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Evidence for Undertreatment in Women and the Elderly

Thomas J. McLaughlin, ScD; Stephen B. Soumerai, ScD; Donald J. Willison, ScD; Jerry H. Gurwitz, MD; Catherine Borbas, PhD; Edward Guadagnoli, PhD; Barbara McLaughlin; Nora Morris, MA; Su Chun Cheng, ScD; Paul J. Hauptman, MD; Elliott Antman, MD; Linda Casey, MS; Richard Asinger, MD; Fredarick Gobel, MD

Arch Intern Med. 1996;156(7):799-805.

Abstract
Background
Evidence-based guidelines for the treatment of patients with acute myocardial infarction (AMI) have been published and disseminated by the American College of Cardiology and the American Heart Association. Few studies have examined the rates of adherence to these guidelines in eligible populations and the influence of age and gender on highly effective AMI treatments in community hospital settings.

Methods
Medical records of 2409 individuals admitted to 37 Minnesota hospitals between October 1992 and July 1993 for AMI, suspected AMI, or rule-out AMI, and meeting electrocardiographic, laboratory, and clinical criteria suggestive of AMI were reviewed to determine the proportion of eligible patients who received thrombolytic, β-blocker, aspirin, and lidocaine hydrochloride therapy. The effects of patient age, gender, and hospital teaching status on the use of these treatments were estimated using logistic regression models.

Results
Eligibility for treatment ranged from 68% (n=1627) for aspirin therapy, 38% (n=906) for lidocaine therapy, and 30% (n=734) for thrombolytic therapy to 19% (n=447) for β-blocker therapy. Seventy-two percent of patients eligible to receive a thrombolytic agent received this therapy; 53% received β-blockers; 81% received aspirin; and 88% received lidocaine. Among patients ineligible for lidocaine therapy (n=1503), 20% received this agent. Use of study drugs was lower among eligible elderly patients, especially those older than 74 years (thrombolytic agent: odds ratio, 0.2; 95% confidence interval, 0.1 to 0.4; aspirin: odds ratio, 0.4, 95% confidence interval, 0.3 to 0.6;β-blocker: odds ratio, 0.4; 95% confidence interval, 0.2 to 0.8). Female gender was associated with lower levels of aspirin use among eligible patients (odds ratio, 0.7; 95% confidence interval, 0.6 to 0.9); and there was a trend toward lower levels of β-blocker and thrombolytic use among eligible women.

Conclusions
Use of lifesaving therapies for eligible patients with AMI is higher than previously reported, particularly for aspirin and thrombolytic use in nonelderly patients. Lidocaine is still used inappropriately in a substantial proportion of patients with AMI. Increased adherence to AMI treatment guidelines is required for elderly patients and women.

(Arch Intern Med. 1996;156:799-805)

Footnotes
The affiliations of the authors appear in the acknowledgment section at the end of the article.

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