Changes in practice patterns affecting in-hospital and post-discharge survival among ACS patients

Effective universal health coverage and improved 1-year survival after acute myocardial infarction: the Chilean experience

In 2005, Chile implemented a universal system of health guarantees (AUGE) aimed at improving equitable access to quality medical care for priority health conditions, including acute myocardial infarction (MI).

OBJECTIVE

To evaluate 1-year survival in MI patients before and after AUGE.

METHODS

Retrospective cohorts of patients with MI (with and without ST segment elevation) discharged alive from six public hospitals between January 2001-June 2005 (pre-AUGE) and July 2008-March 2009 (post-AUGE). Chilean national mortality and MI Registry (hospital-based) databases were linked using a unique identification number (ICD-10 codes I00-I99 were used to identify cardiovascular deaths). One-year survival was assessed using Weibull multivariate regression.

RESULTS

About 1867 patients were discharged alive pre-AUGE and 534 post-AUGE; 25% were women in both periods. When comparing pre-AUGE and post-AUGE, there was an increase in the use of primary and elective angioplasty (1.7 vs 23.6% and 7.3 vs 20.0%), beta-blockers (62 vs 71%) and statins (40 vs 90%); P  <  0.001 all. One-year survival was 92% pre-AUGE (95% CI: 91-93%) and 96% post-AUGE (95% CI: 94-97%) (HR  =  0.50, 95% CI: 0.31-0.82; P  =  0.003). The post-AUGE improvement persisted after adjusting for variables associated with long-term case-fatality (HR  =  0.44, 95% CI: 0.26-0.75). Percutaneous coronary intervention (HR  =  0.31, 95% CI: 0.09-0.99) and statins use at discharge (HR  =  0.45, 95% CI: 0.31-0.66) had the highest effects associated with lower case-fatality and both treatments increased in the post-AUGE period.

CONCLUSIONS

The implementation of AUGE in Chile appears to have contributed to improved treatment of MI in public hospitals and increased 1-year survival, which is consistent with its aim to improve access to quality medical care and to reduce health inequities.

Posthospital Heart-Healthy Behaviors in Adults With Comorbid Diabetes

The purpose of these secondary analyses was to examine relationships between patient factors and patient-provider decision-making style (PDM) on heart-healthy behavior changes in 142 adults with diabetes after hospitalization for an acute coronary syndrome (ACS). A clinical trial randomized adults to either control or a telephone coaching intervention. Generalized estimating equations were used to analyze the relationship between patient factors and PDM style on longitudinal postdischarge changes in three heart-healthy behaviors, avoiding high fat foods, weight loss, and increased physical activity. Neither PDM style nor telephone coaching intervention affected heart-healthy behaviors in this population. Although adults with diabetes preferred collaborative patient-provider decision-making, present levels of provider engagement were not sufficient to support behavior change. Results suggest the need for sustained and tailored nursing interventions to facilitate heart-healthy behavior changes in adults with diabetes after ACS hospitalization.

Adding intravenous unfractionated heparin to standard enoxaparin causes excessive anticoagulation not detected by activated clotting time: results of the STACK-on to ENOXaparin (STACKENOX) study

BACKGROUND

The STACKENOX study assessed the cumulative anticoagulation effect of administering stack-on intravenous unfractionated heparin (UFH) to subjects already receiving enoxaparin.

METHODS

Seventy-two healthy subjects aged 40 to 60 years received subcutaneous enoxaparin (1 mg/kg every 12 hours) for 2.5 days (steady state) and were randomized to receive a 70 IU/kg intravenous UFH bolus 4, 6, or 10 hours after the final enoxaparin dose. Anticoagulation levels were assessed in subjects receiving enoxaparin alone and after the UFH bolus by monitoring activated clotting time (ACT), anti-Xa and anti-IIa activities, and thrombin generation (endogenous thrombin potential [ETP]).

RESULTS

After the final enoxaparin dose, ETP levels decreased by 40%; anti-Xa and anti-IIa activities increased, as expected; and ACT levels did not indicate any anticoagulation effect. Stack-on UFH at 4, 6, or 10 hours after the last enoxaparin dose significantly increased anti-Xa and anti-IIa activities (P < .0001) to well above accepted therapeutic levels and resulted in total inhibition of thrombin generation for > or =2 hours; ACT levels remained within the range commonly observed in subjects receiving UFH.

CONCLUSIONS

The administration of stack-on UFH to subjects already receiving recommended enoxaparin dosing may result in over-anticoagulation, and should be avoided. Activated clotting time assessment did not detect the over-anticoagulation resulting from co-administration of enoxaparin and UFH.

Appropriate secondary prevention of acute atherothrombotic events and strategies to improve guideline adherence

The use of guideline-recommended secondary prevention measures is essential for reducing the risk of subsequent events and mortality in patients who have survived an acute atherothrombotic event or have peripheral arterial disease. Although initial hospitalization provides an ideal environment to initiate such therapies, implementation of effective longterm prevention strategies is hindered by the absence of a systematic approach. In general, evidence-based clinical practice guidelines recommend antiplatelet therapy as a cornerstone of post-discharge secondary prevention, in addition to preventive measures targeting risk factors such as hypertension, dyslipidemia, cigarette smoking, and physical inactivity. Observational data indicate that, although there has been improvement over time, current utilization of guideline-recommended post-discharge treatment remains suboptimal. Recognizing the importance of a systematic approach to discharge planning, numerous hospital-based initiatives have been established. In conjunction with effective lines of communication between hospital and primary care teams, initiation of the most effective secondary prevention strategy at the time of hospital discharge will help to ensure optimal long-term management of patients after an atherothrombotic event.

"Concordance between comorbidity data from patient self-report interviews and medical record documentation"

Background

Comorbidity is an important adjustment measure in research focusing on outcomes such as health status and mortality. One recurrent methodological issue concerns the concordance of comorbidity data obtained from different reporting sources. The purpose of these prospectively planned analyses was to examine the concordance of comorbidity data obtained from patient self-report survey interviews and hospital medical record documentation.

Methods

Comorbidity data were obtained using survey interviews and medical record entries from 525 hospitalized Acute Coronary Syndrome patients. Frequencies and descriptive statistics of individual and composite comorbidity data from both sources were completed. Individual item agreement was evaluated with simple and weighted kappas, Spearman Rho coefficients for composite scores.

Results

On average, patients reported more comorbidities during their patient survey interviews (mean = 1.78, SD = 1.99) than providers had documented in medical records (mean = 1.27, SD = 1.43). Higher proportions of positive responses were obtained from self-reports compared to medical records for all conditions except congestive heart failure and renal disease. Older age and higher depressive symptom levels were significantly associated with poorer levels of data concordance.

Conclusion

These results demonstrate that survey comorbidity data from ACS patients may not be entirely concordat with medical record documentation. In the absence of a gold standard, it is possible that hospital records did not include all pre-admission comorbidities and these patient survey interview methods may need to be refined. Self-report methods to facilitate some patients' complete recall of comorbid conditions may need to be refined by health services researchers.

Trial Registration

ClinicalTrials.gov NCT00416026.