ORIGINAL REPORTS:CARDIOVASCULAR DISEASE AND RISK FACTORS ACUTE MYOCARDIAL INFARCTION QUALITY OF CARE:THE STRONG HEART STUDY Objectives: Evaluate the quality of care Lyle G. Best, MD; Amir Butt, MPH; Britt Conroy, PhD; provided patients with acute myocardial in- Richard B. Devereux, MD; James M. Galloway, MD; farction and compare with similar national and regional data. Stacey Jolly, MD; Elisa T. Lee, PhD; Angela Silverman, CNP; Jeun-Liang Yeh, PhD; Thomas K. Welty, MD; Ilan Kedan, MD Design: Case series. Setting: The Strong Heart Study has extensive INTRODUCTION ation’s Get With The Guidelines coro- population-based data related to cardiovascu- nary artery disease program.9 lar events among American Indians living in three rural regions of the United States. Differences in utilization of health There have been efforts to use these care services and the quality of those programs and quality measures to Participants: Acute myocardial infarction cases services between geographic regions of determine the role they play in the (72) occurring between 1/1/2001 and 12/31/2006 the United States exist.1,2 Public policy, known cardiovascular disease disparities were identified from a cohort of 4549 participants. guidelines, and health care organizations among minority populations.10,11 Car- Outcome measures: The proportion of cases have attempted to address these differ- diovascular disease accounts for a large that were provided standard quality of care ences. In 1992 the Healthcare Financ- proportion of morbidity and mortality therapy, as defined by the Healthcare Financing ing Administration, now the Center for among American Indians.12,13 Yet, Administration and other national organizations. Medicare/Medicaid Services (CMS), studies of cardiovascular disease quality Results: The provision of quality services, such initiated the Cooperative Cardiovascu- of care among American Indians are 14–16 as administration of aspirin on admission and lar Project with the goal of improving limited. at discharge, reperfusion therapy within the quality of care for acute myocardial The Strong Heart Study is a longi- 24 hours, prescription of beta blocker medi- infarction (AMI) nationally.3 Standards tudinal cohort study of cardiovascular cation at discharge, and smoking cessation were developed for the evaluation of disease and its risk factors in American counseling were found to be 94%, 91%, 92%, 86% and 71%, respectively. The unadjusted, quality care based on the guidelines of Indians. It is the longest-running pop- 30 day mortality rate was 17%. the American College of Cardiology ulation-based cohort study among and the American Heart Association.4 American Indians with centers in three Conclusion: Despite considerable challenges The initial results from this national primarily rural geographic regions in the posed by geographic isolation and small survey of AMI quality care was present- United States. It has rich demographic facilities, process measures of the quality of 5 acute myocardial infarction care for partici- ed in 1998 and a follow-up survey and clinical data including physician 6 pants in this American Indian cohort were reported in 2003. National perfor- adjudicated cardiovascular events. In comparable to that reported for Medicare mance since 1999 has been evaluated this study, we describe AMI quality beneficiaries nationally and within the resident primarily on the basis of data from care measures from the Strong Heart states of this cohort. (Ethn Dis. 2011;21(3): voluntary reporting systems, such as the 294–300) Study and then compare them to National Registry of Myocardial Infarc- previously published studies from CMS. 7 Key Words: Acute Myocardial Infarction, tion, The National Cardiovascular 8 Ethnicity, Guideline Adherence, Outcome Data Registry, the CMS and Hospital and Process Assessment, Quality Indicators Quality Alliance Program (begun in 2004), and the American Heart Associ- In this study, we describe AMI From Missouri Breaks Industries Re- quality care measures from the search Inc, Timber Lake, South Dakota Cleveland (SJ) and Medstar Research Insti- (LGB, BC, TKW) and University of Okla- tute, Hyattsville, Maryland (AS) and Cedars- Strong Heart Study and then homa Health Sciences Center, Oklahoma Sinai Hospital, Los Angeles (IK). City (AB, ELT, JLY) and Weill Cornell compare them to previously Medical Center, New York, New York Address correspondence to Lyle G. (RBD) and Feinberg School of Medicine, Best; PO Box 88, 366 786th St.; Rolette, published studies from CMS. Northwestern University, Chicago (JMG) ND 58366; 701.246.3884; 605.964.3415 and Cleveland Clinic Medicine Institute, (fax); [email protected] 294 Ethnicity & Disease, Volume 21, Summer 2011 MYOCARDIAL INFARCTION QUALITY OF CARE - Best et al Table 1. Acute myocardial infarction quality of care criteria Selected Indications, Criterion Candidates Timeliness Standard Contraindications or Exceptions Oral ASA all AMI within 24 hours of admission allergy to ASA, bleeding on admission Beta blocker all AMI within 24 hours of admission pulse,60, CHF, pulmonary edema, shock, heart block, COPD Angiotensin converting enzyme all AMI within 24 hours of admission allergy, history of angioedema inhibitor (ACE-I) Timely reperfusion: thrombolytic chest pain ,12 hours AND within 24 hours of admission bleeding diathesis, age.80, previous stroke, therapy OR revascularization (PCI ST elevation in 2 surgery in past 2 months, bilirubin.2.0, or CABG) contiguous leads warfarin therapy, trauma in past month ASA at discharge all discharges at discharge allergy to ASA, bleeding or platelets,100,000, creatinine.3.0, Hgb,10.0gm/dL Beta blocker at discharge all discharges at discharge pulse,50 (not previously on beta blocker), heart block, COPD, LVEF,30%, SBP, 90mm Hg ACE-I at discharge if LVEF ,40% at discharge creatinine.2.0 mg/dL allergy, aortic stenosis, last SBP,100 (off ACE-I) Smoking cessation counseling all smokers at discharge no reported tobacco abuse Dyslipidemia screening all discharges during hospital stay none Dietary counseling cases with dyslipidemia at discharge none Medication treatment for cases with dyslipidemia at discharge if LDL-C,100mg/dL and triglycerides hyperlipidemia ,150mg/dL Cardiac rehab all discharges at discharge none Note: ASA, aspirin; CHF, congestive heart failure; LVEF, left ventricular ejection fraction; LDL-C, low density lipoprotein, cholesterol; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention; CABG, coronary artery bypass graft surgery; Hgb, hemoglobin. METHODS ing procedures diagnostic of coronary Acute Myocardial Infarction artery disease, (eg, treadmill test, coro- Quality of Care Strong Heart Study nary angiography). Using information The AMI’s ascertained for the The American Indian communities from the medical records, death certif- present study almost invariably included participating in the Strong Heart Study icates, and standard criteria, trained transfer to tertiary care facilities, due to (SHS), the study design, survey meth- physician adjudicators then determined the very rural nature of the populations ods and laboratory techniques have been the specific coronary artery disease and the lack of invasive procedure described previously in detail.17,18 Brief- diagnosis according to standardized capability of most local facilities. Be- ly it is a population based cohort of criteria.17,18 yond this, the quality of care criteria we 4549 participants aged 45 to 74 years evaluated are similar to those of the that began in 1989. At baseline and two Acute Myocardial previous CMS studies.5,6,19 Table 1 subsequent follow-up periods approxi- Infarction Cases shows the quality of care standards that mately 4 and 8 years from baseline, a We included cases if they had were incorporated into an abstraction physical examination, fasting venipunc- sustained a SHS-defined, definite algorithm used by SHS physician re- ture, standardized blood pressure mea- AMI, either fatal or non-fatal, between viewers. surements, and electrocardiograms were January 1, 2001 and December 31, 17,18 obtained. 2006.17,18 The definition did not dif- Demographic and ferentiate between ST segment elevation Clinical Characteristics Cardiovascular Disease Events AMI or non-ST segment elevation AMI Participants were defined as having Ascertainment of fatal and nonfatal cases. We excluded participants with a diabetes according to 1997 American cardiovascular events was accomplished diagnosis of possible AMI, or an AMI Diabetes Association criteria.20 Partici- by medical record review and/or yearly occurring during an acute hospitaliza- pants were defined as having hyperten- participant contact followed by physi- tion for another medical condition. sion if they were taking anti-hyperten- cian adjudication.17,18 Trained medical Additionally, we excluded one case sive medications, had a systolic blood record abstractors reviewed medical because the time between AMI diagno- pressure $140 mm Hg, or a diastolic records for all potential coronary artery sis and subsequent, elective referral was blood pressure $90 mm Hg. The disease events or interventions, includ- an extreme outlier at 23 days. prevalence of hypertension, diabetes or Ethnicity & Disease, Volume 21, Summer 2011 295 MYOCARDIAL INFARCTION QUALITY OF CARE - Best et al prior cardiovascular event was calculated who actually received the measure or and 58 possible AMI by SHS criteria. from those cases with evidence of this criterion. Chi-square statistics were used After exclusions, 72 cases