Abstract 12900: Quality of Care at Discharge is Affected by Hospital Case Volume in Acute Myocardial Infarction Patients. A French Nationwide Assessment
Background: Quality indicators (QI) at discharge (appropriate prescription of aspirin, betablockers, ACEI and statins at discharge after acute myocardial infarction (AMI)) can be used to assess the impact of hospital volume on quality of care.
Methods: A nationwide assessment of QI at AMI discharge was conducted in France by the National Authority for Health (HAS) in 2008 and 2009. Prescription at discharge of aspirin+clopidogrel, beta-blockers, angiotensin conversion enzyme inhibitors (ACEI) when left ventricular ejection fraction <40%, and statins, or non-prescription in case of absolute contra indication, was considered appropriate. All hospitals admitting at least 10 AMI/year collected data for QI calculation in a random selection of up to 60 patient files. From 2008 data, a composite score was computed using the All-or-None method (AON): 1 point was allocated if all QIs scored 1 and 0 points if at least 1 QI scored 0. Odds ratios (OR) adjusted for age and gender were calculated for the probability of inappropriate prescription according to hospital case volume (reference = highest volume). Confirmatory analyses were performed with the 2009 data.
Results: In 2008, 589 hospitals participated for a total of 17,720 patient records; 60% were low volume (<30 AMI per year). The composite AON score showed wide variation according to hospital case volume. After adjustment, patients in the lowest volume category had a 2.1 (CI 1.8-2-5) times greater risk of having at least 1 inappropriate prescription than those in the highest volume category. Each indicator showed the same trend, except ACE prescription, which concerned a lower number of patients. Age and female gender were predictors of inappropriate prescription. Subsequent analysis of 11,744 patient records in 2009 confirmed these results.
Conclusions: Appropriateness of prescription at discharge is lower in low-volume hospitals. Quality of care improves with volume up to a threshold of 120 cases per year.
- © 2011 by American Heart Association, Inc.