May 25, 1998Archives of Internal Medicine128 citations
View Full PaperElderly Patients Receive Less Aggressive Medical and Invasive Management of Unstable Angina
Structured PICO
Does increasing age reduce the likelihood of receiving guideline-concordant care in patients hospitalized with unstable angina?
P
Population
280 nonreferral patients diagnosed with unstable angina hospitalized directly from the emergency department to the intensive care or telemetry unit at an urban academic hospital between October 1, 1991, and September 30, 1992. Half of the patients were older than 66 years.
O
Outcome
Percentage of eligible patients receiving medical treatment concordant with 8 important AHCPR guideline recommendations
Older patients and those presenting with congestive heart failure are significantly less likely to receive guideline-concordant medical and invasive management for unstable angina.
Abstract
BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) released a practice guideline on the diagnosis and management of unstable angina in 1994. OBJECTIVE: To examine practice variation across the age spectrum in the management of patients hospitalized with unstable angina 2 years before release of the AHCPR guideline. DESIGN: Retrospective cohort. SETTING: Urban academic hospital. PATIENTS: All nonreferral patients diagnosed as having unstable angina who were hospitalized directly from the emergency department to the intensive care or telemetry unit between October 1, 1991, and September 30, 1992. MEASUREMENTS: Percentage of eligible patients receiving medical treatment concordant with 8 important AHCPR guideline recommendations. RESULTS: Half of the 280 patients were older than 66 years; women were older than men on average (70 vs 64 years; P<.001). After excluding those with contraindications to therapy, patients in the oldest quartile (age, 75.20-93.37 years) were less likely than younger patients to receive aspirin (P<.009), beta-blockers (P<.04), and referral for cardiac catheterization (P<.001). Overall guideline concordance weighted for the number of eligible patients declined with increasing age (87.4%, 87.4%, 84.0%, and 74.9% for age quartiles 1 to 4, respectively; chi2, P<.001). Increasing age, the presence of congestive heart failure at presentation, a history of congestive heart failure, previous myocardial infarction, increasing comorbidity, and elevated creatinine concentration were associated with care that was less concordant with AHCPR guideline recommendations; only age and congestive heart failure at presentation remained significant in the multivariate analysis (odds ratios, 1.28 per decade 95% confidence interval, 1.02-1.61 and 3.16 95% confidence interval, 1.57-6.36, respectively). CONCLUSIONS: Older patients were less likely to receive standard therapies for unstable angina before release of the 1994 AHCPR guideline. Patients presenting with congestive heart failure also received care that was more discordant with guideline recommendations. The AHCPR guideline allows identification of patients who receive nonstandard care and, if applied to those patients with the greatest likelihood to benefit, could lead to improved health care delivery.