The American Journal of Medicine
Volume 120, Issue 1 , Pages 40-46, January 2007

A Comparison of Acute Coronary Syndrome Care at Academic and Nonacademic Hospitals

  • Manesh R. Patel, MD

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Anita Y. Chen, MS

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Matthew T. Roe, MD, MHS

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • E. Magnus Ohman, MD

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • L. Kristin Newby, MD, MHS

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Robert A. Harrington, MD

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • ,
  • Sydney C. Smith Jr, MD

      Affiliations

    • University of North Carolina at Chapel Hill, Chapel Hill
    • ,
  • W. Brian Gibler, MD

      Affiliations

    • University of Cincinnati School of Medicine, Cincinnati, Ohio
    • ,
  • James E. Calvin, MD

      Affiliations

    • Rush University Medical Center, Chicago, Ill.
    • ,
  • Eric D. Peterson, MD, MPH

      Affiliations

    • Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
    • Corresponding Author InformationRequests for reprints should be addressed to Eric D. Peterson, MD, MPH, P.O. Box 17969, Duke Clinical Research Institute, Durham, NC 27705.

Abstract 

Purpose

Although adherence to guidelines recommendations is assumed to be more difficult for nonacademic community hospitals, patterns of adherence have not been evaluated by hospital type. We sought to identify hospital characteristics associated with high levels of adherence in order to gain insight into successful processes of care.

Methods

From January 2001 through March 2004, we analyzed data from 86,042 patients in the CRUSADE Initiative with high-risk non–ST-segment elevation acute coronary syndromes (NSTE ACS) defined by positive cardiac markers or ischemic ST-segment changes. Academic sites were defined by Council of Teaching Hospital affiliation in the American Hospital Association database. Adherence was determined for each hospital based on guidelines recommendations for the use of 4 acute (<24 hrs) and 5 discharge therapies in patients without contraindications. Multivariable modeling was used to standardize hospital estimates for patient characteristics and control for clustering within centers.

Results

A total of 60,285 patients were admitted to nonacademic hospitals (n=355), and 25,757 were admitted to academic hospitals (n=125). Academic hospitals were larger (median 500 vs 268 beds, P <.001) and more often had bypass services (88% vs 60%, P <.001). Composite adherence to recommended therapies was slightly higher at academic vs. nonacademic hospitals (median 77.8% vs 73.7%, P <0.01), and variance in individual hospital performance was greater among nonacademic sites. Nonacademic hospitals accounted for 15 of the 20 highest performing sites and 19 of the 20 lowest performing sites. In-hospital clinical outcomes, including cardiogenic shock, stroke, and death were similar for patients admitted to both types of hospital.

Conclusion

Adherence to American College of Cardiology and American Heart Association (ACC/AHA) guidelines for NSTE ACS care at academic hospitals is slightly higher than at nonacademic hospitals; however there is significant room for improvement within both systems. The larger performance variation in care among nonacademic hospitals highlights the need for continued emphasis on consistent care processes.

Keywords: Acute coronary syndromes, Patient care, Quality improvement

 

 CRUSADE is a National Quality Improvement Initiative of the Duke Clinical Research Institute. CRUSADE is funded by the Schering-Plough Corporation. The Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc. also funded this research.

PII: S0002-9343(06)01254-X

doi:10.1016/j.amjmed.2006.10.008

The American Journal of Medicine
Volume 120, Issue 1 , Pages 40-46, January 2007

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