Changes in the management of acute myocardial infarction in Southern Tasmania

Quality of care of patients hospitalized with acute coronary syndromes

BACKGROUND

Measurement and improvement of quality of care is a priority issue in health care. Patients hospitalized with acute coronary syndromes (ACS) constitute a high-risk population whose care, if shown to be suboptimal on the basis of available research evidence, may benefit from quality improvement interventions.

AIM

To evaluate the quality of in-hospital care for patients with ACS, using explicit quality indicators.

METHODS

Retrospective case note review was undertaken of 397 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between 1 October 2000 and 17 April 2001. The main outcome measures were 12 process-of-care quality indicators, calculated as either: (i) the proportion of all patients who received specific interventions or (ii) the proportion of ideal patients who received specific interventions (i.e. patients with clear indications and lacking contraindications).

RESULTS

Quality indicators with values above 80% included: (i) patient selection for thrombolysis (100%) and discharge prescription of beta-blockers (84%), (ii) antiplatelet agents (94%) and (iii) lipid-lowering agents (82%). Indicators with values between 50% and 80% included: (i) timely performance of electrocardiogram (ECG) on admission (61%), (ii) early coronary angiography (75%), (iii) measurement of serum lipids (71%) and (iv) discharge prescription of angiotensin-converting-enzyme (ACE) inhibitors (73%). Indicators with values <50% included: (i) timely administration of thrombolysis (35%), (ii) non-invasive risk assessment (23%) and (ii) formal in-hospital, and post-hospital cardiac rehabilitation (47% and 7%, respectively).

CONCLUSION

There were delays in performing ECG and administering thrombolysis to patients who presented to emergency departments with ACS. Improvement is warranted in use of non-invasive procedures for identifying high-risk patients who may benefit from coronary revascularization as well as use of serum lipid measurements, ACE inhibitors and cardiac rehabilitation.

Lipid-lowering therapy following major cardiac events: progress and deficits

OBJECTIVE

To assess hospital prescribing of lipid-lowering agents in a tertiary hospital, and examine continuation of, or changes to, such therapy in the 6-18 months following discharge.

DESIGN

Retrospective data extraction from the hospital records of patients admitted from October 1998 to April 1999. These patients and their general practitioners were then contacted to obtain information about ongoing management after discharge.

SETTING

Tertiary public hospital and community.

PARTICIPANTS

352 patients admitted to hospital with acute myocardial infarction or unstable angina, and their GPs.

MAIN OUTCOME MEASURES

Percentage of eligible patients discharged on lipid-lowering therapy and percentage of patients continuing or starting such therapy 6-18 months after discharge.

RESULTS

10% of inpatients with acute coronary syndromes did not have lipid-level estimations performed or arranged during admission. Documentation of lipid levels in discharge summaries was poor. Eighteen per cent of patients with a total serum cholesterol level greater than 5.5 mmol/L did not receive a discharge prescription for a cholesterol-lowering agent. Compliance with treatment on follow-up was 88% in the group discharged on treatment. However, at follow-up, 70% of patients discharged without therapy had not been commenced on lipid-lowering treatment by their GPs.

CONCLUSIONS

Prescribing of lipid-lowering therapy for secondary prevention following acute coronary syndromes remains suboptimal. Commencing treatment in hospital is likely to result in continuing therapy in the community. Better communication of lipid-level results, treatment and treatment aims between hospitals and GPs might encourage optimal treatment practices.