Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial i

1
Impact of specialty of admitting physician and
type of hospital on care and outcome for
myocardial infarction in England and Walesduring
2004-5 observational study
Myocardial Infarction National Audit Project
BMJ 20063321306-1311
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Management of AMI 1/1/04 31/3/05
Myocardial Infarction National Audit Project
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Management of AMI 1/1/04 31/3/05
Myocardial Infarction National Audit Project
4
Patient characteristics and co-morbidities of
those patients managed by cardiologists and
non-cardiologists
Myocardial Infarction National Audit Project
No significant difference in history of AMI,
angina, hyperlipidaemia, hypertension after
adjustment for age
5
Reperfusion therapy for STEMI
Myocardial Infarction National Audit Project
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Reperfusion therapy for STEMI
Myocardial Infarction National Audit Project
7
Proportion of patients with STEMI who did not get
reperfusion therapy
Myocardial Infarction National Audit Project
Interventional hospital
Non-interventional hospital
8
Myocardial Infarction National Audit Project
Those patients with STEMI admitted under a
cardiologist were more likely to receive
reperfusion therapy
Older patients were less likely to receive
reperfusion therapy
Adjusted risk ratio for no reperfusion therapy
for cardiologist relative to non-cardiologist Int
erventional hospital 0.63 (95CI
0.45-0.87) Non-interventional hospital 0.84
(95CI 0.74-0.96)
9
Proportion of patients with MI who did not get
secondary preventive therapyexcludes inpatient
deaths, interhospital transfer, unknown
destination
Myocardial Infarction National Audit Project
10
Myocardial Infarction National Audit Project
Older patients surviving to discharge were less
likely to receive secondary preventive therapy
Those patients admitted under cardiologists were
more likely to receive statins and beta blockers
on discharge than those admitted under
non-cardiologists
Adjusted risk ratio for no secondary preventive
therapy For cardiologist relative to
non-cardiologist Aspirin 1.00 (95CI
0.86-1.15) Beta-blocker 0.92 (95CI
0.87-0.97) Statin 0.83 (95CI 0.71-0.97) ACEI
0.98 (95CI 0.91-1.06)
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Use of angiography during index admission
Myocardial Infarction National Audit Project
Interventional hospitals
Non-interventional hospitals
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Proportion of patients who underwent angiography
n79,374
Myocardial Infarction National Audit Project
Interventional hospital
Non-interventional hospital
13
Myocardial Infarction National Audit Project
Diagnostic angiography was more likely to be
performed during the index admission if patients
were admitted to an interventional hospital, in
younger patients, and, for those admitted to a
non-interventional hospital, when admitted under
a cardiologist
Adjusted risk ratio for angiography being
performed for cardiologist relative to
non-cardiologist In interventional hospital 1.10
(95CI 0.97-1.25) In non-interventional hospital
1.20 (95CI 1.07-1.38)
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90 day all-cause mortality n76,376
Myocardial Infarction National Audit Project
Interventional hospital
Non-interventional hospital
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Myocardial Infarction National Audit Project
Crude mortality rates show a clear age gradient
with older patients being at greater risk
Crude 90 day mortality rates are higher for
nSTEMI than for STEMI
When adjusted for patient characteristics the
type of hospital did not influence the 90 day
mortality
Overall 90 day mortality 14.0 - STEMI 11.8 -
nSTEMI 15.4 Adjusted risk ratio of death for
interventional vs non-interventional hospital
0.93 (95CI 0.82-1.06)
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Adjusted 90 day mortality risk (95 CI) for
patients admitted under cardiologists relative to
non-cardiologists
Myocardial Infarction National Audit Project
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Conclusions
Myocardial Infarction National Audit Project

• The majority of patients with MI are admitted to
  hospitals without interventional facilities and
  under the care of non-cardiologists
• Patients admitted under cardiologists were
  younger and more likely to be male with less
  co-morbidity, to have STEMI and are more likely
  to receive reperfusion and secondary preventive
  therapies
• Angiography is performed in the minority of
  patients and is related to age of patient, type
  of hospital and (in non-interventional hospitals)
  to specialty of admitting doctor

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Conclusions
Myocardial Infarction National Audit Project

• 90 day all-cause mortality is strongly associated
  with age
• nSTEMI have poorer unadjusted prognosis than
  STEMI
• Adjusted 90 day mortality is lower for patients
  admitted under a cardiologist for both STEMI and
  nSTEMI in both interventional and
  non-interventional hospitals