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Elderly Patients Receive Less Aggressive Medical and Invasive Management of Unstable Angina
Potential Impact of Practice Guidelines
Robert P. Giugliano, MD, SM;
Carlos A. Camargo, Jr, MD, DrPH;
Donald M. Lloyd-Jones, MD;
Jason D. Zagrodsky, MD;
Jeffrey D. Alexis, MD;
Kim A. Eagle, MD;
Valentin Fuster, MD, PhD;
Christopher J. O'Donnell, MD, MPH
Arch Intern Med. 1998;158:1113-1120.
Background The Agency for Health Care Policy and Research (AHCPR) released a practice guideline on the diagnosis and management of unstable angina in 1994.
Objective To examine practice variation across the age spectrum in the management of patients hospitalized with unstable angina 2 years before release of the AHCPR guideline.
Design Retrospective cohort.
Setting Urban academic hospital.
Patients All nonreferral patients diagnosed as having unstable angina who were hospitalized directly from the emergency department to the intensive care or telemetry unit between October 1, 1991, and September 30, 1992.
Measurements Percentage of eligible patients receiving medical treatment concordant with 8 important AHCPR guideline recommendations.
Results Half of the 280 patients were older than 66 years; women were older than men on average (70 vs 64 years; P<.001). After excluding those with contraindications to therapy, patients in the oldest quartile (age, 75.20-93.37 years) were less likely than younger patients to receive aspirin (P<.009),  -blockers (P<.04), and referral for cardiac catheterization (P<.001). Overall guideline concordance weighted for the number of eligible patients declined with increasing age (87.4%, 87.4%, 84.0%, and 74.9% for age quartiles 1 to 4, respectively;  2, P<.001). Increasing age, the presence of congestive heart failure at presentation, a history of congestive heart failure, previous myocardial infarction, increasing comorbidity, and elevated creatinine concentration were associated with care that was less concordant with AHCPR guideline recommendations; only age and congestive heart failure at presentation remained significant in the multivariate analysis (odds ratios, 1.28 per decade [95% confidence interval, 1.02-1.61] and 3.16 [95% confidence interval, 1.57-6.36], respectively).
Conclusions Older patients were less likely to receive standard therapies for unstable angina before release of the 1994 AHCPR guideline. Patients presenting with congestive heart failure also received care that was more discordant with guideline recommendations. The AHCPR guideline allows identification of patients who receive nonstandard care and, if applied to those patients with the greatest likelihood to benefit, could lead to improved health care delivery.
From the Cardiac Unit (Drs Giugliano, Lloyd-Jones, and O'Donnell) and the Departments of Emergency Medicine (Dr Camargo) and Medicine (Drs Zagrodsky and Alexis), Massachusetts General Hospital, and the Channing Laboratory, Department of Medicine, Brigham and Women's Hospital (Dr Camargo), Harvard Medical School, Boston, Mass; the Division of Cardiology, University of Michigan Medical Center, Ann Arbor (Dr Eagle); the Cardiovascular Research Institute, Mount Sinai Medical Center, New York, NY (Dr Fuster); and the National Heart, Lung, and Blood Institute, Framingham Heart Study, Framingham, Mass (Dr O'Donnell). Dr Giugliano is now with the TIMI Study Chairman's Office, Brigham and Women's Hospital. Dr Zagrodsky is now with the Division of Cardiology, University of Texas—Southwestern Medical Center, Dallas. Dr Alexis is now with the Cardiovascular Research Institute, Mount Sinai Medical Center.
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