Sex differences in coronary artery lesions and in-hospital outcomes for patients with ST-segment elevation myocardial infarction under the age of 45.

OBJECTIVE: We aimed to compare baseline characteristics, coronary angiogram findings, and in-hospital outcomes between female and male patients with ST-segment elevation myocardial infarction (STEMI) under the age of 45 years. BACKGROUND: Although sex differences in risk factor profile have been documented for young patients with STEMI, limited data exist on the prevalence of spontaneous coronary artery dissection in these patients. METHODS: As part of an ongoing hospital-based registry of suspected STEMI, we analyzed the original data for 51 women under the age of 45 years matched with 93 men of similar age who underwent coronary angiography at two percutaneous coronary intervention centers, between January 2003 and December 2012. Two interventional cardiologists independently reviewed coronary angiograms for all patients. RESULTS: The mean age for all patients was 39 years (range, 24-44) and the overall prevalence of cigarette smoking, dyslipidemia, hypertension, and diabetes mellitus were 70, 32, 13, and 4%, respectively. Young women were more likely to present with spontaneous coronary artery dissection (22 vs. 3%, p = .003) and more of them experienced reinfarction during the hospital course (15 vs. 1%, p = .01). The in-hospital mortality rate was 2% for both sexes. CONCLUSIONS: Spontaneous coronary artery dissection is an important cause of myocardial infarction in young female adults, accounting for 22% (95% confidence interval, 11-35%) of women with STEMI under the age of 45 years. The true prevalence of spontaneous coronary artery dissection might even be underestimated, because of the limited availability of advanced imaging techniques at the time of our study.

[Quality of service provided by a university hospital: general practitioners' opinion]. / Qualité des services rendus par un Centre hospitalier universitaire: le point de vue de médecins généralistes.

OBJECTIVE: The interface between primary care and hospital care is the main divide in the delivery of health care. The aim of this study was to assess the opinion of general practitioners (GPs) on the quality of service provided by hospitals and their relationships with hospital teams. METHODS: Self-administered questionnaires were mailed to GPs belonging to the Grenoble University Hospital health territory. RESULTS: Among the 778 GPs included in the study, 327 (42%) returned an evaluable questionnaire. The overall satisfaction score was 55.5/100. The indicator for care delivered to patients obtained the highest mean score (66/100), followed by indicators for continuity of care (45/100) and access to health care (43.9/100). Lowest scores were obtained for the discharge summary (35.9/100) and preparation of hospital discharge (29.3/100). GPs were critical about their relationships with hospital physicians, particularly concerning the difficulty of contacting hospital physicians (20.2% of favourable opinions). They were dissatisfied with the time required to obtain information (17.1%) and considered that hospital physicians did not allow them to be actively involved in decisions concerning their patients (4.6%). CONCLUSION: Communication between GPs and hospital physician was unsatisfactory. This study proposes ways of improving the interface between hospital and primary care.

Efficacy and safety of glycoprotein IIb/IIIa receptor antagonists for patients undergoing percutaneous coronary intervention within twelve hours of fibrinolysis.

OBJECTIVE: To compare clinical outcomes between glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients who underwent percutaneous coronary intervention (PCI) within 12 hr of fibrinolysis. BACKGROUND: Despite limited evidence, glycoprotein IIb/IIIa receptor antagonists are widely used in ST-elevation myocardial infarction (STEMI) patients undergoing routine early or rescue PCI after fibrinolysis. METHODS: We evaluated 87 and 556 glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients enrolled in a regional registry of STEMI between October 2002 and December 2005. The primary efficacy endpoint was a composite of death from any cause, reinfarction, and stroke at 1 year of follow-up. The primary safety endpoint was the rate of in-hospital major bleeding that was not related to coronary artery bypass grafting. RESULTS: The primary efficacy endpoint occurred in 12% (10 of 81) and 13% (72 of 525) of glycoprotein IIb/IIIa receptor antagonist recipients and nonrecipients, respectively (P = 0.74). The corresponding rates of major bleeding during index hospitalization were 4.8% (4 of 84) and 5.1% (28 of 544) (P = 0.88), respectively. Two glycoprotein IIb/IIIa receptor antagonist recipients and five nonrecipients experienced intracranial hemorrhage. After adjusting for propensity score, the odds of primary efficacy (odds ratio, 0.79; 95% confidence interval, 0.34-1.83) and safety (odds ratio, 0.75; 95% confidence interval, 0.22-2.62) endpoints did not differ according to the use of glycoprotein IIb/IIIa receptor antagonists. CONCLUSION: In this observational cohort study of unselected patients with STEMI, the administration of glycoprotein IIb/IIIa receptor antagonists provided no additional benefit to PCI performed within 12 hr of fibrinolysis, nor did it compromise patient safety.

Inappropriate dispatcher decision for emergency medical service users with acute myocardial infarction.

OBJECTIVES: Current guidelines recommend utilization of prehospital emergency medical services (EMSs) by patients with ST-elevation myocardial infarction (STEMI). The aims of this study were to estimate the percentage of inappropriate initial dispatcher decisions and determine their impact on delays in reperfusion therapy for EMS users with STEMI. METHODS: As part of a prospective regional registry of patients with STEMI, we analyzed the original data for 245 patients who called a university hospital-affiliated EMS call center in France. The primary study outcome was time to reperfusion therapy calculated from the documented date and time of the first patient call. RESULTS: The initial EMS dispatcher's decision was appropriate (ie, dispatching a mobile intensive care unit staffed by an emergency or critical care physician) for 171 (70%) patients and inappropriate for 74 (30%) patients. Inappropriate decisions included referring the patient to a family physician (n = 59), providing medical advice (n = 9), and dispatching an ambulance (n = 6). Inappropriate initial decisions resulted in increased median time to reperfusion for 140 patients receiving fibrinolysis (95 vs 53 minutes; P < .001) and 91 patients undergoing primary percutaneous coronary intervention (170 vs 107 minutes; P < .001). In-hospital mortality was not different between the 2 study groups (6.8% vs 9.9%; P = .42). CONCLUSION: The initial dispatcher's decision is inappropriate for 30% of EMS users with STEMI and results in substantial delays in time to reperfusion therapy. Accuracy of telephone triage should be improved for patients who activate EMSs in response to symptoms suggestive of acute coronary syndrome.

Outcomes of myocardial infarction in hospitals with percutaneous coronary intervention facilities.

BACKGROUND: Despite evidence on the efficacy and safety of percutaneous coronary intervention (PCI) for patients with acute myocardial infarction, it is unclear whether patients admitted to hospitals with on-site PCI facilities (herein after, PCI hospitals) have improved outcomes in routine practice. METHODS: We compared processes of care, hospital outcomes, and 1-year mortality rate for 1176 consecutive patients admitted to 126 PCI hospitals and 738 patients admitted to 190 non-PCI hospitals in France from November 1 to November 30, 2000. RESULTS: Patients admitted to PCI hospitals were more likely to receive evidence-based acute (within 48 hours of admission) and discharge medications and to undergo PCI within 48 hours of admission than those admitted to non-PCI hospitals (54% vs 6.2%; P<.001). Despite comparable rates of in-hospital stroke (0.9% vs 1.1%; P=.75) and reinfarction (1.7% vs 2.5%; P=.25), patients admitted to PCI vs non-PCI hospitals had lower in-hospital (7.5% vs 12%; P=.001) and 1-year (13% vs 20%; P<.001) mortality rates. Admission to PCI hospitals was associated with decreased hazard ratios of mortality after adjusting for baseline characteristics (0.75; 95% confidence interval, 0.57-0.98) or propensity score (0.76; 95% confidence interval, 0.59-0.97). Most of the survival benefit of admission to a PCI hospital was explained by the use of PCI and evidence-based discharge medications. CONCLUSIONS: In this prospective observational study, admission of patients with acute myocardial infarction to PCI hospitals was associated with greater use of PCI and evidence-based medications and with improved 1-year survival. Although we cannot exclude the possibility that some unmeasured confounding factors might explain the survival benefit of admission to PCI hospitals, our findings support routine use of PCI and evidence-based medications for these patients.

Managed care's clinical and economic impact on patients with type II diabetes in France: a controlled population-based study.

PURPOSE: The purpose of this paper is to assess the impact of five type II diabetes managed care programmes (MCPs) in clinical and economic terms at the community level in which these programmes function in the Provence-Alpes-Côte d'Azur region of France. DESIGN/METHODOLOGY/APPROACH: A prospective, controlled, before-and-after study (2001-2004) compared diabetic patients who lived in departments (localities) with (the experimental group) and without a MCP (the control group). Quality of care was estimated by the conformity of health care professionals' practices when following-up type II diabetes. Costs are compared from a health service perspective. FINDINGS: The study finds that of 626 patients enrolled, 529 lived in departments with an MCP and 97 patients in departments without. Type II diabetes follow-up globally improved between the two study periods (2001 and 2004), but the study did not show significant differences between the two groups, except for the proportion of creatinine and ophthalmologic examinations, which were higher for the control group. The study did not find significant differences in the increase of costs between the two groups from 2001 to 2004. RESEARCH LIMITATIONS/IMPLICATIONS: This type of study could constitute a methodological model to assess the MCPs population impact. PRACTICAL IMPLICATIONS: MCPs probably did not reach a critical size in terms of patient recruitment and healthcare professional adhesion to have a significant impact at a population level. ORIGINALITY/VALUE: The study highlights a number of points to consider for future MCPs in France.

Age-Related Differences in Reperfusion Therapy and Outcomes for ST-Segment Elevation Myocardial Infarction.

OBJECTIVES: To compare timely access to reperfusion therapy and outcomes according to age of older adults with ST-segment elevation myocardial infarction (STEM) managed within an integrated regional system of care. DESIGN: Ongoing, prospective, regional, hospital-based clinical registry. SETTING: Twenty-three public and private hospitals in the Northern Alps in France. PARTICIPANTS: Individuals presenting with STEMI evolving for less than 12 hours from symptom onset between January 2009 and December 2015 (N=4,813; 3,716 (77.2%) <75, 782 (16.2%) 75-84, 315 (6.5%) ≥85). MEASUREMENTS: Delivery of any reperfusion therapy (primary percutaneous coronary intervention (PCI), intravenous fibrinolysis), primary PCI, and timely reperfusion therapy and in-hospital outcomes. RESULTS: The percentages of patients receiving any reperfusion therapy were 92.9% for those younger than 75, 89.0% for those aged 75 to 84, and 78.7% for those aged 85 and older (P < .001). The percentages of patients undergoing primary PCI were 63.7%, 70.3%, 72.4% (P < .001); and the percentages of patients receiving timely delivery of reperfusion therapy were 44.6%, 36.8%, 29.9% (P < .001). In-hospital all-cause mortality was 3.4% for those younger than 75, 10.2% for those aged 75 to 84, and 19.8% for those aged 85 and older (P <.001). In multivariable analysis adjusting for baseline characteristics, timely delivery of reperfusion therapy was associated with lower in-hospital mortality (adjusted odds ratio=0.63, 95% confidence interval=0.46-0.85) with no significant heterogeneity between age groups (P-value for interaction = .45). CONCLUSION: Older adults meeting contemporary eligibility criteria for reperfusion therapy continue to receive delayed reperfusion therapy and experience higher mortality than their younger counterparts.

Compliance with guidelines on antibiotic prophylaxis in total hip replacement surgery: results of a retrospective study of 416 patients in a teaching hospital.

OBJECTIVE: To assess compliance of anesthesiologist practices in antibiotic prophylaxis during total hip replacement (THR) surgery with the French Society of Anesthesiology and Intensive Care consensus-based guidelines. DESIGN: Retrospective review of medical records. Compliance of anesthesiologist practices with the guidelines was assessed according to antibiotic prophylaxis use, antimicrobial agent, dosage of first injection, time from first dose to incision, and total duration of antibiotic prophylaxis. SETTING: Orthopedic surgery wards in a 2,200-bed French teaching hospital. PATIENTS: A random sample of 416 patients undergoing THR from January 1999 to December 2000. RESULTS: Three hundred eighty-six (93%) of the sampled medical records were usable. Antibiotic prophylaxis was used for 366 (95%) of the patients. Total duration of prophylaxis did not exceed 48 hours in 98% (359 of 366) of the patients. Drug selection complied with national guidelines in 259 (71%) of the patients. Dosage and timing of the first injection were appropriate in 98% (290 of 296) and 80% (236 of 296) of the patients, respectively, who received one of the recommended antibiotics. Overall, 53% (203 of 386) of the patients met all five criteria. In multivariate analysis, there was a significant anesthesiologist effect on overall compliance with the guidelines (likelihood ratio chi-square with 9 degrees of freedom, 25.7; P < .01). Undergoing surgery during 2000 was the only patient characteristic associated with an increased rate of appropriate practices (adjusted OR, 1.56; CI95 1.02-2.38). CONCLUSION: The overall compliance rate should be improved by disseminating the guidelines and the results of this study following audit and feedback.

[Management of acute community-acquired pneumonia in a health centre. Assessment of 101 cases using the retrospective clinical audit method]. / Prise en charge des pneumonies aiguës communautaires en établissement de santé. Evaluation de 101 cas par la méthode d'audit clinicque rétrospectif.

OBJECTIVE: To assess the conformity of practitioners' practices in the management of community acquired pneumonia with the French Agence Nationale d'Accréditation et d'Evaluation en Santé (Anaes) guidelines. METHODS: We retrospectively reviewed a random sample of 210 medical records which included a principal or associated diagnosis of pneumonia in a French university hospital. RESULTS: A hundred and one medical records were assessable. Sixty-two patients were high risk (Pneumonia Severity Index class IV or V of the prediction rule of Fine et al.), and 10 patients were admitted into an intensive care unit. The overall in-hospital mortality was 14 patients [8-22]. The level of care was appropriate according to the guidelines in 40 cases ([30-50)]. Seven patients did not require hospitalisation, 31 patients required admission into a medical department, 56 patients into an intensive care unit and 7 patients were managed in non specified conditions. Eighteen patients ([11-27]) had appropriate microbiologic investigations. Forty-three patients (([33-53]) received antibiotics within 8 hours of arrival. Empirical antibiotic treatment (dosage and molecule) was appropriate in 38 patients ([28-48]). There was no significant relationship between compliance with the guidelines and in-hospital mortality. CONCLUSION: The rate of conformity of practitioners' practices with the Anaes guidelines for management of community-acquired pneumonia is low in our hospital. It could be improved by active implementation of these guidelines.

Refinement and validation of a French in-patient experience questionnaire.

The objective of this study was to check psychometric properties of a French-language in-patient experience questionnaire in a test sample different from the development sample. The questionnaire was sent out to 5,736 in-patients, within two to four weeks of discharge from a teaching hospital of 2,200 beds. Overall 4,095 questionnaires (71.4 per cent) were returned. Of these, 3,879 questionnaires were analyzed. In principal component analysis, seven principal components accounted for 62.4 per cent of the total variance. Cronbach's alpha coefficient ranged from 0.62 to 0.90, with the exception of the seventh scale (convenience scale, two items, Cronbach = 0.39). The overall patient experience score increased with increasing patient age (except for patients older than 65), male sex, low education level, use of a single room, and prior stay in the department. It also differed with respect to patients' behavioral intentions, answers to an overall satisfaction item, and open-ended comments.

Compliance with instructions for writing structured care management tools.

The aim of this study was to assess whether clinical guidelines complied with the instructions for writing structured care management tools in a French university hospital. A cross-sectional study of guidelines for appropriate antimicrobial agent use in the authors' institution was carried out. A total of 221 guidelines were retrieved in 62 hospital units. The number of guidelines by unit ranged from one to 22 and 198 guidelines (90 per cent) had been developed at the local level. None of the guidelines fully complied with the ten criteria of the instructions. Each guideline met, on average, 4.2 criteria (3.9-4.5). The partial compliance rate was 75 per cent (68-80). In two-level multivariate analysis, factors associated with partial compliance were: dissemination of guidelines after implementation of the instructions (odds ratio = 6.25 (2.41-16.21)), existence of more than one storage site for guidelines in each unit (OR = 3.26 (1.03-10.32)), and hospital unit (variance of the intercept = 1.54).

Regional system of care for ST-segment elevation myocardial infarction in the Northern Alps: a controlled pre- and postintervention study.

BACKGROUND: Regionalization of care for ST-segment elevation myocardial infarction (STEMI) has been advocated, although its effect on processes of care and clinical outcomes remains uncertain. AIM: To assess the impact of a regional system of care on provision of reperfusion therapy for STEMI patients relative to control hospitals. METHODS: We analysed the original data from two nationwide prospective cohort studies conducted in 2000 and 2005, respectively. Overall, 160 hospitals participated in both studies, including seven hospitals involved in a regional system of care implemented in the Northern Alps in 2002 and 153 control hospitals located in other French areas. RESULTS: A total of 102 and 2377 STEMI patients were enrolled in Northern Alps and control hospitals, respectively. Overall, patients enrolled in 2005 were more likely to receive any reperfusion therapy (60% vs 52%; P < 0.001), prehospital fibrinolysis (33% vs 15%; P < 0.001), and primary percutaneous coronary intervention (32% vs 26%; P < 0.001) than those enrolled in 2000. However, the regional system of care was associated with a larger absolute change in the use of prehospital fibrinolysis (45.0 vs 17.0; P = 0.02) and rescue or early routine coronary angiography or intervention after fibrinolysis (35.3 vs 15.2; P = 0.01). Patients enrolled in 2005 had lower adjusted hazard ratios for death (0.70, 95% confidence interval 0.57-0.87; P = 0.001), with no significant interaction between study groups. CONCLUSION: Regionalization of care for STEMI patients improves access to reperfusion therapy, although its impact on clinical outcomes deserves further study.

Quality of care for myocardial infarction at academic and nonacademic hospitals.

BACKGROUND: Whether academic hospitals provide better quality of care for patients with acute myocardial infarction is widely debated. The aim of this study was to compare processes of care and mortality between academic and nonacademic hospitals in the contemporary era of acute myocardial infarction management. METHODS: We analyzed the original data from a prospective cohort study of 3059 patients, including 1714 with ST-segment elevation and 1345 with non-ST-segment elevation myocardial infarction, enrolled at 39 and 183 academic and nonacademic hospitals, respectively, in France. RESULTS: Unadjusted 1-year mortality for academic and nonacademic hospitals was 10% versus 15% for patients with ST-segment elevation myocardial infarction (P=.01) and 13% versus 14% for patients with non-ST-segment elevation myocardial infarction (P=.75). Patients treated in academic or nonacademic hospitals with percutaneous coronary intervention capability were more likely to receive reperfusion and recommended drug therapies than those treated in nonacademic hospitals without percutaneous coronary intervention capability. After adjusting for baseline characteristics, the hazards of death associated with admission to nonacademic hospitals with and without percutaneous coronary intervention capability relative to academic hospitals were 1.13 (95% confidence interval [CI], 0.79-1.62) and 1.65 (95% CI, 1.09-2.49) for those with ST-segment elevation myocardial infarction and 0.95 (95% CI, 0.66-1.36) and 1.06 (95% CI, 0.72-1.58) for those with non-ST-segment elevation myocardial infarction, respectively. Further adjustment for receipt of acute reperfusion and recommended drug therapies eliminated all differences in mortality between the study groups. CONCLUSION: Admission to academic hospitals was associated with a more frequent use of recommended therapies, conveying a survival advantage for patients with ST-segment elevation myocardial infarction.

[Factors associated with delay in calling Emergency Medical Services ("15") for patients with ST-elevation myocardial infarction in southern Isère]. / Facteurs associés au délai d'appel au centre 15 du service d'aide médicale urgente chez les patients ayant un syndrome coronaire aigu avec sus-décalage du segment ST dans le sud du département de l'Isère.

BACKGROUND: Time until revascularization is an important prognostic factor for patients with ST-elevation myocardial infarction. The objective of this study was to investigate the factors associated with patients' delay in calling for emergency medical services (SAMU, "15" in France). METHODS: We analyzed the original data of a permanent prospective register of patients receiving care from mobile intensive care units staffed by emergency physicians and dispatched by SAMU in southern Isère (France), from October 1, 2002, through December 31, 2004. RESULTS: Of the 380 patients analyzed, 71% were men and 15% had a history of coronary disease. The median age was 60 years for men and 72 for women. The median time from symptom onset to calling SAMU was 63 minutes (interquartile range, 27 to 144). In the univariate analyses, the time to the call was higher for women (90 v 58, p<0.01) and increased with age (p<0.01) and prior calls to a physician or nurse (115 v 45, p<0.001). In the multivariable analysis, factors independently associated with delay in calling SAMU included female gender, age of 55-64 years, prior calls to a physician or nurse, and onset of pain during the weekend or at night. The media call delay did not differ for patients with and without a history of coronary disease. CONCLUSION: The subpopulations of patients characterized by the factors associated with delayed calls should be the target of programs to stress the importance of calling SAMU quickly, regardless of the time of day; the effectiveness of these programs should be evaluated by randomized studies before they enter general use.

Assessment of a structured in-hospital educational intervention addressing breastfeeding: a prospective randomised open trial.

OBJECTIVE: To determine whether a single one-to-one in-hospital education session could increase the rate of breastfeeding at 17 weeks. DESIGN: A prospective, randomised, parallel group, open trial. SETTING: A level two maternity hospital in France. SAMPLE: Breastfeeding mothers who were employed outside the home prenatally and were delivered of a healthy singleton. INTERVENTION: A structured one-to-one in-hospital education session. METHODS: One hundred and six mother-infant pairs were allocated to the intervention group and 104 to the control group (receiving usual verbal encouragement). A total of 93 mother-infant pairs in the intervention group and 97 in the control group provided complete data for final evaluation of efficacy. MAIN OUTCOME MEASURE: Rate of breastfeeding at infant age of 17 weeks. RESULTS: There was no significant difference between the two groups in the rate of any breastfeeding (34.4% in the intervention group vs 40.2% in the control group, relative risk = 0.86 [0.52-1.40]), and in the rate of exclusive breastfeeding (14.0% in the intervention group vs 14.4% in the control group, relative risk = 0.97 [0.42-2.22]). CONCLUSION: Our findings suggest that a single in-hospital educational intervention has no effect on the breastfeeding rate at four months. Guidance provided by maternity staff should be reinforced by a long term multifaceted support programme in countries with a low to intermediate rate of breastfeeding.

Patient compliance with medical advice given by telephone.

Data on compliance with medical advice given by telephone consultation services are currently lacking. The aim of this study was to assess patient compliance with medical advice given by a call center. A cross-sectional telephone survey was carried out on a random sample of 463 callers 72 hours after contacting the Grenoble Dial 15 center in France. Four hundred nine subjects (88.3%) participated in the study. Of these, 286 callers (69.9%) complied with the medical advice given. Compliance was 61.4% among patients who were advised to treat themselves, 83.9% among patients who were advised to consult a general practitioner during business hours, and 64.0% among patients who were advised to go to an accident and ED (P <.01). The survey pointed out adverse events resulting from the service. Assessing patient compliance can be an important source of information for improving aspects of patient management provided by telephone consultation services.