients with LAT orders appear to receive care that is less aggressive and less congruent with acute myocardial infarction care guidelines compared with patients without such orders. Quality improvement measures will need to take this difference into account and ensure that physicians are not penalized for complying with patient care preferences.
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Data were provided by StratisHealth, the Quality Improvement Organization for Minnesota and the University of Minnesota, Twin Cities.The analyses on which this publication is based were performed under Dissertation Fellowship Grant No. 30-P-91016/5-01, entitled “Assessing the relationship between hospital competition and guideline adherence for acute myocardial infarction,” sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is the direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from the analysis of patterns of care, and therefore required no special funding on the part of this contractor. Feedback to the author concerning the issues presented is welcomed.None of the study’s authors have real or perceived conflicts of interest related to this research.
PII: S1525-8610(06)00336-7
doi:10.1016/j.jamda.2006.06.004
© 2007 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.
