Quality of care of Medicare beneficiaries with acute myocardial infarction: who is included in quality improvement measurement?

OBJECTIVES: To determine the proportion of older patients hospitalized with acute myocardial infarction (AMI) incorporated in a commonly used set of AMI quality indicators.

DESIGN: Retrospective analysis of a medical record database.

SETTING: Nongovernmental U.S. acute care hospitals.

PARTICIPANTS: Medicare patients hospitalized for AMI between January 1994 and February 1996.

MEASUREMENTS: Proportion of patients aged 65 and older classified as ideal candidates (without absolute or relative contraindications) for six Centers for Medicare & Medicaid Services AMI quality indicators: aspirin (admission, discharge), beta-blocker (admission, discharge), angiotensin-converting enzyme (ACE) inhibitors at discharge, and time to reperfusion therapy.

RESULTS: Of the 149,996 patients eligible for admission therapies, 10.1% were ideal candidates for reperfusion therapy, 65.0% for aspirin, and 34.7% for beta-blockers. Of the 116,919 patients eligible for discharge therapies, 47.7% were ideal candidates for aspirin, 17.6% for beta-blockers, and 15.2% for ACE inhibitors. More than one-quarter (26.8%) of all patients were ineligible for any of the six quality indicators; this proportion increased with age, ranging from 23.7% of patients aged 65 to 69 to 30.2% of patients aged 85 and older.

CONCLUSION: A substantial proportion of older patients were not included in AMI process quality measurement, with the proportion excluded higher in successively older age groups. The data highlight the need for additional research to determine effective treatment strategies for patients for whom the evidence base for clinical decision-making remains weak.