title: Mortality and missed opportunities along the pathway of care for ST-elevation myocardial infarction: a national cohort study.
abstract: OBJECTIVE
  To examine the association between cumulative missed opportunities for care (CMOC) and mortality in patients with ST-elevation myocardial infarction (STEMI).
  
  
  METHODS
  A cohort study of 112,286 STEMI patients discharged from hospital alive between January 2007 and December 2010, using data from the Myocardial Ischaemia National Audit Project (MINAP). A CMOC score was calculated for each patient and included: pre-hospital ECG, acute use of aspirin, timely reperfusion, prescription at hospital discharge of aspirin, thienopyridine inhibitor, ACE-inhibitor (or equivalent), HMG-CoA reductase inhibitor and β-blocker, and referral for cardiac rehabilitation. Mixed-effects logistic regression models evaluated the effect of CMOC on risk-adjusted 30-day and 1-year mortality (RAMR).
  
  
  RESULTS
  44.5% of patients were ineligible for ≥1 care component. Of patients eligible for all nine components, 50.6% missed ≥1 opportunity. Pre-hospital ECG and timely reperfusion were most frequently missed, predicting further missed care at discharge (pre-hospital ECG incident rate ratio [95% CI]: 1.64 [1.58-1.70]; timely reperfusion 9.94 [9.51-10.40]). Patients ineligible for care had higher RAMR than those eligible for care (30-days: 1.7% vs. 1.1%; 1-year: 8.6% vs. 5.2%), whilst those with no missed care had lower mortality than patients with ≥4 CMOC (30-days: 0.5% vs. 5.4%, adjusted OR (aOR) per CMOC group 1.22, 95% CI: 1.05-1.42; 1-year: 3.2% vs. 22.8%, aOR 1.23, 1.13-1.34).
  
  
  CONCLUSIONS
  Opportunities for care in STEMI are commonly missed and significantly associated with early and later mortality. Thus, outcomes after STEMI may be improved by greater attention to missed opportunities to eligible care.
authors.affiliation: Centre for Epidemiology and Biostatistics, University of Leeds, UK Hull and York Medical School, University of York, UK.
authors.forename: A D
authors.initials: AD
authors.lastname: Simms
authors.affiliation: College of Medicine, Swansea University, UK.
authors.forename: C F
authors.initials: CF
authors.lastname: Weston
authors.affiliation: Leeds Institute for Health Sciences, University of Leeds, UK.
authors.forename: R M
authors.initials: RM
authors.lastname: West
authors.affiliation: Centre for Epidemiology and Biostatistics, University of Leeds, UK Department of Cardiology, Leeds General Infirmary, UK.
authors.forename: A S
authors.initials: AS
authors.lastname: Hall
authors.affiliation: Department of Cardiology, Pinderfields General Hospital, Wakefield, UK.
authors.forename: P D
authors.initials: PD
authors.lastname: Batin
authors.affiliation: The National Institute for Health Biomedical Research Unit, Barts Health, London, UK.
authors.forename: A
authors.initials: A
authors.lastname: Timmis
authors.affiliation: Research Department of Epidemiology and Public Health, University College London, UK.
authors.forename: H
authors.initials: H
authors.lastname: Hemingway
authors.affiliation: Centre for Cardiovascular Science, University of Edinburgh, UK.
authors.forename: Kaa
authors.initials: K
authors.lastname: Fox
authors.affiliation: Centre for Epidemiology and Biostatistics, University of Leeds, UK Department of Cardiology, York Teaching Hospital, UK c.p.gale@leeds.ac.uk.
authors.forename: C P
authors.initials: CP
authors.lastname: Gale
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy; D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage; D001241:Aspirin / Q000008:administration & dosage; D015331:Cohort Studies; D004739:England / Q000453:epidemiology; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality*; D017202:Myocardial Ischemia / Q000453:epidemiology* / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D012042:Registries; D016896:Treatment Outcome; D014852:Wales / Q000453:epidemiology
chemical_list: D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D001241:Aspirin
keywords: Missed opportunities for care; STEMI; mortality