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(Circulation. 2006;114:2806-2814.)
© 2006 American Heart Association, Inc.

Health Services and Outcomes Research

Trends in Acute Myocardial Infarction in 4 US States Between 1992 and 2001

Clinical Characteristics, Quality of Care, and Outcomes

Frederick A. Masoudi, MD, MSPH; JoAnne M. Foody, MD; Edward P. Havranek, MD; Yongfei Wang, MS; Martha J. Radford, MD; Richard M. Allman, MD; Jay Gold, MD, JD; R. Todd Wiblin, MD; Harlan M. Krumholz, MD, SM

From the Department of Medicine, Denver Health Medical Center (F.A.M., E.P.H.), and Department of Medicine, University of Colorado Health Sciences Center (F.A.M., E.P.H.), Denver, Colo; Colorado Foundation for Medical Care (F.A.M., E.P.H.) and Colorado Health Outcomes Program (F.A.M.), Aurora, Colo; Department of Medicine, Yale University School of Medicine, New Haven, Conn (J.M.F., Y.W., H.M.K.); Qualidigm, Middletown, Conn (J.M.F., H.M.K.); Department of Medicine, West Haven VA Medical Center, West Haven, Conn (J.M.F.); Department of Medicine, New York University School of Medicine, New York, NY (M.J.R.); Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center, Birmingham, Ala (R.M.A.); Center for Aging and Division of Gerontology and Geriatric Medicine, University of Alabama at Birmingham (R.M.A.); Alabama Quality Assurance Foundation (R.M.A.), Birmingham, Ala; MetaStar, Madison, Wisc (J.G.); University of Iowa Carver College of Medicine, Iowa City (R.T.W.); Iowa Foundation for Medical Care, West Des Moines (R.T.W.); the Department of Epidemiology and Public Health, Yale School of Medicine, New Haven, Conn (H.M.K.); and Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Conn (H.M.K.).

Correspondence to Frederick A. Masoudi, MD, MSPH, Division of Cardiology MC 0960, Denver Health Medical Center, 777 Bannock St, Denver, CO 80204. E-mail fred.masoudi{at}uchsc.edu

Received January 1, 2006; revision received September 29, 2006; accepted October 10, 2006.

Background— Because of the health impact of acute myocardial infarction (AMI), substantial resources have been dedicated to improving AMI care and outcomes. Long-term trends in the clinical characteristics, quality of care, and outcomes for AMI over time from the health system perspective in geographically diverse populations are not well known.

Methods and Results— The present study included 20 550 Medicare patients aged 65 years hospitalized in 4 US states (Alabama, Connecticut, Iowa, Wisconsin) with the confirmed primary discharge diagnosis of AMI in 4 periods: 1992–1993 (n=10 292), 1995 (n=5566), 1998–1999 (n=2413), and 2000–2001 (n=2279). With the use of standard quality indicator definitions, treatment of ideal candidates with aspirin and ß-blockers within 24 hours after presentation, ß-blockers, and angiotensin-converting enzyme inhibitors at discharge was assessed. Multivariable models were constructed to calculate adjusted 1-year mortality. The hospitalized Medicare population with AMI changed substantially during 1992–2001, with increasing age, more comorbidity, and fewer meeting ideal treatment criteria. Although treatment rates increased significantly for all medications, aspirin, ß-blockers, and angiotensin-converting enzyme inhibitors were not provided at discharge to 12.6%, 19.7%, and 25.2% of ideal candidates, respectively, in 2000–2001. Crude 1-year mortality increased (27.6%, 28.3%, 30.6%, and 31.0%; P=0.003 for trend, but adjusted mortality declined (compared with 1992–1993, relative risk in 1995=0.94 [95% CI, 0.88 to 1.01]; relative risk in 1998–1999=0.91 [95% CI, 0.85 to 0.98]; relative risk in 2000–2001=0.87 [95% CI, 0.81 to 0.94]).

Conclusions— The quality of care and adjusted 1-year mortality improved significantly for Medicare beneficiaries with AMI during 1992–2001. Nevertheless, fewer were ideal for guideline-based therapy, and absolute mortality remains high, suggesting the need for treatment strategies applicable to a broader range of older patients.

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