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Process and Outcome of Care for Acute Myocardial Infarction among Medicare Beneficiaries in Connecticut: A Quality Improvement Demonstration Project

Thomas P. Meehan, MD, MPH; John Hennen, PhD; Martha J. Radford, MD; Marcia K. Petrillo, MA; Paul Elstein, PhD; and David J. Ballard, MD, PhD
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From the Connecticut Peer Review Organization, Middletown, Connecticut. Kerr L. White Institute for Health Services Research, Decatur, Georgia. University of Connecticut School of Medicine, Farmington, Connecticut. Emory University Center for Clinical Evaluation Sciences, Decatur, Georgia. The Health Care Financing Administration, Baltimore, Maryland. Requests for Reprints: David J. Ballard, MD, PhD, Emory University Center for Clinical Evaluation Sciences, 101 West Ponce de Leon Avenue, Suite 620, Decatur, GA 30030. Acknowledgments: The authors thank Lesley Welch Allen and Rebecca Baggett for technical assistance in preparing and editing the manuscript and the members of the Connecticut Interhospital Study and the Acute Myocardial Infarction Committees for their time, clinical input, and support throughout this study. Grant Support: In part by a career development award from the Merck, Sharp & Dohme/Society for Epidemiologic Research Clinical Epidemiology Fellowship Program.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(12):928-936. doi:10.7326/0003-4819-122-12-199506150-00007
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Objective: To evaluate the feasibility of linking claims-based pattern analysis with medical record review in the assessment of quality of hospital care among Medicare beneficiaries with acute myocardial infarction.

Design: An analysis of risk-adjusted mortality after hospital admission for acute myocardial infarction using the regression model from the Health Care Financing Administration for predicting mortality rates. Hospital records for 300 patients admitted for myocardial infarction were abstracted to evaluate the accuracy of diagnostic coding and the adequacy of claims data-based risk adjustment and to assess process measures of quality care.

Setting: Six Connecticut hospitals in the pilot study of the Medicare Hospital Information Project.

Patients: Medicare beneficiaries 65 years of age or older who were hospitalized with a primary diagnosis of acute myocardial infarction from 1989 to 1991.

Main Outcome Measures: Principal diagnosis code verification rates for acute myocardial infarction; observed mortality rates at 30 and 365 days; 30-day standardized mortality ratios; and utilization rates for thrombolytic agents, aspirin, and β-blockers.

Results: The coding of acute myocardial infarction diagnosis had an overall accuracy of 96%. Little change was noted in relative mortality ratio hospital rank order after the exclusion of 13 patients who did not fulfill criteria for acute myocardial infarction and after additional risk adjustment with Killip class data. Utilization rates for therapies among eligible patients were as follows: aspirin, 73%; β-blockers, 41%; and thrombolytic agents, 43%. The use of thrombolytic agents was associated with a lower 30-day mortality; the use of thrombolytic agents, aspirin, and β-blockers was related to lower mortality rates at 1 year after discharge; and the use of these three therapies was lower in the two hospitals with the highest risk-adjusted mortality.

Conclusions: Medicare principal diagnosis codes for acute myocardial infarction were accurate in the six study hospitals. Therapies that have been endorsed by clinicians in Connecticut were underused in elderly patients. Pattern analysis of Medicare claims data can be useful as a quality-of-care screening tool; however, additional clinical information is required to stimulate quality improvement efforts within hospitals.

Figures

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Figure 1.
Distribution of Killip class among confirmed patients with acute myocardial infarction.

The six Connecticut hospitals participated in the pilot study of the Medicare Hospital Information Project from 1988 to 1990.

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Figure 2.
One-year survival from date of admission for confirmed patients with acute myocardial infarction among four Killip classifications.

Six Connecticut hospitals participated in the pilot study of the Medicare Hospital Information Project from 1989 to 1991. See Methods section for Killip classifications (class 1, no congestive heart failure; class 4, cardiogenic shock).

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Figure 3.
One-year survival from date of admission for patients with confirmed acute myocardial infarction among quartiles of 180-day predicted mortality values from the Health Care Financing Administration.

Six Connecticut hospitals participated in this pilot study of the Medicare Hospital Information Project from 1989. to 1991.

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Figure 4.
One-year survival from date of discharge for patients with confirmed acute myocardial infarction who did and did not receive therapy.

Patients were discharged alive and were eligible for at least one of three therapies. One group received none of the three therapies (thrombolytic agents at admission, β-blockers at discharge, or aspirin at discharge); the other group received at least one of the three therapies.

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