How many heart attack patients receive effective treatment in the hospital to help prevent another heart attack?

Hospitals provided six recommended services to 54 percent to 89 percent of Medicare beneficiaries hospitalized for a heart attack in 2003. Overall, hospitals provided 82 percent of the recommended care, an increase of 5 percentage points from 2000–2001. The proportion who received a prescription at hospital discharge for a beta-blocker medication (one measure to prevent recurrent heart attacks) ranged from 75 percent to 93 percent among the states in 2003.

Why is this important?

• Coronary heart disease manifests in more than 565,000 first heart attacks and 300,000 recurrent heart attacks each year (Thom et al. 2006).
• More than 220,000 Americans die as a result of heart attacks each year, most of them ages 65 and older. Heart attack victims lose 14 years of life on average. Heart attack is a leading cause of disability in the labor force (Thom et al. 2006).
• Giving heart attack patients proven medications and smoking cessation counseling in the hospital reduces their risk of suffering a recurrent heart attack and of death (Antman et al. 2004). Patients who do not receive a prescription for recommended medications when they are discharged from the hospital are less likely to take them later (Butler et al. 2002; Butler et al. 2004).

Findings

Hospitals missed about one of five opportunities to provide timely and effective care to eligible Medicare heart attack patients in 2003, with modest overall improvement from 2000–2001 (AHRQ 2006).

• Hospitals performed most poorly in providing smoking cessation counseling, which little more than one-half of patients received in 2003. On the other hand, aspirin was prescribed to almost nine of 10 eligible patients at hospital discharge.
• The largest improvements were achieved in indicators with the lowest rates of performance in 2000–2001: prescribing beta blocker medication at hospital discharge and providing counseling for smoking cessation (9 percentage point increase each).
• About one of five Medicare heart attack patients did not receive a beta-blocker at hospital discharge in the bottom quartile of states. In only eight states did more than 90 percent of eligible patients receive a beta-blocker at discharge.
• Angiotensin-converting enzyme (ACE) inhibitors were prescribed to fewer eligible patients in 2003 than in 2000–2001, although this might reflect the substitution of a newer medication called an angiotensin receptor blocker (ARB) for some patients.

Implications

• The quality of heart attack treatment has improved substantially from 1994–1995, when only about half of Medicare heart attack patients received beta blockers and only three-quarters received aspirin (Burwen et al. 2003).
• Further improvement could save many more lives. For example, initiating and continuing beta-blocker treatment among all eligible heart attack survivors annually for 20 years would result in 62,000 fewer heart attacks and 72,000 fewer deaths from heart disease, saving an estimated $18 million in medical costs compared to treatment levels in 2000 (Phillips et al. 2000).

Improvement Ideas and Resources

• The American College of Cardiology's Guidelines Applied in Practice Program has been associated with improved process and outcomes of cardiovascular care (Eagle et al. 2005; Mehta et al. 2002). Key components of the program include guideline-oriented tools (e.g., standard admission orders and discharge forms), local physician and nurse opinion leadership, and performance measurement and feedback.
• A discharge medication program at a multihospital system, Intermountain Healthcare, was associated with higher prescription of cardiovascular drugs and lower 30-day rates of deaths and readmissions (Lappe et al. 2004). Interventions included educating physicians and nurses, printing reminders on discharge forms, following-up with physicians who did not prescribe recommended medications, and tracking performance.
• Some hospitals report that information technology is an important means to facilitate reinforcement of evidence-based guidelines and achieve better performance on these measures (Butler et al. 2006; Crute 2005).

Measure:

The denominator for the six process-of-care measures includes Medicare fee-for-service beneficiaries discharged from the hospital with a primary diagnosis of acute myocardial infarction and without documented contraindication for the specified medication. (The ACE Inhibitor measure is limited to those with left ventricular systolic dysfunction.) The numerator includes the subset of the denominator population who received specified services recommended in evidence-based guidelines issued by the American Heart Association and the American College of Cardiology (Antman et al. 2004). The denominator for the "overall" measure is the total number of opportunities to provide the six recommended services, and the numerator is the subset of those opportunities in which recommended care was provided.

Limitations:

These data are not representative of treatment for all heart attack patients. In particular, the data do not include Medicare Advantage plan members. Rates may understate compliance to the degree that valid contraindications to medications were not documented in medical records; field experience suggests that this occurs infrequently (Jencks et al. 2003).

Source:

The Centers for Medicare and Medicaid Services sponsors the Medicare Quality Improvement Organization Program, which collects hospital medical record data from systematic random samples of hospital discharges of Medicare fee-for-service beneficiaries in each state. Results were reported by the Agency for Healthcare Research and Quality (AHRQ 2006).

References:

* Indicates source of data used in the chart(s).* AHRQ (Agency for Healthcare Research and Quality). 2006. National Healthcare Quality Report, 2005. Rockville, Md.: Agency for Healthcare Research and Quality. Antman, E. M., D. T. Anbe, P. W. Armstrong et al. 2004. ACC/AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 110 (9): e82–292. Burwen, D. R., D. H. Galusha, J. M. Lewis et al. 2003. National and State Trends in Quality of Care for Acute Myocardial Infarction Between 1994–1995 and 1998–1999: The Medicare Health Care Quality Improvement Program. Archives of Internal Medicine 163 (12): 1430–9. Butler, J., P. G. Arbogast, R. BeLue et al. 2002. Outpatient Adherence to Beta-Blocker Therapy After Acute Myocardial Infarction. Journal of the American College of Cardiology 40 (9): 1589–95. Butler, J., P. G. Arbogast, J. Daugherty et al. 2004. Outpatient Utilization of Angiotensin-Converting Enzyme Inhibitors Among Heart Failure Patients After Hospital Discharge. Journal of the American College of Cardiology 43 (11): 2036–43. Butler, J., T. Speroff, P. G. Arbogast et al. 2006. Improved Compliance with Quality Measures at Hospital Discharge with a Computerized Physician Order Entry System. American Heart Journal 151 (3): 643–53. Crute, S. 2005. Case Study: Achieving High-Quality Care at Reid Hospital & Health Care Services. Quality Matters (Dec). New York: The Commonwealth Fund. Eagle, K. A., C. K. Montoye, A. L. Riba et al. 2005. Guideline-Based Standardized Care Is Associated with Substantially Lower Mortality in Medicare Oatients with Acute Myocardial Infarction: The American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan. Journal of the American College of Cardiology 46 (7): 1242–8. Jencks, S. F., E. D. Huff, and T. Cuerdon. 2003. Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001. Journal of the American Medical Association 289 (3): 305–12. Lappe, J. M., J. B. Muhlestein, D. L. Lappe et al. 2004. Improvements in 1-Year Cardiovascular Clinical Outcomes Associated with a Hospital-Based Discharge Medication Program. Annals of Internal Medicine 141 (6): 446–53. Mehta, R. H., C. K. Montoye, M. Gallogly et al. 2002. Improving Quality of Care for Acute Myocardial Infarction: The Guidelines Applied in Practice (GAP) Initiative. Journal of the American Medical Association 287 (10): 1269–76. Phillips, K. A., M. G. Shlipak, P. Coxson et al. 2000. Health and Economic Benefits of Increased Beta-Blocker Use Following Myocardial Infarction. Journal of the American Medical Association 284 (21): 2748–54. Thom, T., N. Haase, W. Rosamond et al. 2006. Heart Disease and Stroke Statistics—2006 Update: A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 113 (6): e85–151.