A Comparison of Acute Coronary Syndrome Care at Academic and Nonacademic Hospitals
Article Outline
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
Significant advances in cardiovascular medicine have resulted in the development of several acute interventions and secondary prevention medications that are beneficial to patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). These advances are summarized in the American College of Cardiology and American Heart Association (ACC/AHA) guidelines recommendations.1 Unfortunately, gaps remain in the quality of care that patients with acute coronary syndromes receive across the country.2 Performance appears to vary considerably from one center to another; some centers have high adherence to proven therapies and others do not.3 Therefore, identifying hospital characteristics associated with high levels of adherence may provide insight into successful processes of care.
Some researchers have postulated that a hospital’s classification as a “teaching hospital” with close academic affiliation is predictive of its higher quality of care.4 Previous reports have attributed improved outcomes in patients with acute myocardial infarction at teaching hospitals to greater adherence to the use of evidence-based therapies.5, 6 Based on these initial studies, adherence to guidelines recommendations for patients with ACS has been assumed to be a larger issue for nonteaching community hospitals than for academic teaching hospitals. However, these early studies were based on data from the late 1980s and early 1990s. Since then, care guidelines have been widely disseminated. In addition, public reporting and performance-based reimbursement are now a reality for community-based hospitals, as well as for academic sites. Therefore, we sought to determine the use of ACC/AHA guidelines recommendations in patients at academic and nonacademic hospitals in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative. We hypothesized that guidelines adherence would be higher at academic sites and that inter-hospital variation would be minimal.
Methods
Patients
Patients included in the CRUSADE Initiative have ischemic symptoms at rest within 24 hours before presentation and high-risk features, including ST-segment depression ≥0.5 mm, transient ST-segment elevation 0.5-1.0 mm (lasting for <10 minutes), or positive cardiac markers (elevated troponin I or T or creatine kinase-MB >upper limit of normal for the local laboratory assay).
Patients who were enrolled in CRUSADE between January 1, 2001 and March 31, 2004 were evaluated for this analysis. We excluded patients who were transferred out to other institutions because data were collected in an anonymous fashion only during the initial hospitalization. The institutional review board of each institution approved participation in this initiative. Data collected included baseline clinical characteristics, use of acute medications (within 24 hours of presentation), use and timing of invasive cardiac procedures, laboratory results, clinical outcomes, and discharge therapies and interventions. Contraindications to guidelines-recommended therapies were also recorded.7
Definitions and Endpoints
Hospitals were identified as academic hospitals according to their Council of Teaching Hospital affiliation in the American Hospital Association database. We assessed use of individual Class I ACC/AHA guidelines recommendations for 4 acute (<24 hours) therapies (anti-platelets, beta-blockers, any heparin, and glycoprotein IIb/IIIa inhibitors) and 5 discharge therapies (aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme [ACE] inhibitors, and any lipid-lowering therapy). For each of these, we assessed use among those patients without documented contraindications. Use of ACE inhibitor was limited to those patients with ideal eligibility (ie, those with left ventricular function <40%, diabetes, or hypertension). Similarly, lipid-lowering therapy was assessed in those patients with hyperlipidemia or a measured total serum cholesterol >100 mg/dL. Hospital composite adherence scores were also calculated based on the use of the 4 acute therapies and 5 discharge medications. Composite adherence scores, expressed as a percentage, were calculated as the number of times guidelines-recommended care was provided divided by the total number of eligible “opportunities” encountered by a center in the care of its NSTE ACS patients who did not have contraindications. Data on in-hospital clinical events, such as cardiogenic shock, congestive heart failure, stroke, and death were also collected. Signs of heart failure on admission were defined as exertional dyspnea, orthopnea, shortness of breath, labored breathing, fatigue either at rest or with normal exertion, rales greater than 1/3 of the lung fields, elevated jugular venous pressure (JVP), S3 gallop, or pulmonary congestion on x-ray believed to represent cardiac dysfunction.
Statistical Analysis
Patient characteristics, care patterns, and in-hospital clinical outcomes were compared in patients admitted to both academic and nonacademic hospitals. Wilcoxon rank-sum tests were used for continuous variables and chi-square tests for categorical variables.
To examine the relationship between academic hospitals, nonacademic community hospitals, and in-hospital outcomes, multivariable models were adjusted for a broad range of patient and hospital characteristics. Because patients within a hospital were more likely to be similar to one another than to patients at different hospitals, all adjusted analyses were performed using generalized estimating equations models8 to account for correlations among clustered responses (eg, within-hospital correlations). All odds ratios are reported with nonacademic hospitals as the reference group.
In order to examine the variability of performance among academic and nonacademic hospitals, the individual and overall performance scores were calculated for each site. The standard deviation for the 2 groups was compared. F-tests were performed to determine whether the variance for the groups was equal. The top 20 and bottom 20 hospitals with regard to overall adherence were also listed by hospital type. A P value of <.05 was established as the level of statistical significance for all tests. All analyses were performed using SAS software (version 8.2, SAS Institute, Cary, NC).
Results
Patient Characteristics
The analysis population comprised 86,042 patients admitted to 480 hospitals across the United States between January 2001 and March 2004. A total of 60,285 (70.1%) patients were admitted to nonacademic hospitals (n=355), and 25,757 (29.9%) were admitted to academic hospitals (n=125). Patients admitted to academic teaching hospitals were younger, less likely to be female, more frequently diabetic, and more likely to have renal insufficiency than patients admitted to nonacademic community hospitals (Table 1). The majority of patients in both groups (>88%) had positive cardiac markers, and patients admitted to academic teaching hospitals were more likely to have signs of congestive heart failure on admission.
Table 1. Baseline Patient Characteristics by Hospital Teaching Status
| Characteristic | Academic⁎ (n = 25,757) | Nonacademic⁎ (n = 60,285) | P Value |
|---|---|---|---|
| Demographics | |||
| Age (years)† | 66(55,77) | 69(57,79) | <.001 |
| Female sex (%) | 38.7 | 41.1 | <.001 |
| White race (%) | 68.8 | 84.8 | <.001 |
| Body mass index, (kg/m2) | 27.6 | 27.5 | .009 |
| Insurance status | |||
| HMO/private (%) | 41.8 | 45.6 | <.001 |
| Medicaid/Medicare (%) | 47.7 | 48.0 | |
| Self/none (%) | 8.6 | 5.3 | |
| Risk factors | |||
| Family history of CAD (%) | 34.8 | 35.6 | .004 |
| Hypertension (%) | 71.9 | 68.1 | <.001 |
| Diabetes mellitus (%) | 34.3 | 32.1 | <.001 |
| Current/recent smoker (%)‡ | 29.0 | 26.2 | <.001 |
| Hypercholesterolemia (%)§ | 49.1 | 46.3 | <.001 |
| Medical history | |||
| Prior myocardial infarction (%) | 31.8 | 30.3 | <.001 |
| Prior bypass surgery (%) | 19.5 | 20.8 | <.001 |
| Prior heart failure (%) | 19.9 | 18.4 | <.001 |
| Prior stroke (%) | 11.0 | 11.0 | .74 |
| Renal insufficiency (%)∥ | 15.6 | 13.4 | <.001 |
| Presenting signs and symptoms | |||
| Heart rate, (beats/min) | 82.0 | 82.0 | .65 |
| SBP, (mm Hg)† | 143(122,164) | 144(124,165) | <.001 |
| Transient ST depression (%) | 37 | 37.4 | <.001 |
| Positive cardiac markers (%) | 90.8 | 88.6 | <.001 |
| Signs of heart failure (%)¶ | 23.7 | 22.7 | .003 |
⁎Academic hospital status defined by the Council of Teaching Hospitals. |
†Presented as median (25th, 75th percentile). |
‡Patient-reported current or recent (within the past 6 weeks before hospitalization) smoking habit. Refers to cigarette and cigar smoking only, not to other forms of tobacco. |
§Known total serum cholesterol >200 mg/dL (5.2 mmol/L) or chronic treatment with a lipid-lowering agent. |
∥Defined as creatinine level >2.0 mg/dL, calculated creatinine clearance <30 mL/min, or need for chronic renal dialysis. |
¶Defined in Methods section. |
Hospital Characteristics
Geographically, there were more hospitals identified as academic teaching hospitals in the Northeast and Midwest than in the South and West. All of the academic hospitals were located in urban areas and were larger (defined by total beds) and more likely to have coronary bypass services than the nonacademic hospitals (Table 2).
Table 2. Hospital Characteristics by Teaching Status
| Characteristic | Academic (n = 125) | Nonacademic (n = 355) | P Value |
|---|---|---|---|
| Region | |||
| West (%) | 5.6 | 15.8 | <.001 |
| Northeast (%) | 34.4 | 20.8 | |
| Midwest (%) | 34.4 | 20.3 | |
| South (%) | 25.6 | 43.1 | |
| Urban | |||
| <100,000 population (%) | 0.0 | 13.8 | <.001 |
| 100,000-250,000 population (%) | 5.6 | 12.4 | |
| 250,000-500,000 population (%) | 8.8 | 16.6 | |
| 500,000-1,000,000 population (%) | 20.0 | 14.1 | |
| 1,000,000-2,500,000 population (%) | 25.6 | 28.5 | |
| >2,500,000 population (%) | 40.0 | 14.7 | |
| Hospital characteristics | |||
| Total hospital beds⁎ | 500(378,656) | 268(184,392) | <.001 |
| PCI, no surgery (%) | 2.4 | 8.5 | <.001 |
| Bypass surgery service (%) | 88.0 | 60.0 |
⁎Presented as median (25th, 75th percentile). |
Acute and Discharge Therapies and Adherence
Acutely, all therapies were used at a slightly higher rate at academic hospitals than at nonacademic community hospitals (Table 3). However, the treatment differences were slight, with 3% being the largest difference between academic and nonacademic use. At discharge, all therapies evaluated (aspirin, beta-blocker, lipid-lowering agent, and ACE inhibitor) were used at a higher rate at academic hospitals than at nonacademic hospitals, except for clopidogrel (Table 3).
Table 3. Acute and Discharge Therapies by Hospital Teaching Status
| Therapies | Academic (n = 25,757) | Academic (n = 25,757) | P Value |
|---|---|---|---|
| Acute medications (within 24 h) | |||
| Aspirin⁎ | 93.5 | 91.3 | <.001 |
| Beta-blocker⁎ | 82.6 | 79.0 | <.001 |
| Heparin (UFH or LMWH)⁎ | 83.9 | 82.6 | <.001 |
| GP IIb-IIIa inhibitor⁎ | 38.8 | 36.4 | <.001 |
| PCI patients | 60.2 | 60.1 | .86 |
| Non-PCI patients | 22.6 | 20.0 | <.001 |
| Discharge therapies† | |||
| Aspirin⁎ | 92.0 | 89.5 | <.001 |
| Beta-blocker⁎ | 86.4 | 83.8 | <.001 |
| Lipid-lowering agent⁎ | 82.8 | 79.4 | <.001 |
| ACE inhibitor⁎ | 66.6 | 59.6 | <.001 |
| Clopidogrel⁎ | 55.2 | 56.7 | <.001 |
| In-hospital procedures | |||
| Diagnostic catheterization⁎ | 73.3 | 76.6 | <.001 |
| PCI | 42.1 | 44.3 | <.001 |
| CABG | 12.2 | 14.1 | <.001 |
| Any revascularization | 53.4 | 57.4 | <.001 |
⁎Rates for patients without contraindications to therapy. |
†Excludes deaths. |
Patients at nonacademic community hospitals were significantly more likely to undergo diagnostic catheterization, percutaneous coronary intervention, and coronary artery bypass surgery than were patients at academic hospitals (Table 3). Additionally, these procedures were used earlier in the course of patients’ ACS events. The median time to catheterization was significantly shorter at nonacademic versus academic sites (25.5 vs 26.7 hours respectively, P <.001).
The overall adherence score for academic hospitals was slightly greater than the adherence score for nonacademic hospitals (Table 4). Aside from discharge clopidogrel, the adherence to acute and discharge therapies was slightly greater at academic hospitals as compared with nonacademic community hospitals. The variance, or standard deviation, between academic hospitals was significantly less than between nonacademic hospitals. The variation in performance was greater for overall, acute, and discharge therapy adherence at nonacademic community hospitals. Nonacademic hospitals accounted for 15 of the top 20 performing hospitals and 19 of the bottom 20 performing hospitals.
Table 4. Overall, Acute, and Discharge Adherence by Hospital Teaching Status
| Adherence | Academic (n = 125) | Nonacademic (n = 355) | P Value |
|---|---|---|---|
| Overall adherence score⁎ | |||
| Median (25th, 75th percentile) | 77.8(73.0-82.2) | 73.7(67.1-79.1) | |
| • SD (95% CI) | 8.7(7.7-9.9) | 10.3(9.6-11.8) | .032 |
| Acute therapies | |||
| Aspirin, median (25th, 75th percentile) | 96.0(93.8-98.5) | 94.3(89.6-97.1) | |
| • SD (95% CI) | 4.2(3.7-4.7) | 7.0(6.5-7.6) | <.001 |
| Beta-blocker, median (25th, 75th percentile) | 85.7(78.1-90.5) | 80.3(70.4-89.2) | |
| • SD (95% CI) | 11.8(10.4-13.4) | 14.2(13.2-15.3) | .014 |
| Any heparin, median (25th, 75th percentile) | 86.6(79.0-92.5) | 83.3(73.8-90.3) | |
| • SD (95% CI) | 12.5(11.1-14.2) | 15.4(14.4-16.6) | .006 |
| Any GP IIb/IIIa, median (25th, 75th percentile) | 43.1(28.2-56.4) | 38.5(24.4-55.0) | |
| • SD (95% CI) | 19.2(17.0-21.8) | 22.3(20.8-24.1) | .048 |
| Discharge therapies† | |||
| Aspirin, median (25th, 75th percentile) | 96.0(92.7-97.9) | 94.1(88.9-97.1) | |
| • SD (95% CI) | 5.0(4.4-5.7) | 10.3(9.6-11.1) | <.001 |
| Beta-blocker, median (25th, 75th percentile) | 89.5(82.6-92.4) | 85.2(76.7-91.2) | |
| • SD (95% CI) | 11.1(9.8-12.6) | 14.4(13.4-15.5) | <.001 |
| Lipid-lowering agent, median (25th, 75th percentile) | 83.3(75.8-89.2) | 79.3(70.0-86.0) | |
| • SD (95% CI) | 10.5(9.3-11.9) | 16.7(15.6-18.1) | <.001 |
| Clopidogrel, median (25th, 75th percentile) | 55.9(46.7-62.9) | 55.4(40.0-63.8) | |
| • SD (95% CI) | 17.7(15.7-20.1) | 20.1(18.7-21.7) | .10 |
⁎Adherence score equation is percentage of eligible patients without contraindication who received therapy divided by the total opportunities to provide therapy. |
†Discharge adherence excludes deaths. |
In-Hospital Outcomes
The overall in-hospital mortality rate was 4.8%, ranging from 4.5% at academic hospitals to 4.9% at nonacademic sites (P=.022) (Table 5). After adjusting for baseline demographics and clinical factors, in-hospital mortality rates were similar by academic status. Similarly, after controlling for patient characteristics, the odds for clinical events of shock, congestive heart failure, stroke, and blood transfusion were similar at academic and nonacademic hospitals.
Table 5. In-Hospital Clinical Event Rates with Odds Ratio for Events by Academic (vs Nonacademic) Hospital, Adjusting for Within-Hospital Clustering and Other Potential Variables⁎
| Outcomes | Academic n = 25,757 % | Nonacademic n = 60,285 % | Unadjusted Odds Ratio | Adjusted Odds Ratio (95% CI) |
|---|---|---|---|---|
| Cardiogenic shock | 2.8 | 2.6 | 0.97 | 1.05(0.83-1.34) |
| CHF | 10.1 | 8.7 | 0.89 | 1.19(0.80-1.77) |
| Stroke | 0.9 | 0.8 | 1.01 | 1.17(0.97-1.42) |
| Any RBC transfusion | 16.6 | 14.0 | 1.14 | 1.08(0.96-1.22) |
| Death | 4.5 | 4.9 | 0.78 | 1.05(0.92-1.20) |
⁎Variables in the model include: academic status, age, male sex, body mass index, white race, family history of coronary artery disease, hypertension, diabetes, current/recent smoker, hypercholesterolemia, prior myocardial infarction, prior percutaneous coronary intervention, prior coronary artery bypass grafting, prior congestive heart failure, prior stroke, renal insufficiency, ST depression, transient ST elevation, positive cardiac markers, signs of congestive heart failure, heart rate, systolic blood pressure, insurance (HMO/private, Medicare/Medicaid, self/none), total number of hospital beds, region (West, Northeast, Midwest, South), facility (no services, cath lab only, percutaneous coronary intervention but no surgery, surgery), and cardiologist. |
Discussion
Emphasis on adherence to recommended therapies for ACS is part of a national push to improve the quality of medical care that was ignited by the Institute of Medicine’s (IOM) landmark report, “Crossing the Quality Chasm.” The report called for a health care system that avoids the overuse of ineffective care and the underuse of effective care.9, 10 In an effort to quantify the quality of care, different groups have developed quality indicators or performance measures to translate guidelines recommendations for effective care into measurable quality.11, 12 The goal of these projects is to both increase the use of effective therapies and decrease the variation in performance across national hospital systems.
In our analysis of a geographically diverse cohort of ACS patients admitted to 480 hospitals, academic hospitals had only slightly better overall adherence to guidelines recommendations than nonacademic community hospitals. We determined that, instead of academic status, variation among individual centers likely plays the largest role in determining the quality of care that patients with ACS receive. While some nonacademic community hospitals demonstrated very low adherence to guidelines recommendations, others had adherence rates that were better than all academic sites.
Understanding the reasons for these differences among hospitals warrants further investigation. It seems that certain centers, both nonacademic and academic, have mastered care processes that allow for high levels of adherence to proven therapies, while other centers have not. Notably, the variance or range of adherence at nonacademic community hospitals was greater than at academic hospitals. This was highlighted by the finding that 15 of the top 20 performing hospitals and 19 of the bottom 20 performing hospitals are nonacademic community hospitals. These findings have important implications for continued quality improvement.
The majority of patients with ACS are cared for in nonacademic community centers, as was the case in this study where 70% of the patients received care at community hospitals. Our findings demonstrate that both academic and nonacademic hospitals, on average, provide similar levels of overall care, with academic centers having only slightly higher rates of use with regard to most therapies. However, overall care varies to a greater extent among nonacademic community hospitals than among academic centers. Therefore, the greatest opportunity for improvement of ACS care at the national level lies in increasing the consistency of use of guidelines recommendations among all nonacademic community hospitals. Current accreditation systems apparently do not decrease this variation in performance.13 The national focus should continue to emphasize improving adherence to guidelines recommendations at all hospitals and allocate resources to ensure improvement at those nonacademic community hospitals that are lagging behind.
Additionally, resources should be devoted to the purpose of increasing the use of all therapies, including both patented and generic therapies. A patented therapy, clopidogrel, was the only therapy found to have similar rates of use at academic and nonacademic community hospitals. Although some of this use could be related to the higher rate of percutaneous coronary intervention at nonacademic centers, findings were similar among patients who did not undergo this procedure.
It should be noted that numerous factors in addition to hospital type have been previously correlated to the use of proven medical therapies. These include patient-specific factors such as age, sex, and race.14, 15, 16, 17 Community factors, such as regional variation in care, income level of patients, and insurance status have also been associated with use of therapies.18, 19, 20, 21 However, our analysis of clinical outcomes did control for patient-specific factors and regional clustering.
The similarity in patient outcomes may be due to a balancing of care practices. Whereas academic sites used more evidence-based therapies, nonacademic sites were more likely to use invasive procedures and interventions, often with a shorter time period to procedure. This balancing has been seen previously in regional analyses, in which the Northeast was shown to have higher adherence to proven medical therapies but less invasive care with as good or better outcomes when compared with the rest of the country. Again, there is significant room for improvement at both academic and nonacademic sites, as outcomes could be improved by timely treatment with both medications and interventions.
Limitations
Because this was an observational study, patients were not randomized to the type of hospital to which they were admitted. Therefore, we can only describe associations and not directly test causality. All academic and nonacademic hospitals are not the same. However, this analysis did exclude patients transferred from other institutions, and it does control for on-site catheterization facilities. Finally, outcomes including shock, heart failure, stroke, and death were measured during hospitalization, and differences in outcomes due to discharge therapies cannot be determined.
Conclusion
Overall adherence to guidelines recommendations is modest (around 75%) and is slightly higher at academic hospitals. However, there remains significant room for improvement at both academic hospitals and nonacademic hospitals. The variation in adherence was greater among community hospitals and is a point of significant concern as we strive to improve care of ACS for all Americans. National attention should continue to be paid to improving adherence to guidelines recommendations at all hospitals, with a special emphasis placed on improving the consistency of care at nonacademic community hospitals.
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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
© 2007 Elsevier Inc. All rights reserved.
