title: Guideline-discordant care in acute myocardial infarction: predictors and outcomes.
abstract: OBJECTIVE
  To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Two community general hospitals.
  
  
  METHODS
  607 consecutive patients admitted with AMI between July 1997 and December 2000.
  
  
  METHODS
  Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay.
  
  
  RESULTS
  At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% CI, 1.7-3.6), silent infarction (OR, 2.7; 95% CI, 1.6-4.6), anterior infarction (OR, 2.5; 95% CI, 1.7-3.8), a history of heart failure (OR, 6.3; 95% CI, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% CI, 1.5-6.4); and heart rate >/= 100 beats/min (OR, 2.1; 95% CI, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% CI, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% CI, 0.90-7.1).
  
  
  CONCLUSIONS
  Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI. Such care appears to increase the risk of inhospital death.
authors.affiliation: Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD 4102, Australia. ian_scott@health.qld.gov.au
authors.forename: Ian A
authors.initials: IA
authors.lastname: Scott
authors.forename: Catherine M
authors.initials: CM
authors.lastname: Harper
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D017410:Practice Guidelines as Topic; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome