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New perspectives on observed variations in treatment of acute myocardial infarction between different hospitals based on multivariable analyses of a large prospective cohort
Linköping University, Department of Medicine and Care, Cardiology. Linköping University, Faculty of Health Sciences.
Uppsala Clinical Research Center, University Hospital Uppsala, and Statisticon AB, Sweden..
Department of Cardiology, Uppsala Clinical Research Center, University Hospital Uppsala, Sweden.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aim: To investigate the differences in treatment of acute myocardial infarction (AMI) between different hospitals within one country, and the causes of these differences.

Method: The Register of Information and Knowledge about Swedish Heart Intensive care Admissions recorded every CCU admitted patient in 67 hospitals 1999-2000. The use often generally recommended treatments and examinations in patients with AMI were compared between the hospitals after 23 different background characteristics were encountered for by propensity score analyses.

Results: 32954 primary admissions for AMI were included. After adjustment for patient characteristics there were few significant deviations between hospitals in the proportion treated with acute reperlusion, aspirin, beta-blockade or ACE-inhibition at discharge. There were, however, 3 to more than 10 fold differences between hospitals in the proportion of patients treated with intravenous B-blockers, intravenous nitroglycerin, intravenous or subcutaneous anticoagulants, and discharge lipid lowering medication and even larger discrepancies in the use of in echocardiography and coronary angiography. There was a significant (r=0.668;p<0.001) correlation between hospital average rank between the years but no correlation between hospital size and the hospital's average rank for the adjusted use of these treatments (r-0.003 and p=0.98).

Conclusion: After differences between the patients background characteristics and chance findings have been taken into account, most hospitals provide similar regimens concerning treatment modalities where there is strong evidence for efficacy. The remaining large treatment variations mainly concern treatment where the indications and evidence are in development or where uncertainties remain or where there are differences in immediately available treatment facilities. In order to ascertain the quality and equality of treatment in acute myocardial infarction continuous quality control of treatments and outcomes are essential especially in areas with a rapid development of new treatments and in centres with limited resources.

National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-81625OAI: diva2:555245
Available from: 2012-09-19 Created: 2012-09-19 Last updated: 2012-09-19Bibliographically approved
In thesis
1. Improving outcome in acute myocardial infarction
Open this publication in new window or tab >>Improving outcome in acute myocardial infarction
2002 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Despite common guidelines there are vanatlons in the treatment of acute myocardial infarction (AMI) between hospitals in Sweden. Uncertainties remain regarding the efficacy of early statin therapy and early revascularisation in AMI patients. In the elderly patients also the role of fibrinolytic therapy has been questioned.

Methods: We created a national quality assurance register named RIKS-HIA including all patients admitted to participating hospitals' ICCU. The database accumulates information about baseline characteristics, interventions, complications and outcome in consecutive patients. The merging of the database with the Cause of Death Register provides  opportunity to compare the effects of treatments on long-term outcome. Multivariate Cox regression analysis and propensity score was used to evaluate outcome in AMI patients of the studied interventions, and to compare activity level between different hospitals.

Results: After patient characteristics were taken into account there were still significant differences between the hospitals in some treatment modalities that remained over time. There was no correlation between hospital size and activity level. In 19 599 in-hospital survivors after their first registry-recorded AMI at an age below 80 years early statin treatment was associated with a 25 % relative risk reduction of I-year mortality. In 21 912 patients with first registry-recorded AMI younger than 80 years and alive at day 14, early revascularisation was associated with a 50 % relative reduction of I-year mortality. For both therapies the effects were homogeneous among all subgroups based on age, gender, baseline characteristics, previous disease manifestations and medication. Fibrinolytic therapy in ST-segment elevation myocardial infarction patients 75 years of age and older showed a net benefit of 13% in outcome when non-fatal intracranial haemorrhage and I-year survival were analysed.

Conclusion: The results indicates the need of continuous quality assurance, and strategies to reduce the differences in AMI therapy between hospitals. They lend support to early statin and early revascularisation regimens in AMI patients. Fibrinolytic therapy is recommended also in the elderly patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2002. 73 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 740
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-27543 (URN)12202 (Local ID)91-7373-189-7 (ISBN)12202 (Archive number)12202 (OAI)
Public defence
2002-11-07, Elsa Brändströmsalen, Campus US, Linköpings universtiet, Linköping, 13:00 (Swedish)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-19Bibliographically approved

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