title: Geographic variation in the treatment of non-ST-segment myocardial infarction in the English National Health Service: a cohort study.
abstract: To investigate geographic variation in guideline-indicated treatments for non-ST-elevation myocardial infarction (NSTEMI) in the English National Health Service (NHS).
  
  
  
  Cohort study using registry data from the Myocardial Ischaemia National Audit Project.
  
  
  
  All Clinical Commissioning Groups (CCGs) (n=211) in the English NHS.
  
  
  
  357 228 patients with NSTEMI between 1 January 2003 and 30 June 2013.
  
  
  
  Proportion of eligible NSTEMI who received all eligible guideline-indicated treatments (optimal care) according to the date of guideline publication.
  
  
  
  The proportion of NSTEMI who received optimal care was low (48 257/357 228; 13.5%) and varied between CCGs (median 12.8%, IQR 0.7-18.1%). The greatest geographic variation was for aldosterone antagonists (16.7%, 0.0-40.0%) and least for use of an ECG (96.7%, 92.5-98.7%). The highest rates of care were for acute aspirin (median 92.8%, IQR 88.6-97.1%), and aspirin (90.1%, 85.1-93.3%) and statins (86.4%, 82.3-91.2%) at hospital discharge. The lowest rates were for smoking cessation advice (median 11.6%, IQR 8.7-16.6%), dietary advice (32.4%, 23.9-41.7%) and the prescription of P2Y12 inhibitors (39.7%, 32.4-46.9%). After adjustment for case mix, nearly all (99.6%) of the variation was due to between-hospital differences (median 64.7%, IQR 57.4-70.0%; between-hospital variance: 1.92, 95% CI 1.51 to 2.44; interclass correlation 0.996, 95% CI 0.976 to 0.999).
  
  
  
  Across the English NHS, the optimal use of guideline-indicated treatments for NSTEMI was low. Variation in the use of specific treatments for NSTEMI was mostly explained by between-hospital differences in care. Performance-based commissioning may increase the use of NSTEMI treatments and, therefore, reduce premature cardiovascular deaths.
  
  
  
  NCT02436187.
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK.
authors.forename: T B
authors.initials: TB
authors.lastname: Dondo
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK.
authors.forename: M
authors.initials: M
authors.lastname: Hall
authors.affiliation: The National Institute for Health Biomedical Research Unit, Barts Health, London, UK.
authors.forename: A D
authors.initials: AD
authors.lastname: Timmis
authors.affiliation: Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: A T
authors.initials: AT
authors.lastname: Yan
authors.affiliation: Department of Cardiology, The Mid Yorkshire Hospitals NHS Trust, Wakefield, UK.
authors.forename: P D
authors.initials: PD
authors.lastname: Batin
authors.affiliation: National Health Service cardiac service user, West Yorkshire, UK.
authors.forename: G
authors.initials: G
authors.lastname: Oliver
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK.
authors.forename: O A
authors.initials: OA
authors.lastname: Alabas
authors.affiliation: School of Geography, University of Leeds, Leeds, UK.
authors.forename: P
authors.initials: P
authors.lastname: Norman
authors.affiliation: National Institute for Cardiovascular Outcomes Research, University College London, London, UK.
authors.forename: J E
authors.initials: JE
authors.lastname: Deanfield
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: K
authors.initials: K
authors.lastname: Bloor
authors.affiliation: The Farr Institute, University College London, London, UK.
authors.forename: H
authors.initials: H
authors.lastname: Hemingway
authors.affiliation: Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds, UK York Teaching Hospital NHS Foundation Trust, York, UK.
authors.forename: C P
authors.initials: CP
authors.lastname: Gale
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000627:therapeutic use; D015331:Cohort Studies; D004452:Echocardiography; D004739:England; D005260:Female; D019983:Guideline Adherence; D054625:Healthcare Disparities; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D000451:Mineralocorticoid Receptor Antagonists; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy*; D017202:Myocardial Ischemia; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D058921:Purinergic P2Y Receptor Antagonists / Q000627:therapeutic use; D012111:Residence Characteristics; D062206:Spatial Analysis; D013222:State Medicine
chemical_list: D000451:Mineralocorticoid Receptor Antagonists; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D001241:Aspirin
keywords: Clinical Commissioning Groups; Geographic variation; Inequalities; MINAP; NSTEMI; National Health Service