Variations in quality of care for heart failure.

BACKGROUND: The objective of our study was to assess hospital-to-hospital variations for the management and treatment of heart failure (HF) patients. METHODS: We performed a cross-sectional study among randomly selected patients with ICD-10 (International Classification of Disease, 10th revision) HF hospitalised in three Swiss university hospitals in 1999. Demographic characteristics, risk factors, symptoms and findings at admission and discharge medications were abstracted. The main outcome measure was the percentage of patients receiving appropriate management and treatment as defined by quality of care indicators derived from evidence-based guidelines. Quality indicators were considered only when they could be applied (no contra-indications). RESULTS: Among 1153 eligible patients with HF the mean age (SD) was 75.3 (12.7), 54.3% were male. Among potential candidates for specific interventions left ventricular function (LVF) was determined in 68.5% of patients; 53.8% received target dose of angiotensin converting enzyme inhibitors (ACEI), 86.0% any dose of angiotensin receptor blockers; 21.9% b-blockers, and 62.1% anticoagulants at discharge. Compared to hospital B (reference), the adjusted odds ratios (OR) (95% CI) for LVF not determined were 3.82 (2.50 to 5.85) in hospital A and 3.25 (1.78 to 5.93) in hospital C. The adjusted OR (95% CI) for not receiving target dose ACEI was 1.76 (0.95 to 3.26) for hospital A and 3.20 (1.34 to 7.65) for hospital C compared to hospital B. CONCLUSIONS: Apparently, important hospital-to-hospital variations in the quality of care given to patients with HF could have existed between three academic medical centers

Variations in the quality of care of patients with acute myocardial infarction among Swiss university hospitals.

OBJECTIVE: The objective of our study was to assess hospital variations in the quality of care delivered to acute myocardial infarction (AMI) patients among three Swiss academic medical centres. DESIGN: Cross-sectional study. SETTING: Three Swiss university hospitals. STUDY PARTICIPANTS: We selected 1129 eligible patients discharged from these hospitals from 1 January to 31 December 1999, with a primary or secondary diagnosis code [International Classification of Diseases, 10th revision (ICD-10)] of AMI. We abstracted medical records for information on demographic characteristics, risk factors, symptoms, and findings at admission. We also recorded the main ECG and laboratory findings, as well as hospital and discharge management and treatment. We excluded patients transferred to another hospital and who did not meet the clinical definition of AMI. MAIN OUTCOME MEASURES: Percentage of patients receiving appropriate intervention as defined by six quality of care indicators derived from clinical practical guidelines. RESULTS: Among 577 eligible patients with AMI in this study, the mean (SD) age was 68.2 (13.9), and 65% were male. In the assessment of the quality indicators we excluded patients who were not eligible for the procedure. Among cohorts of 'ideal candidates' for specific interventions, 64% in hospital A and 73% in hospital C had reperfusion within 12 hours either with thrombolytics or percutaneous transluminal coronary angioplasty (P = 0.367). Further, in hospitals A, B, and C, respectively 97, 94, and 84% were prescribed aspirin during the initial hospitalization (P = 0.0002), and respectively 68, 91, and 75% received angiotensin converting enzyme inhibitors at discharge in the case of left ventricular systolic dysfunction (P = 0.003). CONCLUSIONS: Our results showed important hospital-to-hospital variations in the quality of care provided to patients with AMI between these three university hospitals

Processes and outcomes for acute myocardial infarction patients

PURPOSE: The purpose of this paper is to determine whether process quality indicators for acute myocardial infarction (AMI) one associated with outcome indicators (hospital mortality and early readmission). DESIGN/METHODOLOGY/APPROACH: A retrospective cohort study was conducted among patients discharged from three Swiss university hospitals with a primary or secondary International Classification of Diseases, 10th revision (ICD-10) AMI code in 1999. A total of 1,129 patients' records were abstructed. Demographic characteristics and risk factors at admission were recorded. The main ECG and laboratory findings were further abstracted as well as hospital and discharge management and treatment. The main outcome measure was process quality indicators derived from evidence-based guidelines, and hospital mortality and early readmissions. FINDINGS: After exclusions, 577 patients with AMI were eligible for this study. The mean (SD) age was 68.2 (13.9). In the assessment of quality indicators patients with potential contra-indications were excluded. Among cohorts of "ideal candidates" for specific interventions, aspirin was not prescribed within 24 hours after admission in 33 (6.2 percent) patients. Among those, 17 (51.5 percent) died (p<0.0001). The adjusted OR for no aspirin after admission was 3.61 (95 percent CI 1.11-11.77) for hospital mortality. Further, 78 (19.5 percent) patients did not receive ß-blockers at discharge. Among them nine (11.5 percent) were readmitted (p=0.133). The adjusted OR for no ß-blockers at discharge was 2.15 (95 percent CI 0.86-5.41) for readmissions. Among patients with AMI, not prescribing aspirin within 24 hours after admission was associated with hospital mortality. However, process indicators derived from evidence-based guidelines were not related to early readmission in this study. ORIGINALITY/VALUE: The paper stresses the importance of clinicians confronting their decisions with recommendations of evidence-based guidelines for the management and treatment of AMI patients