Low utilization and wide interhospital variation in investigation of patients after acute myocardial infarction: inadequate resources or insufficient evidence?
BACKGROUND
Guidelines for the management of patients with acute myocardial infarction are available, but implementation may be difficult when resources are limited.


OBJECTIVE
The aim of this study was to investigate whether resources, manpower or access to specialist facilities affect care following myocardial infarction.


METHODS
A representative sample of 1595 patients in all 19 district general hospitals in Wales was analysed for differences in use of investigations and prescription of secondary prevention and how these factors were related to provision of cardiologists and coronary care beds and distance from specialist cardiac services.


RESULTS
Inpatient investigation rates were low and there were wide interhospital variations for exercise testing [mean 42%; interquartile range (IQR) 27-59%] and echocardiography (mean 46%; IQR 33-66%). In comparison, prescription of secondary prevention was similar to European standards and showed less interhospital variation (beta blockers mean 48%; IQR 44-54%; angiotensin-converting enzyme inhibitors mean 59%; IQR 43-63%). There was little association between investigation or secondary prevention rates and cardiac services, but overall rates and provision were low.


CONCLUSIONS
Delivery of care after acute myocardial infarction for stratifying risk and preventing recurrence was unrelated to relative provision or distance from specialist centres. Low use of investigations and high interhospital variability could imply limited access to resources such as echocardiography. Higher rates of prescription of drugs, with less variation between hospitals, argues against low utilization because of insufficient evidence.
Williams
R Ian
RI
Wales Heart Research Institute, University of Wales College of Medicine, Cardiff CF14 4XN, UK.
Fraser
Alan G
AG
West
Robert R
RR
D005260:Female; D019983:Guideline Adherence; D006295:Health Resources / Q000600:supply & distribution*; D006297:Health Services Accessibility; D006779:Hospitals, Public; D006801:Humans; D008297:Male; D008511:Medicine; D009203:Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards*; D013038:Specialization; D014852:Wales