title: Elderly patients receive less aggressive medical and invasive management of unstable angina: potential impact of practice guidelines.
abstract: BACKGROUND
  The Agency for Health Care Policy and Research (AHCPR) released a practice guideline on the diagnosis and management of unstable angina in 1994.
  
  
  OBJECTIVE
  To examine practice variation across the age spectrum in the management of patients hospitalized with unstable angina 2 years before release of the AHCPR guideline.
  
  
  METHODS
  Retrospective cohort.
  
  
  METHODS
  Urban academic hospital.
  
  
  METHODS
  All nonreferral patients diagnosed as having unstable angina who were hospitalized directly from the emergency department to the intensive care or telemetry unit between October 1, 1991, and September 30, 1992.
  
  
  METHODS
  Percentage of eligible patients receiving medical treatment concordant with 8 important AHCPR guideline recommendations.
  
  
  RESULTS
  Half of the 280 patients were older than 66 years; women were older than men on average (70 vs 64 years; P<.001). After excluding those with contraindications to therapy, patients in the oldest quartile (age, 75.20-93.37 years) were less likely than younger patients to receive aspirin (P<.009), beta-blockers (P<.04), and referral for cardiac catheterization (P<.001). Overall guideline concordance weighted for the number of eligible patients declined with increasing age (87.4%, 87.4%, 84.0%, and 74.9% for age quartiles 1 to 4, respectively; chi2, P<.001). Increasing age, the presence of congestive heart failure at presentation, a history of congestive heart failure, previous myocardial infarction, increasing comorbidity, and elevated creatinine concentration were associated with care that was less concordant with AHCPR guideline recommendations; only age and congestive heart failure at presentation remained significant in the multivariate analysis (odds ratios, 1.28 per decade [95% confidence interval, 1.02-1.61] and 3.16 [95% confidence interval, 1.57-6.36], respectively).
  
  
  CONCLUSIONS
  Older patients were less likely to receive standard therapies for unstable angina before release of the 1994 AHCPR guideline. Patients presenting with congestive heart failure also received care that was more discordant with guideline recommendations. The AHCPR guideline allows identification of patients who receive nonstandard care and, if applied to those patients with the greatest likelihood to benefit, could lead to improved health care delivery.
authors.affiliation: Cardiac Unit, Massachusetts General Hospital, Harvard Medical School, Boston, USA. rgiugliano@rics.bwh.harvard.edu
authors.forename: R P
authors.initials: RP
authors.lastname: Giugliano
authors.forename: C A
authors.initials: CA
authors.lastname: Camargo
authors.forename: D M
authors.initials: DM
authors.lastname: Lloyd-Jones
authors.forename: J D
authors.initials: JD
authors.lastname: Zagrodsky
authors.forename: J D
authors.initials: JD
authors.lastname: Alexis
authors.forename: K A
authors.initials: KA
authors.lastname: Eagle
authors.forename: V
authors.initials: V
authors.lastname: Fuster
authors.forename: C J
authors.initials: CJ
authors.lastname: O'Donnell
mesh_terms: D000367:Age Factors; D000368:Aged; D000789:Angina, Unstable / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy*; D005260:Female; D006333:Heart Failure / Q000209:etiology; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D012307:Risk Factors; D028761:Withholding Treatment