Missed opportunities for reperfusion therapy for ST-segment elevation myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study.

BACKGROUND: Although it is known that reperfusion therapy for ST-elevation myocardial infarction (STEMI) is underused, the reasons for the failure to provide this potentially life-saving treatment are not well described. METHODS: In a cohort of 2215 consecutive patients presenting with acute myocardial infarction to 5 emergency departments in Colorado and California between 2000 and 2002, patients with ischemic symptoms and ST-segment elevation on electrocardiogram without documented guideline-based contraindications to therapy were identified as eligible reperfusion candidates. Multivariable logistic models were constructed to identify factors associated with the failure to receive reperfusion. The emergency department records of patients not receiving reperfusion were reviewed to categorize the reasons therapy was not provided. RESULTS: Of 460 eligible patients, 102 (22%) did not receive reperfusion therapy. Patient factors associated with failure to receive reperfusion therapy included older age, peripheral vascular disease, and absence of chest pain; patients seen by both resident and attending physicians were more likely to receive treatment than those seen by an attending alone. In cases where reperfusion was not provided, ST-segment elevation was not identified in 34% (n = 35), left bundle-branch block was not considered as an indication in 13% (n = 13), there was documentation of a reason for withholding therapy not supported by guidelines in 34% (n = 35), and there was no documentation of reasons for withholding reperfusion in 19% (n = 19). CONCLUSIONS: Initiatives to improve electrocardiogram interpretation and evidence-based patient selection may reduce gaps in the delivery of reperfusion therapy to eligible candidates and thereby potentially improve STEMI outcomes.

Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study.

BACKGROUND: The impact of misinterpretation of the ECG in patients with acute myocardial infarction (AMI) in the emergency department (ED) setting is not well known. Our goal was to assess the prevalence of the failure to identify high-risk ECG findings in ED patients with AMI and to determine whether this failure is associated with lower-quality care. METHODS AND RESULTS: In a retrospective cohort study of consecutive patients presenting to 5 EDs in California and Colorado from July 1, 2000, through June 30, 2002, with confirmed AMI (n=1684), we determined the frequency of the failure by the treating provider to identify significant ST-segment depressions, ST-segment elevations, or T-wave inversions on the presenting ECG. In multivariable models, we assessed the relationship between missed high-risk ECG findings and evidence-based therapy in the ED after adjustment for patient characteristics and site of care. High-risk ECG findings were not documented in 201 patients (12%). The failure to identify high-risk findings was independently associated with a higher odds of not receiving treatment among ideal candidates for aspirin (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.51 to 2.94), beta-blockers (OR, 1.85; 95% CI, 1.14 to 3.03), and reperfusion therapy (OR, 7.69; 95% CI, 3.57 to 16.67). Among patients with missed high-risk ECG findings, in-hospital mortality was 7.9% compared with 4.9% among those without missed findings (P=0.1). CONCLUSIONS: The failure to identify high-risk ECG findings in patients with AMI results in lower-quality care in the ED. Systematic processes to improve ECG interpretation may have important implications for patient treatment and outcomes.

Patient sex and quality of ED care for patients with myocardial infarction.

OBJECTIVE: The aim of the study was to assess the quality of care between male and female emergency department (ED) patients with acute myocardial infarction (AMI). METHODS: A 2-year retrospective cohort study of 2215 patients with AMI presenting immediately to 5 EDs from July 1, 2000, through June 30, 2002 was conducted. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from chart and electrocardiogram reviews. Multivariable regression models were used to assess the independent association between sex and the ED administration of aspirin, beta-blockers, and reperfusion therapy to eligible patients with AMI. RESULTS: There were 849 women and 1366 men in the study. Female patients were older than male patients (74.3 years for women vs 66.8 years for men, P < .001). Among ideal patients, women were less likely than men to receive aspirin (76.3% of women vs 81.3% of men, P < .01), beta-blockers (51.7% of women vs 61.4% of men, P < .01), and reperfusion therapy (64.0% of women vs 72.8% of men, P < .05). However, after adjustment for age, there was no longer a significant relationship between sex and the use of aspirin (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.95-1.03), beta-blockers (OR, 0.94; 95% CI, 0.82-1.04), or reperfusion therapy (OR, 1.01; 95% CI, 0.89-1.09). In models adjusting for additional demographic, clinical, and hospital characteristics, there remained no association between sex and the processes of care. CONCLUSION: Women with AMI treated in the ED have a lower likelihood of receiving aspirin, beta-blocker, and reperfusion therapy. However, this association appears to be explained by the age difference between men and women with AMI. Although there are no apparent sex disparities in care, ED AMI management remains suboptimal for both sexes.

Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients.

STUDY OBJECTIVE: We assessed the independent relationship between age and the quality of medical care provided to patients presenting to the emergency department (ED) with acute myocardial infarction. METHODS: We conducted a 2-year retrospective cohort study of 2,216 acute myocardial infarction patients presenting urgently to 5 EDs in Colorado and California from July 1, 2000, through June 30, 2002. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from the ED record and ECG review. Patients were divided into 6 groups based on their age at the time of their ED visit: younger than 50 years, 50 to 59 years, 60 to 69 years, 70 to 79 years, 80 to 89 years, and 90 years or older. Hierarchic multivariable regression was used to assess the independent association between age and the provision of aspirin, beta-blockers, and reperfusion therapy (fibrinolytic agent or percutaneous coronary intervention) in the ED to eligible acute myocardial infarction patients. RESULTS: Of ideal candidates for treatment in the ED, 1,639 (80.5%) of 2,036 received aspirin, 552 (60.3%) of 916 received beta-blockers, and 358 (77.8%) of 460 received acute reperfusion therapy. After adjustment for demographic, medical history, and clinical factors, older patients were less likely to receive aspirin (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.77 to 0.93), beta-blockers (OR 0.79, 95% CI 0.71 to 0.88), and reperfusion therapy (OR 0.30, 95% CI 0.18 to 0.52). CONCLUSION: Older patients presenting to the ED with acute myocardial infarction receive lower-quality medical care than younger patients. Further investigation to identify the reasons for this disparity and to intervene to reduce gaps in care quality will likely lead to improved outcomes for older acute myocardial infarction patients.