Volume of Acute MI Cases Linked with Appropriate Medication Prescribing

The volume of acute myocardial infarction (MI) cases is a valid indicator of quality, with high-volume hospitals coming out well ahead of lower-volume centers with regard to appropriate prescribing of medications at discharge, according to a large French study published online December 11, 2012, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

Researchers led by François Schiele, MD, PhD, of the University Hospital Jean Minjoz (Besançon, France), compiled data from 46,390 records from nearly all health care centers in France from 2008 to 2010. An independent medical team then analyzed prescriptions using a computer-based algorithm. Quality indicators for acute MI were defined as appropriate prescription at discharge of aspirin, clopidogrel, beta blockers, statins, and ACE inhibitors in patients with LVEF less than 0.40.

Volume per hospital was classified into 7 categories according to total number of admissions for AMI.

High Volume Wins Out

Compared with the highest-volume hospitals (> 300 cases), centers with the lowest volume (10-29) were less likely to meet all measures of quality. Although appropriate prescribing of antiplatelets, beta-blockers, ACE inhibitors, and statins at discharge increased over time, the relationship between volume and quality of care persisted (tables 1 and 2).

Table 1. Lowest Volume Centers

Table 2. Highest Volume Centers

The study authors say the findings go beyond previous reports suggesting a link between volume and mortality.

“These observations suggest that the difference in mortality is truly related [not to volume alone but] to the quality of care,” they write. “The progression in quality with increasing volume seems linear, without any clear threshold value. This contradicts what has been shown for the volume-mortality association, for which a threshold was seen of > 600 cases per year.”

Furthermore, the authors say quality indicators are a more comprehensive form of measurement than mortality outcomes alone because the magnitude of the difference in these metrics according to volume is comparable to the rate of contraindications recorded for beta blockers or ACE inhibitors. They also point out that current guidelines from the European Society of Cardiology recommend that the indicators be recorded after AMI with or without STEMI.

Quality Improvement Programs May Help

In an e-mail communication with TCTMD, Deepak L. Bhatt, MD, MPH, of Brigham and Women’s Hospital (Boston, MA), said the results likely apply to the United States, as well.

“Centers that are higher volume, in general, tend to have greater compliance with following the guidelines,” he noted. “However, there is a bit of subtlety to these types of associations. Larger, higher volume centers may have more resources available for infrastructure and quality improvement initiatives. They may have more resources for better documentation. And they may also have more expertise just from taking care of more patients. However, studies in the United States have shown that even lower volume hospitals can achieve very good performance if they participate in a quality improvement initiative (such as those sponsored by the [American Heart Association and the American College of Cardiology]).”

 

---

Source:
Schiele F, Capuano F, Loirat P, et al. Hospital case volume and appropriate prescriptions at hospital discharge after acute myocardial infarction: A nationwide assessment. Circ Cardiovasc Qual Outcomes. 2013;Epub ahead of print.

 

 

Related Stories:

• AMI Patients Have Lower 30-Day Mortality at High-Volume Hospitals
• Primary PCI Volume May Not Affect In-Hospital Mortality
• For Low Mortality in Primary PCI, It’s All About Volume