Do orders limiting aggressive treatment impact care for acute myocardial infarction?
OBJECTIVE
Little is known about whether advance directives impact inpatient care for a condition with clear treatment guidelines. The goal of this research was to determine the association between limitation of aggressive treatment (LAT) orders and guideline adherence for acute myocardial infarction (AMI).


METHODS
Secondary examination of data from the national Cooperative Cardiovascular Project (CCP) baseline data. We used seemingly unrelated regression to correct for potential selection bias between patients with and without LAT orders and to determine whether such orders predict guideline adherence for several treatments related to acute myocardial infarction.


METHODS
The setting included 4111 short-term non-federal acute care hospitals in the United States.


METHODS
Participants were 147,475 AMI cases with complete data abstracted from inpatient hospital charts, representing most fee-for-service Medicare patients who were hospitalized with AMI between February 1994 and July 1995.


METHODS
Adherence to guidelines for treating acute myocardial infarction, including aspirin, Beta blockers, and reperfusion via thrombolytics or PTCA.


RESULTS
Patients with LAT orders are less likely to receive care in accordance with guidelines when controlling for other factors that may explain a lower likelihood of guideline adherence. After adjustment for selection effects, we found a lower predicted probability that patients received more invasive treatments.


CONCLUSIONS
Patients with LAT orders appear to receive care that is less aggressive and less congruent with acute myocardial infarction care guidelines compared with patients without such orders. Quality improvement measures will need to take this difference into account and ensure that physicians are not penalized for complying with patient care preferences.
Radcliff
Tiffany A
TA
VA Eastern Colorado Healthcare System, HSR and D TREP for Long-term Care Research, Denver, CO 80220, USA. Tiffany.Radcliff@uchsc.edu
Dobalian
Aram
A
Levy
Cari
C
D018806:APACHE; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D024362:Advance Directive Adherence / Q000706:statistics & numerical data; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000627:therapeutic use; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006302:Health Services Research; D006801:Humans; D008297:Male; D008485:Medical Audit; D006278:Medicare / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology / Q000628:therapy*; D015425:Myocardial Reperfusion / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012044:Regression Analysis; D016414:Resuscitation Orders; D012189:Retrospective Studies; D015983:Selection Bias; D014481:United States
D000319:Adrenergic beta-Antagonists; D005343:Fibrinolytic Agents; D001241:Aspirin