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National and State Trends in Quality of Care for Acute Myocardial Infarction Between 1994-1995 and 1998-1999
The Medicare Health Care Quality Improvement Program
Dale R. Burwen, MD, MPH;
Deron H. Galusha, MS;
Jennifer M. Lewis, RN, BSN;
Marjorie R. Bedinger, BA;
Martha J. Radford, MD;
Harlan M. Krumholz, MD;
JoAnne Micale Foody, MD
Arch Intern Med. 2003;163:1430-1439.
Background National efforts have focused attention on quality of care, but relatively little is known about whether, and to what extent, improvement has occurred during this recent period. Furthermore, the variability of the recent change over time is not known.
Methods We sought to determine national and state trends in quality of care for Medicare patients hospitalized with acute myocardial infarction (AMI) between 1994-1995 (n = 234 754 discharges) and 1998-1999 (n = 35 713 discharges) as part of the Centers for Medicare & Medicaid Services (CMS) National AMI Project. We assessed change in evidence-based, guideline-recommended processes of care.
Results Nationally, among patients without contraindications to therapy, discharge  -blocker prescription increased by 20.5 percentage points (50.3% to 70.7%); early administration of -blocker increased by 17.4 percentage points (51.1% to 68.4%); discharge angiotensin-converting enzyme inhibitor prescription for systolic dysfunction increased by 8.0 percentage points (62.8% to 70.8%); early administration of aspirin increased by 6.6 percentage points (76.4% to 82.9%); and aspirin prescribed at discharge increased by 5.6 percentage points (77.3% to 82.9%) (P<.001 for all categories). Smoking cessation counseling decreased by 3.6 percentage points (40.8% to 37.2%; P<.001). Rates of acute reperfusion therapy did not significantly change (59.2% to 60.6%; P = .35). The median time from hospital arrival to initiation of thrombolytic therapy decreased by 7 minutes (P<.001); and the median time from hospital arrival to initiation of primary percutaneous transluminal coronary angioplasty decreased by 12 minutes (P = .09).
Conclusions During this 4-year period, quality of care for AMI improved, but substantial variation was observed at both time points. While meaningful population-based improvement has been achieved, ample opportunities for improvement exist. Further work is required to elucidate the strategies associated with improvements in quality of care.
From the Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration), Baltimore, Md (Dr Burwen and Ms Bedinger); Qualidigm, Middletown, Conn (Mr Galusha, Ms Lewis, and Drs Radford, Krumholz, and Foody); Sections of Cardiovascular Medicine, Department of Medicine (Drs Radford, Krumholzs, and Foody), and Health Policy and Administration, Department of Epidemiology and Public Health (Dr Krumholz), Yale University School of Medicine, and Yale–New Haven Hospital Center for Outcomes Research and Evaluation (Drs Radford and Krumholz), New Haven, Conn. The authors have no relevant financial interest in this article.
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