Quality of Care for Medicare Patients With Acute Myocardial Infarction

OBJECTIVE: To develop and test indicators of the quality of care for patients with acute myocardial infarction (AMI). DESIGN: Retrospective medical record review. SETTING: All acute care hospitals in Alabama, Connecticut, Iowa, and Wisconsin. PATIENTS: All hospitalizations for Medicare patients discharged with a principal diagnosis of AMI between June 1, 1992, and February 28, 1993, were identified (N = 16,869). MAIN OUTCOME MEASURE: Percentage of patients receiving appropriate interventions as defined by 11 quality-of-care indicators derived from clinical practice guidelines that were modified and updated in consultation with a national group of physicians and other health care professionals. RESULTS: We abstracted data from 16,124 (96%) of the hospitalizations, representing 14,108 primary hospitalizations and 2016 hospitalizations resulting from transfers. Potential exclusions to the use of standard treatments in AMI care were common with 90% and 70% of patients having potential exclusions for thrombolytics and beta-blockers, respectively. In cohorts of "ideal candidates" for specific interventions, 83% received aspirin, 69% received thrombolytics, and 70% received heparin during the initial hospitalization; 77% received aspirin and 45% received beta-blockers at discharge. CONCLUSIONS: These data demonstrate that many Medicare patients may not be ideal candidates for standard AMI therapies, but these treatments are underused, even in the absence of discernible contraindications. Hospitals and physicians who apply these quality indicators to their practices are likely to find opportunities for improvement.