Acute Myocardial Infarction in Nursing Home Residents: Adherence to Treatment Guidelines Reduces Mortality, But Why Is Adherence So Low?
Objectives
To investigate the applicability of clinical practice guidelines (CPGs) to the care of nursing home (NH) residents who experience acute myocardial infarction (AMI).
Design
Secondary examination of data from the national Cooperative Cardiovascular Project.
Setting
6684 US hospitals.
Participants
A NH-dwelling (N = 8151) cohort and a community-dwelling cohort (N = 119,012).
Measurements
Adherence to AMI guidelines and associated mortality rates.
Results
Mortality at 30 days and 1 year respectively was 39.5% and 65.4% in the NH cohort versus 17.5% and 31.1% in the community-dwelling cohort (P < .001). Among patients who were ideally eligible to receive aspirin, 58.8% of the NH cohort and 78.9% of the community-dwelling cohort actually received aspirin (P < .001). Among patients who were ideally eligible for beta-blockers, 43.8% of the NH cohort and 61.4% of the community-dwelling cohort received beta-blockers (P < .001). The 30-day mortality for NH patients who were ideally eligible for aspirin but did not receive aspirin was significantly higher compared with NH patients who were ideally eligible but did receive aspirin (49.2% versus 26.0%, P < .001). Similarly, mortality was significantly higher for NH patients who were ideally eligible for beta-blockers but did not receive a beta-blocker (35.3% versus 18.6%, P < .001).
Conclusion
Only half of NH patients who are ideally eligible for aspirin and beta-blockers received these medications, yet mortality was significantly lower in patients who were treated with these medications. These results demonstrate the effect of applying AMI guidelines to NH patients while also raising the question of what factors guided decisions not to provide these medications.
Keywords: Nursing home, clinical practice guidelines, geriatrics, acute myocardial infarction
C.R.L. is funded by a Veterans Affairs Career Development Award. She has no other financial disclosures. T.A.R. receives salary support through the US Department of Veterans Affairs Health Services Research & Development Research Enhancement Award Program (HSRD REA 06–0173) at the Denver VA Medical Center. She has no other financial disclosures. E.T.W. receives salary support through the US Department of Veterans Affairs Health Services Research & Development Research Enhancement Award Program (HSRD REA 06–0173) at the Denver VA Medical Center. She has no other financial disclosures. E.H. receives salary support through the US Department of Veterans Affairs Health Services Research & Development Research Enhancement Award Program (HSRD REA 06–0173) at the Denver VA Medical Center. She has no other financial disclosures.
Data were provided by StratisHealth, the Quality Improvement Organization for Minnesota, the Centers for Medicare and Medicaid Services, and the University of Minnesota, Twin Cities.
The analyses using Cooperative Cardiovascular Project (CCP) baseline data were performed under a Centers for Medicare & Medicaid Services Dissertation Fellowship Grant (No. 30-P-91016/5–01) awarded in 1999, which was extended through a data use agreement until 12/31/2009. 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 patterns of care, and therefore required no special funding on the part of the contractor. Feedback to the authors concerning the issues presented is welcomed.
PII: S1525-8610(08)00275-2
doi:10.1016/j.jamda.2008.08.009
Published by Elsevier Inc.
