Medication errors in the homes of children with chronic conditions

BACKGROUND

Children with chronic conditions often have complex medication regimens, usually administered at home by their parents.

OBJECTIVE

To describe the types of medication errors in the homes of children with chronic conditions. METHODS Our home visit methods include direct observation of administration, medication review and prescription dose checking. Parents of children with sickle cell disease and seizure disorders taking daily medications were recruited from paediatric subspecialty clinics from November 2007 to April 2009. Potential errors were reviewed by two physicians who made judgments about whether an error had occurred or not, and its severity.

RESULTS

On 52 home visits, the authors reviewed 280 medications and found 61 medication errors (95% CI 46 to 123), including 31 with a potential to injure the child and 9 which did injure the child. Injuries often occurred when parents failed to fill prescriptions or to change doses due to communication problems, leading to further testing or continued pain, inflammation, seizures, vitamin deficiencies or other injuries. Errors not previously reported in the literature included communication failures between two parents at home leading to administration errors and difficulty preparing the medication for administration. 95% of parents not using support tools (eg, alarms, reminders) for medication use at home had an error compared to 44% of those using supports (χ(2)=13.9, p=0.0002).

CONCLUSIONS

Home visits detected previously undescribed types of outpatient errors which were common among children with sickle cell disease and seizure disorders. These should be targeted in future intervention development.

Exclusion of older adults and women from recent trials of acute coronary syndromes

OBJECTIVES

To determine whether the participation of older adults and women in published clinical trials has increased during recent years.

DESIGN

Systematic review to identify clinical trials of acute coronary syndromes (ACSs) published from May 2007 to May 2009. Trials were excluded if they enrolled fewer than 50 participants, were substudies of previously published trials, or initiated treatment more than 3 weeks after the acute cardiac event.

SETTING

A search of MEDLINE and the Cochrane Central Register of Controlled Trials.

PARTICIPANTS

Sixty-eight thousand sixteen participants of 80 trials.

MEASUREMENTS

Information on the age of trial participants, percentage of participants who were female, and whether there were specific exclusions based on age were abstracted from all included trials.

RESULTS

Twenty-three trials (29.7%) had explicit exclusion criteria based on age. Only 13.8% of study participants were aged 75 and older, and 27.7% were women. These percentages are below the representation of all U.S. adults experiencing an ACS in recent years who were aged 75 and older (41.9%) or female (41.5%). The average age of all study participants was 61.6 ± 3.8. There was a significant association between the mean age of a study population and the proportion of women enrolled in the trial.

CONCLUSION

Older adults and women remain underrepresented in recent clinical trials of people hospitalized with an ACS. These exclusions may hinder efforts to inform evidence-based clinical decision-making in these high-risk populations.

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach

BACKGROUND

More than 1.6 million Americans currently reside in nursing homes. As many as 12% of them receive long-term anticoagulant therapy with warfarin. Prior research has demonstrated compelling evidence of safety problems with warfarin therapy in this setting, often associated with suboptimal communication between nursing home staff and prescribing physicians.

METHODS

We conducted a randomized trial of a warfarin management protocol using facilitated telephone communication between nurses and physicians in 26 nursing homes in Connecticut in 2007-2008. Intervention facilities received a warfarin management communication protocol using the approach "Situation, Background, Assessment, and Recommendation" (SBAR). The protocol included an SBAR template to standardize telephone communication about residents on warfarin by requiring information about the situation triggering the call, the background, the nurse's assessment, and recommendations.

RESULTS

There were 435 residents who received warfarin therapy during the study period for 55,167 resident days in the intervention homes and 53,601 in control homes. In intervention homes, residents' international normalized ratio (INR) values were in the therapeutic range a statistically significant 4.50% more time than in control homes (95% confidence interval [CI], 0.31%-8.69%). There was no difference in obtaining a follow-up INR within 3 days after an INR value ≥4.5 (odds ratio 1.02; 95% CI, 0.44-2.4). Rates of preventable adverse warfarin-related events were lower in intervention homes, although this result was not statistically significant: the incident rate ratio for any preventable adverse warfarin-related event was .87 (95% CI, .54-1.4).

CONCLUSION

Facilitated telephone communication between nurses and physicians using the SBAR approach modestly improves the quality of warfarin management for nursing home residents.

Declining length of stay for patients hospitalized with AMI: impact on mortality and readmissions

BACKGROUND

Length of hospital stay after acute myocardial infarction decreased significantly in the 1980s and 1990s. Whether length of stay has continued to decrease during the 2000s, and the impact of decreasing length of stay on rehospitalization and mortality, is unclear. We describe decade-long (1995-2005) trends in length of stay after acute myocardial infarction, and examine whether declining length of stay has impacted early rehospitalization and postdischarge mortality in a population-based sample of hospitalized patients.

METHODS

The study sample consisted of 4184 patients hospitalized with acute myocardial infarction in a central New England metropolitan area during 6 annual periods (1995, 1997, 1999, 2001, 2003, 2005).

RESULTS

The average age of the study sample was 71 years, and 54% were men. The average length of stay decreased by nearly one third over the 10-year study period, from 7.2 days in 1995 to 5.0 days in 2005 (P <.001). Younger patients (<65 years), men, and patients with an uncomplicated hospital stay had significantly shorter lengths of stay than respective comparison groups. Lengths of stay shorter than the median were not associated with significantly higher odds of hospital readmission at 7 or 30 days postdischarge, or with mortality in the year after discharge. In contrast, longer lengths of stay were associated with significantly higher odds of short-term mortality. These findings did not vary by year under study.

CONCLUSIONS

Length of stay in patients hospitalized for acute myocardial infarction decreased significantly between 1995 and 2005. Declining length of stay is not associated with an increased risk for early readmission or all-cause mortality.

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting

OBJECTIVES

To develop guidelines to monitor high-risk medications and to assess the prevalence of laboratory testing for these medications among a multispecialty group practice.

STUDY DESIGN

Safety intervention trial.

METHODS

We developed guidelines for the laboratory monitoring of high-risk medications as part of a patient safety intervention trial. An advisory committee of national experts and local leaders used a 2-round Internet-based Delphi process to select guideline medications based on the importance of monitoring for efficacy, safety, and drug-drug interactions. Test frequency recommendations were developed by academic pharmacists based on a literature review and local interdisciplinary consensus. To estimate the potential effect of the planned intervention, we determined the prevalence of high-risk drug dispensings and laboratory testing for guideline medications between January 1, 2008, and July 31, 2008.

RESULTS

Consensus on medications to include in the guidelines was achieved in 2 rounds. Final guidelines included 35 drugs or drug classes and 61 laboratory tests. The prevalence of monitoring ranged from less than 50.0% to greater than 90.0%, with infrequently prescribed drugs having a lower prevalence of recommended testing (P <.001 for new dispensings and P <.01 for chronic dispensings, nonparametric test for trend). When more than 1 test was recommended for a selected medication, monitoring within a medication sometimes differed by greater than 50.0%.

CONCLUSIONS

Even among drugs for which there is general consensus that laboratory monitoring is important, the prevalence of monitoring is highly variable. Furthermore, infrequently prescribed medications are at higher risk for poor monitoring.

The Cardiovascular Research Network: a new paradigm for cardiovascular quality and outcomes research

BACKGROUND

A clear need exists for a more systematic understanding of the epidemiology, diagnosis, and management of cardiovascular diseases. More robust data are also needed on how well clinical trials are translated into contemporary community practice and the associated resource use, costs, and outcomes.

METHODS AND RESULTS

The National Heart, Lung, and Blood Institute recently established the Cardiovascular Research Network, which represents a new paradigm to evaluate the epidemiology, quality of care, and outcomes of cardiovascular disease and to conduct future clinical trials using a community-based model. The network includes 15 geographically distributed health plans with dedicated research centers, National Heart, Lung, and Blood Institute representatives, and an external collaboration and advisory committee. Cardiovascular research network sites bring complementary content and methodological expertise and a diverse population of approximately 11 million individuals treated through various health care delivery models. Each site's rich electronic databases (eg, sociodemographic characteristics, inpatient and outpatient diagnoses and procedures, pharmacy, laboratory, and cost data) are being mapped to create a standardized virtual data warehouse to facilitate rapid and efficient large-scale research studies. Initial projects focus on (1) hypertension recognition and management, (2) quality and outcomes of warfarin therapy, and (3) use, outcomes, and costs of implantable cardioverter defibrillators.

CONCLUSIONS

The Cardiovascular Research Network represents a new paradigm in the approach to cardiovascular quality of care and outcomes research among community-based populations. Its unique ability to characterize longitudinally large, diverse populations will yield novel insights into contemporary disease and risk factor surveillance, management, outcomes, and costs. The Cardiovascular Research Network aims to become the national research partner of choice for efforts to improve the prevention, diagnosis, treatment, and outcomes of cardiovascular diseases.

Out-of-pocket burden of health care spending and the adequacy of the Medicare Part D low-income subsidy

BACKGROUND

Evaluating the adequacy of Medicare prescription drug program (Part D) and its low-income subsidy (LIS) requires a comprehensive understanding of drug spending in relation to household resources.

OBJECTIVE

: To estimate out-of-pocket health care costs in the year before Part D, in context of total household spending, health status, and LIS eligibility.

RESEARCH DESIGN

Nationally representative cross-sectional study.

SUBJECTS

Two thousand two hundred thirty-one Medicare families in the 2005/2006 Health and Retirement Study.

METHODS

We assessed health care costs as a share of household resources remaining after spending on essential housing, food, personal care, and transportation. Burdensome health care costs were defined as exceeding 40% of nonessential resources. We used logistic regressions to assess the probability of incurring burdensome health expenditures, controlling for LIS eligibility.

RESULTS

In the year before Part D, more than half of Medicare families [56.0%; 95% confidence interval (CI): 55.3-59.9] experienced burdensome health care costs. Families in poor health allocated a median of 68.1% [interquartile range (IQR): 35.1-82.9] of nonessential resources to health care (compared with 34.0% median; IQR 11.9-52.2 among families in excellent health, P < 0.011). Most (64%) out-of-pocket health care spending was allocated to health insurance premiums and medications. As many as 26% of Medicare families had burdensome health care costs but were not eligible for LIS assistance.

CONCLUSIONS

Before Part D, burdensome health care expenditures were common in Medicare families. Our estimates of Part D and LIS benefits indicate a limited scope of relief.

Medicare part D's exclusion of benzodiazepines and fracture risk in nursing homes

BACKGROUND

Medicare Part D excludes benzodiazepine medications from coverage, and some state Medicaid programs also limit coverage. We assessed whether such policies decrease the risk of fractures in elderly individuals living in nursing homes.

METHODS

This is a quasi-experimental study with interrupted time-series estimation and extended Cox proportional hazards models comparing changes in outcomes before and after implementation of Medicare Part D in a nationwide sample of nursing home residents in 48 states. The study included 1 068 104 residents and a subsample of 50 874 residents with fracture data from 1 pharmacy. We assessed monthly prescribing rates of benzodiazepines and potential substitutes from January 1, 2005, through June 30, 2007, and hazard ratios for incident hip fracture and falls, adjusted for age, sex, and race/ethnicity. Estimates were stratified by concurrent Medicaid limits on benzodiazepines: no supplemental coverage (1 state), partial supplemental coverage (6 states), or complete supplemental coverage (41 states).

RESULTS

The no-supplemental-coverage policy resulted in an immediate and significant reduction of 10 absolute points in benzodiazepine use (27.0% to 17.0%) after Medicare Part D was implemented (95% confidence interval, -0.11 to -0.09; P < .001). Benzodiazepine use remained stable in the partial-supplemental- and complete-supplemental-coverage states. Hazard ratios for incident hip fracture were 1.60 (95% confidence interval, 1.05 to 2.45; P = .03) in the no-supplemental-coverage state after Medicare Part D implementation and 1.17 (95% confidence interval, 0.93 to 1.46; P = .18) in the partial-supplemental-coverage states, relative to complete-supplemental-coverage states.

CONCLUSION

Supplemental drug coverage exclusion policies affect the medication use of nursing home residents and may not decrease their fracture risk.

Unexplained variation across US nursing homes in antipsychotic prescribing rates

BACKGROUND

Serious safety concerns related to the use of antipsychotics have not decreased the prescribing of these agents to nursing home (NH) residents. We assessed the extent to which resident clinical characteristics and institutional prescribing practice were associated with antipsychotic prescribing.

METHODS

Antipsychotic prescribing was assessed for a nationwide, cross-sectional population of 16 586 newly admitted NH residents in 2006. We computed facility-level antipsychotic rates based on the previous year's (2005) prescribing patterns. Poisson regressions with generalized estimating equations were used to identify the likelihood of resident-level antipsychotic medication use in 2006, given 2005 facility-level prescribing pattern and NH resident indication for antipsychotic therapy (psychosis, dementia, and behavioral disturbance).

RESULTS

More than 29% (n = 4818) of study residents received at least 1 antipsychotic medication in 2006. Of the antipsychotic medication users, 32% (n = 1545) had no identified clinical indication for this therapy. Residents entering NHs with the highest facility-level antipsychotic rates were 1.37 times more likely to receive antipsychotics relative to those entering the lowest prescribing rate NHs, after adjusting for potential clinical indications (risk ratio [RR], 1.37; 95% confidence interval [CI], 1.24-1.51). The elevated risk associated with facility-level prescribing rates was apparent for only NH residents with dementia but no psychosis (RR, 1.40; 95% CI, 1.23-1.59) and residents without dementia or psychosis (RR, 1.54; 95% CI, 1.24-1.91).

CONCLUSIONS

The NH antipsychotic prescribing rate was independently associated with the use of antipsychotics in NH residents. Future research is needed to determine why such a prescribing culture exists and whether it could result in adverse health consequences.

Nurse-physician communication in the long-term care setting: perceived barriers and impact on patient safety

PURPOSE

Clear and complete communication between health care providers is a prerequisite for safe patient management and is a major priority of the Joint Commission's 2008 National Patient Safety Goals. The goal of this study was to describe nurses' perceptions of nurse-physician communication in the long-term care (LTC) setting.

METHODS

Mixed-method study including a self-administered questionnaire and qualitative semistructured telephone interviews of licensed nurses from 26 LTC facilities in Connecticut. The questionnaire measured perceived openness to communication, mutual understanding, language comprehension, frustration, professional respect, nurse preparedness, time burden, and logistical barriers. Qualitative interviews focused on identifying barriers to effective nurse-physician communication that may not have previously been considered and eliciting nurses' recommendations for overcoming those barriers.

RESULTS

Three hundred seventy-five nurses completed the questionnaire, and 21 nurses completed qualitative interviews. Nurses identified several barriers to effective nurse-physician communication: lack of physician openness to communication, logistic challenges, lack of professionalism, and language barriers. Feeling hurried by the physician was the most frequent barrier (28%), followed by finding a quiet place to call (25%), and difficulty reaching the physician (21%). In qualitative interviews, there was consensus that nurses needed to be brief and prepared with relevant clinical information when communicating with physicians and that physicians needed to be more open to listening.

CONCLUSIONS

A combination of nurse and physician behaviors contributes to ineffective communication in the LTC setting. These findings have important implications for patient safety and support the development of structured communication interventions to improve quality of nurse-physician communication.

Nursing home residents and enrollment in Medicare Part D

OBJECTIVES

To assess the impact of Medicare Part D in the nursing home (NH) setting.

DESIGN

A population-based study using 2005/06 prescription dispensing records, Poisson regressions with generalized estimating equations, and interrupted times series estimation with segmented regression methods.

SETTING

Nursing Homes.

PARTICIPANTS

A nationwide sample of long-stay Medicare enrollees in NHs (N=861,082).

MEASUREMENTS

Probability of Part D enrollment, changes in source of drug payments, changes in average number of monthly prescriptions dispensed per resident.

RESULTS

In 2006, 81.0% of NH residents were enrolled in Part D, 16.1% had other drug coverage, and 3.0% (n=11,000) remained without drug coverage, which was the same rate of no drug coverage as in 2005. NH residents who did not enroll in Part D were the oldest (relative risk (RR)=0.82, P<.001), had no drug coverage in 2005 (RR=0.84, P<.001), and had high comorbidity burden (RR=0.94, P<.001). The proportion of prescription drugs paid out of pocket decreased from 11.0% in 2005 to 8.1% in 2006 (P<.001). Average monthly prescription use per resident in 2006 decreased by half a prescription from 2005 levels (9.6 vs 10.1, P=.003).

CONCLUSION

Part D decreased some out-of-pocket drug costs but did not expand drug coverage in the NH population or reach some vulnerable segments. Part D was also associated with some disruption in NH drug use, especially right after implementation.

Computerized clinical decision support during medication ordering for long-term care residents with renal insufficiency

OBJECTIVE To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency. DESIGN Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. Measurement The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information. RESULTS The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units-relative risk 1.2 (1.0, 1.4). CONCLUSIONS Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions.

TRIAL REGISTRATION

http://clinicaltrials.gov Identifier: NCT00599209.

Changing trends (1986-2003) in the use of lipid lowering medication in patients hospitalized with acute myocardial infarction: a community-based perspective

OBJECTIVES

The objectives of this community-wide observational study were to describe nearly two decade long (1986-2003) trends in the use of lipid lowering therapy in patients hospitalized with acute myocardial infarction (AMI) and clinical and demographic factors associated with underutilization of this treatment regimen.

METHODS

A total of 9429 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003 comprised the study population. Hospital medical records were reviewed to ascertain the prescribing of lipid lowering agents during hospitalization for AMI.

RESULTS

The mean age of the study sample was 70 years, 58% were men, and the average total and LDL serum cholesterol levels were 203 and 114 mg/dL, respectively. There was a marked increase in the use of lipid lowering therapy in greater Worcester residents hospitalized with AMI between 1986 (<1%) and 2003 (76%). Increasing use of lipid lowering medication was observed both with regards to the maintenance of this therapy in patients who were already on this treatment regimen and in the new initiation of lipid lowering medication in patients who had not been previously treated with this therapy. Several patient demographic and clinical factors, including advanced age and an initial AMI, were associated with the failure to be prescribed lipid lowering therapy during hospitalization for AMI.

CONCLUSIONS

The results of this study suggest encouraging increases over time in the use of lipid lowering therapy in patients hospitalized with AMI. Despite these encouraging trends, several high-risk patient groups remain suboptimally treated.

Comparative effectiveness of different beta-adrenergic antagonists on mortality among adults with heart failure in clinical practice

BACKGROUND

Randomized trials have demonstrated the efficacy of selected beta-blockers in systolic heart failure, but the comparative effectiveness of different beta-blockers in practice is poorly understood.

METHODS

We compared mortality associated with different beta-blockers following hospitalization for heart failure between 2001 and 2003. Longitudinal exposure to beta-blockers was ascertained from pharmacy databases. Patient characteristics and other medication use were identified from administrative, hospitalization, outpatient, and pharmacy databases. Death was identified from administrative, state mortality, and Social Security Administration databases. Multivariate Cox regression was used to examine the association between different beta-blockers and death.

RESULTS

Among 11 326 adults surviving a hospitalization for heart failure, 7976 received beta-blockers (atenolol, 38.5%; metoprolol tartrate, 43.2%; carvedilol, 11.6%; and other, 6.7%) during follow-up. The rate (per 100 person-years) of death during the 12 months after discharge varied by exposure and type of beta-blocker (atenolol, 20.1; metoprolol tartrate, 22.8; carvedilol, 17.7; and no beta-blockers, 37.0). After adjustment for confounders and the propensity to receive carvedilol, the risk of death compared with atenolol was higher for metoprolol tartrate (adjusted hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.01-1.34) and no beta-blockers (HR, 1.63; 95% CI, 1.44-1.84) but was not significantly different for carvedilol (HR, 1.16; 95% CI, 0.92-1.44).

CONCLUSIONS

Compared with atenolol, the adjusted risks of death were slightly higher with shorter-acting metoprolol tartrate but did not significantly differ for carvedilol in adults with heart failure. Our results should be interpreted cautiously and they suggest the need for randomized trials within real-world settings comparing a broader spectrum of beta-blockers for heart failure.

Pay-for-performance in nursing homes

Information on the impact of pay-for-performance programs is lacking in the nursing home setting. This literature review (1980-2007) identified 13 prior examples of pay-for-performance programs in the nursing home setting: 7 programs were active as of 2007, while 6 had been terminated. The programs were mostly short-lived, varied considerably in the choice of performance measures and pay incentives, and evaluations of the impact were rare.

Medication errors among adults and children with cancer in the outpatient setting

PURPOSE

Outpatients with cancer receive complicated medication regimens in the clinic and home. Medication errors in this setting are not well described. We aimed to determine rates and types of medication errors and systems factors associated with error in outpatients with cancer.

METHODS

We retrospectively reviewed records from visits to three adult and one pediatric oncology clinic in the Southeast, Southwest, Northeast, and Northwest for medication errors using established methods. Two physicians independently judged whether an error occurred (kappa = 0.65), identified its severity (kappa = 0.76), and listed possible interventions.

RESULTS

Of 1,262 adult patient visits involving 10,995 medications, 7.1% (n = 90; 95% CI, 5.7% to 8.6%) were associated with a medication error. Of 117 pediatric visits involving 913 medications, 18.8% (n = 22; 95% CI, 12.5% to 26.9%) were associated with a medication error. Among all visits, 64 of the 112 errors had the potential to cause harm, and 15 errors resulted in injury. There was a range in the rates of chemotherapy errors (0.3 to 5.8 per 100 visits) and home medication errors (0 to 14.5 per 100 visits in children) at different sites. Errors most commonly occurred in administration (56%). Administration errors were often due to confusion over two sets of orders, one written at diagnosis and another adjusted dose on the day of administration. Physician reviewers selected improved communication most often to prevent error.

CONCLUSION

Medication error rates are high among adult and pediatric outpatients with cancer. Our findings suggest some practical targets for intervention, including improved communication about medication administration in the clinic and home.

Trends in prehospital delay in patients with acute myocardial infarction (from the Worcester Heart Attack Study)

Delay in seeking medical care after symptom onset in patients with an acute myocardial infarction (AMI) is related to increased morbidity and mortality. Duration of prehospital delay in patients hospitalized with AMI has not been well characterized over time, and potentially changing patient characteristics associated with prolonged delay are not well understood. The study sample consisted of 5,967 residents (mean age 76 years; 39% women) of the Worcester, Massachusetts, metropolitan area hospitalized with AMI in 11 annual periods from 1986 to 2005. Mean and median delay times have remained essentially unchanged during the past 2 decades. Mean and median prehospital delay times were 4.1 and 2.0 hours in 1986, 4.7 and 2.2 hours in 1995, and 4.6 and 2.0 hours in 2005, respectively. Approximately 45% of patients with AMI presented within 2 hours of acute symptom onset, whereas an additional one third presented from 2 to 6 hours after the onset of acute coronary symptoms. Advancing age and history of either diabetes or MI were associated with prolonged delay. Compared with patients arriving within 2 hours of symptom onset, those with prolonged prehospital delay were less likely to receive thrombolytic therapy and percutaneous coronary intervention within 90 minutes of hospital arrival. In conclusion, results of this population-based study suggest that a large proportion of patients with AMI continue to show prolonged prehospital delay.

Twenty-year trends in the incidence of stroke complicating acute myocardial infarction: Worcester Heart Attack Study

BACKGROUND

Given the improved survival of patients after acute myocardial infarction (AMI), more patients are at risk for cerebrovascular complications of AMI. Trends in the magnitude of stroke in the setting of AMI are not well characterized, however, and neither have contemporary trends in the hospital death rates of patients developing acute stroke been examined.

RESULTS

Of 9220 patients without a history of stroke hospitalized with confirmed AMI between 1986 and 2005 in all greater Worcester medical centers, 132 (1.4%) experienced an acute stroke during hospitalization. The proportion of patients with AMI who developed a stroke increased through the 1980s and 1990s but declined slightly thereafter. Advanced age, female sex, a previous myocardial infarction (MI), and the occurrence of atrial fibrillation during hospitalization were associated with a greater risk of stroke. Receipt of a percutaneous coronary intervention during hospitalization was associated with a lower risk of stroke. Compared with patients who did not experience a stroke, patients developing a stroke in the 1990s were approximately 3 times more likely to die during hospitalization (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.72-5.19), whereas those experiencing a stroke in the 2000s were 5 times more likely to die (OR, 5.36; 95% CI, 2.71-10.64).

CONCLUSIONS

Although the incidence rates of stroke complicating AMI have declined somewhat since 1999, there is not a corresponding decline in the odds of dying during hospitalization in those developing a stroke. Although contemporary therapies may be reducing the risk of stroke in patients with AMI, more attention should be directed to improving the short-term prognosis of these high-risk patients.