Trends in the quality of care for Medicare beneficiaries admitted to the hospital with unstable angina.
OBJECTIVE
We sought to 1) determine the proportion of appropriate elderly patients admitted to the hospital with unstable angina who are treated with aspirin and heparin; 2) identify patient factors associated with the Agency for Health Care Policy and Research (AHCPR) guideline-based use of aspirin and heparin; and 3) compare practice patterns and patient outcomes before and after publication of the AHCPR guidelines.


BACKGROUND
Improving the care of patients with unstable angina may provide immediate opportunities to mitigate the adverse consequences of unstable angina. However, despite the importance of this diagnosis, there is a paucity of information on the patterns of treatment and outcomes across diverse sites and recent trends in practice that have occurred, especially since the publication of the AHCPR practice guidelines.


METHODS
We performed a retrospective cohort study using data created from medical charts and administrative files. The sample included 300 consecutive patients admitted to one of three Connecticut hospitals in the period 1993 to 1994 and 150 consecutive patients admitted in 1995 with a principal discharge diagnosis of unstable angina or chest pain.


RESULTS
Of the 384 patients > or =65 years old who had no contraindications to aspirin on hospital admission, 276 (72%) received it. Of the 369 patients > or =65 years old who had no contraindications to heparin on admission, 88 (24%) received it. Among the 321 patients > or =65 years old who had no contraindications to aspirin at hospital discharge, 208 (65%) were prescribed it. When 1995 was compared with 1993 to 1994, the use of aspirin (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3 to 4.0) and heparin (OR 2.8, 95% CI 1.6 to 4.9) on hospital admission significantly increased, and the use of aspirin at discharge (OR 1.4, 95% CI 0.8 to 2.4) increased. Concomitantly, there was a significant reduction in 30-day readmission (OR 0.52, 95% CI 0.27 to 0.99).


CONCLUSIONS
Our results indicate an improvement in the care and outcomes of elderly patients with unstable angina, but there remain opportunities for further improvement.
Krumholz
H M
HM
Section of Cardiovascular Medicine, Yale School of Medicine, Yale-New Haven Hospital, CT 06520-8025, USA. harlan.krumholz@Yale.edu
Philbin
D M
DM
Wang
Y
Y
Vaccarino
V
V
Murillo
J E
JE
Therrien
M L
ML
Williams
J
J
Radford
M J
MJ
D000368:Aged; D000369:Aged, 80 and over; D000789:Angina, Unstable / Q000188:drug therapy* / Q000401:mortality; D000925:Anticoagulants / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use*; D003237:Connecticut; D005260:Female; D019983:Guideline Adherence; D006493:Heparin / Q000627:therapeutic use*; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D006278:Medicare / Q000592:standards*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care / Q000639:trends*; D012189:Retrospective Studies; D016019:Survival Analysis; D014481:United States
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D006493:Heparin; D001241:Aspirin