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A Four-State Pilot Study From the Cooperative Cardiovascular Project

Edward F. Ellerbeck, MD; Stephen F. Jencks, MD; Martha J. Radford, MD; Timothy F., MD; Alan S. Craig, MD; Jay A. Gold, MD; Harlan M. Krumholz, MD; Robert A. Vogel, MD

JAMA. 1995;273(19):1509-1514.

Abstract
Objective.
—To develop and test indicators of the quality of care for patients with acute myocardial infarction (AMI).

Design.
—Retrospective medical record review.

Setting.
—All acute care hospitals in Alabama, Connecticut, Iowa, and Wisconsin.

Patients.
—All hospitalizations for Medicare patients discharged with a principal diagnosis of AMI between June 1, 1992, and February 28, 1993, were identified (N=16 869).

Main Outcome Measure.
—Percentage of patients receiving appropriate interventions as defined by 11 quality-of-care indicators derived from clinical practice guidelines that were modified and updated in consultation with a national group of physicians and other health care professionals.

Results.
—We abstracted data from 16124 (96%) of the hospitalizations, representing 14 108 primary hospitalizations and 2016 hospitalizations resulting from transfers. Potential exclusions to the use of standard treatments in AMI care were common with 90% and 70% of patients having potential exclusions for thrombolytics and β-blockers, respectively. In cohorts of "ideal candidates" for specific interventions, 83% received aspirin, 69% received thrombolytics, and 70% received heparin during the initial hospitalization; 77% received aspirin and 45% received β-blockers at discharge.

Conclusions.
—These data demonstrate that many Medicare patients may not be ideal candidates for standard AMI therapies, but these treatments are under-used, even in the absence of discernible contraindications. Hospitals and physicians who apply these quality indicators to their practices are likely to find opportunities for improvement.

(JAMA. 1995;273:1509-1514)

Author Affiliations
From the Health Standards and Quality Bureau, Health Care Financing Administration, Baltimore, Md (Drs Ellerbeck and Jencks); the Connecticut Peer Review Organization, Middleton (Drs Radford and Krumholz); the Department of Cardiology, University of Connecticut, Farmington (Dr Radford); the Iowa Foundation for Medical Care, Des Moines, and the Department of Surgery, University of Iowa, Iowa City (Dr Kresowik); the Alabama Quality Assurance Foundation and the Department of Internal Medicine, University of Alabama, Birmingham (Dr Craig); the Wisconsin Peer Review Organization, Madison, the Department of Pre-; ventive Medicine, Medical College of Wisconsin, Milwaukee, and the University of Wisconsin, Madison (Dr Gold); the Cardiovascular Section, Yale University School of Medicine, New Haven, Conn (Dr Krumholz); and the Department of Cardiology, University of Maryland, Baltimore (Dr Vogel).

Footnotes
Opinions in this article should not be taken to be the official position of the Health Care Financing Administration.

Corresponding author: Edward F. Ellerbeck, MD, Health Care Financing Administration, 601 E 12th St, Room 242, Kansas City, MO 64106.

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