Abstract
Background
There have been substantial improvements in the use of evidence-based, guideline-recommended
therapies for patients with acute myocardial infarction. Nevertheless, some gaps,
disparities, and variations in use remain. To understand how such gaps in recommended
care may be narrowed further, it may be useful to determine those factors associated
with lessened adherence to guideline-based care.
Methods
The Get with the Guidelines-Coronary Artery Disease registry measured adherence with
6 performance measures (aspirin within 24 hours, discharge on aspirin and beta-blockers,
patients with low ejection fraction discharged on angiotensin-converting enzyme inhibitor/angiotensin
receptor blocker, smoking cessation counseling, use of lipid-lowering medications)
in 148,654 patients with acute myocardial infarction between 2002 and 2009. Logistic
multivariable regression models using generalized estimating equations were utilized
to identify patient and hospital characteristics associated with adherence to each
of 6 measures, and to a summary score of performance for all measures, in eligible
patients.
Results
We identified 10 variables that were associated significantly with either greater
adherence (hypertension, hyperlipidemia, hospital with full interventional capabilities,
calendar year) or worse adherence (age, female sex, congestive heart failure, chronic
renal insufficiency, atrial fibrillation, chronic dialysis) in at least 4 of the 6
treatment adherence models, as well as the summary score adherence model. Age, sex,
and calendar year were significant in all models.
Conclusions
Use of evidence-based acute myocardial infarction treatments remains less than ideal
for certain high-risk populations. The close correlations among factors associated
with underperformance highlights the potential for specifically targeting and tailoring
quality improvement interventions.
Keywords
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Article info
Publication history
Published online: August 27, 2012
Footnotes
Funding: This study is supported by a Young Investigator grant from the Council on Clinical Cardiology of the American Heart Association to Dr Dharam Kumbhani. GWTG-CAD is a program of the American Heart Association and is supported by an unrestricted educational grant from Merck/Schering-Plough Pharmaceutical. Data collection and management were performed by Outcome, Inc. (Cambridge, Mass). The analysis of registry data was performed at Duke Clinical Research Institute (Durham, NC), which also receives funding from the American Heart Association. The sponsor was not involved in the management, analysis, or interpretation of data or the preparation of the manuscript.
Conflicts of Interest: DJ Kumbhani: None; GC Fonarow: None; CP Cannon: Research grants/support from: Accumetrics, AstraZeneca, Essentialis, GlaxoSmithKline, Merck, Regeneron, Sanofi, Takeda. Advisory Board (but funds donated to charity): Alnylam, Bristol-Myers Squibb, Pfizer. Clinical Advisor, equity: Automedics Medical Systems; AF Hernandez: Research grants/support from: Accumetrics, AstraZeneca, Essentialis, GlaxoSmithKline, Merck, Regeneron, Sanofi, Takeda. Advisory Board (but funds donated to charity): Alnylam, Bristol-Myers Squibb, Pfizer. Clinical Advisor, equity: Automedics Medical Systems. AF Hernandez: Research Grants from Johnson and Johnson; ED Peterson: Research Grants from BMS Sanofi, Merck, Eli Lilly, and Ortho McNeil Pharmaceutical; WF Peacock: Research Grants (Significant) from Abbott, Alere, Brahms, Corthera, EKR, Nanosphere, The Medicine's Company; Consultant (Modest) for Abbott, Alere, Beckman Coulter, Electrocore, The Medicine's Company; Speaker's Bureau (Modest) for Abbott, Alere; Ownership Interest (Modest) in Comprehensive Research Associates LLC, Vital Sensors, Emergencies in Medicine LLC; WK Laskey: None; W Pan: None; LH Schwamm: None; DL Bhatt: Advisory Board: Medscape Cardiology; Board of Directors: Boston VA Research Institute, Society of Chest Pain Centers; Chair: American Heart Association Get With The Guidelines Science Subcommittee; Honoraria: American College of Cardiology (Editor, Clinical Trials, Cardiosource), Duke Clinical Research Institute (clinical trial steering committees), Slack Publications (Chief Medical Editor, Cardiology Today Intervention), WebMD (CME steering committees); Research Grants: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company; Unfunded Research: FlowCo, PLx Pharma, Takeda.
Authorship: All authors had access to the data and played a role in writing this manuscript.
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