Quality of Inpatient Care Provided for Older Patients with Acute Myocardial Infarction (AMI): Findings from the National Healthcare Quality Report (NHQR)

Introduction: The Agency for Healthcare Research and Quality (AHRQ)'s annual NHQR tracks changes in the quality of health care provided for several key conditions. This abstract describes NHQR data from the Medicare Quality Improvement Organization (QIO) Program on process measures of the quality of inpatient care provided for AMI, along with outcomes measure data from AHRQ's Nationwide Inpatient Sample (NIS).

Methods: Within states and equivalent jurisdictions, the QIO Program annually reviews medical records of stratified random samples of fee-for-service Medicare discharges. Data abstracted include receipt of widely recommended care components not contraindicated in individual patients. For non-transferred AMI patients, such care components include: aspirin administered within 24 hours of hospital arrival and at discharge, beta-blockers administered within 24 hours of arrival and at discharge, angiotensin-II converting enzyme (ACE) inhibitors administered to patients with left ventricular systolic dysfunction (LVSD), and smoking cessation counseling provided to smokers. Composite measures assess the total proportion of times that inpatients receive individual care components for which they are eligible. For AMI patients meeting specific criteria, time intervals from hospital arrival to receipt of fibrinolytic therapy or percutaneous coronary intervention (PCI) are also measured. NIS inpatient mortality data reflect outcomes of AMI discharges (excluding transfers) from stratified samples of non-federal hospitals.

Results: Nationally, the use of aspirin initially and at discharge, beta-blockers initially and at discharge, use of listed ACE inhibitors for LVSD and counseling for smoking cessation all rose, increasing from 85.3%, 87.5%, 76.5%, 81.5%, 66.8% and 49.5% respectively in 2002 to 88.5%, 91.0%, 82.5%, 89.0%, 68.5% and 68.1% in 2004. The composite measure score rose from 80.0% to 85.6%. The listed median time to initiation of fibrinolytic therapy actually rose from 47 minutes in 2002 to 51 minutes in 2004. The listed median time to initiation of PCI also increased, going from 188 minutes in 2002 to 248 minutes in 2004. Individual states varied considerably in the provision of various components of recommended care. For inpatients 65+ years old, nationwide adjusted mortality fell from 110 deaths/1,000 AMI discharges in 2002 to 101/1,000 in 2004.

Conclusions: The quality of AMI care for Medicare beneficiaries improved at a modest pace across most process measures, although the meaning of revascularization times is unclear. Related inpatient mortality continued to decline. The variability of results across states and across measures over time identifies some areas of high-quality performance, as well as areas where further improvement is potentially achievable.