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SDR 03-289 – QUERI Project

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SDR 03-289
Evaluating Quality of Care for Acute Coronary Syndromes in VHA
Stephan D. Fihn MD MPH
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: October 2004 - June 2008

BACKGROUND/RATIONALE:
A VA-commissioned audit suggested that VA patients had higher one-year mortality and fewer cardiac procedures following acute myocardial infarction (AMI) compared with patients admitted to Medicare facilities. In response, we prospectively collected data to further evaluate quality of care and outcomes for patients with acute coronary syndromes (ACS) admitted to VA facilities.

OBJECTIVE(S):
Objectives were to: compare patient characteristics, processes of care, and clinical and patient-reported outcomes for ACS between patients treated in VA and other systems; validate sensitivity of case-finding methods employed by VA's external peer review program (EPRP); and evaluate structural and process components of change in cardiac care within VA. Subsequently, we added an objective to examine care and outcomes of patients presenting with ACS symptoms who were deemed not to have ACS by their physician but who ultimately had laboratory results suggesting AMI, specifically, elevated troponins.

METHODS:
We prospectively collected data from nine VA facilities. Four were tertiary care centers capable of performing percutaneous coronary intervention (PCI), including Portland, OR, Denver, CO, Minneapolis, MI, and Durham, NC. Four others were the closest, most frequently referring non-tertiary facilities, including Roseburg, OR, Sheridan, WY, Fargo, MN, and Salisbury, NC, respectively. A ninth site added to increase recruitment was a PCI-capable tertiary facility in Tampa, FL. Patients were screened based on admitting symptoms of ACS or suspicion of ACS for other reasons. Detailed information was collected from patients and VISTA.

FINDINGS/RESULTS:
We screened 3352 patients admitted with suspected ACS and enrolled 832. Eighty were diagnosed with ST-segment-elevated AMI (STEMI), 425 were diagnosed as having non-ST elevation MI (NSTEMI), and 327 were diagnosed with unstable angina. To compare patients with elevated troponin levels but not ACS to those with AMI, we collected limited data on 564 patients not initially enrolled. Relative to data published from other prospective registries, VA patients had more coexisting chronic illnesses such as diabetes and kidney disease and higher prevalence of prior CABG (coronary artery bypass grafting). VA patients also underwent more cardiac procedures and were more frequently prescribed discharge medications. Compared with results from other studies, a larger percentage of VA patients with AMI arrived more than 12 hours after symptom onset. A high proportion of patients had positive troponin levels but were considered by attending cardiologist not to have ACS, although proportion varied dramatically by site. Compared to patients with ACS, patients with troponin-positive non-ACS had more coexisting chronic illnesses and worse in-hospital mortality.

IMPACT:
Largely descriptive findings suggest that VA patients with ACS differ in important ways from those included in non-VA registries. In particular, the proportion with STEMI was considerably smaller, most likely due to characteristics of patients (e.g., greater burden of chronic illness) as well as system-level factors (e.g., proximity to VA facility) that have been associated with delays in seeking care. Patients with elevated troponins and no diagnosis of ACS were also very common, again likely reflecting high level of comorbidities. These findings provide important information for policies for clinical magement of ACS in VHA.

PUBLICATIONS:

Journal Articles

  1. Maynard C, Bradley SM. Acute coronary syndromes: Bypassing the emergency department to treat STEMI. Nature reviews. Cardiology. 2013 Sep 1; 10(9):491-2.
Journal Other

  1. Larsen GC, Zoble R, McFalls E, Pineros SL, Neugaard B, Rumsfeld JS, Bradley M, Tenney S, Sales AE, Fihn SD. Characteristics and outcomes of inpatients with elevated troponins but without an Acute Coronary Syndrome in 9 Veterans Affairs Hospitals: A prospective multicenter study. [Abstract]. Circulation. 2008 Oct 1; 117:e409.
  2. Helfrich CD, Sharp ND, Pineros SL, Lowey E, McDermott KA, Sales AE, Larsen GC, Fihn SD. How Veterans Health Administration facilities have changed practices to improve care for patients with acute coronary syndromes. [Abstract]. Circulation. 2007 Oct 1; 115(21):e591.
  3. Pineros SL, Rumsfeld J, Larsen G, Wang L, McFalls E, Zoble R, Haley J, Tenney S, Bradley M, Steinberg S, Hefner W, Shaikh M, Morris K, Fihn SD. Is quality of care for unstable angina comparable to that for acute myocardial infarction in the Veterans Health Administration? [Abstract]. Circulation. 2007 Oct 1; 115(21):e598.
  4. Pineros SL, Rumsfeld J, Larsen G, Wang L, McFalls E, Zoble R, Haley J, Tenny S, Bradley M, Steinberg S, Hefner W, Shaikh M, Morris K, Fihn S. Outcomes of Acute Coronary Syndrome patients who report in-hospital depressive symptoms in Veterans Health Administration. [Abstract]. Circulation. 2007 Oct 1; 115(21):e595.
Conference Presentations

  1. McDermott K, Maynard CC, Lowy E, Heagerty P, Fihn SD. Patient, context and symptom characteristics associated with presentation over 12 hours after symptom onset of Acute Myocardial Infarction (AMI) to Veteran Health Administration Facilities (VA). Presented at: AcademyHealth Annual Research Meeting; 2009 Jun 15; Chicago, IL.
  2. Larsen GC, Zoble RG, McFalls EO, Pineros S, Li YF, Neugaard B, Rumsfeld J, Bradley M, Tenney SS, Sales A, Fihn SD. Characteristics and Outcomes of Inpatients with Elevated Troponins but Without an Acute Coronary Syndrome in 9 Veterans Affairs Hospitals: A Prospective Multicenter Study (Concurrent Session). Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2008 May 9; Baltimore, MD.
  3. Neugaard B, Zoble R, Moadhadi S, Larsen GC, Pineros S, Rumsfeld JS, Morris K, McFalls E, Fihn SD. Prescription of cholesterol-lowering medications in patients admitted with acute coronary syndrome. Presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  4. Helfrich CD, Sharp ND, Pineros SL, Lowy E, McDermott K, Sales AE, Larsen GC, Fihn SD. How Veterans Health Administration facilities have changed practices to improve care for patients with acute coronary syndromes. Presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Forum; 2007 May 7; Washington, DC.
  5. Pineros SL, Rumsfeld JS, Larsen GC, Wang L, McFalls E, Zoble R, Haley J, Tenney S, Bradley M, Steinberg S, Hefner W, Shaikh M, Morris K, Fihn SD. Outcomes of Acute Coronary Syndrome patients who report in-hospital depressive symptoms in Veterans Health Administration. Presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2007 May 7; Washington, DC.
  6. Pineros SL, Rumsfeld JS, Larsen GC, Wang L, McFalls E, Zoble R, Haley J, Tenney S, Bradley M, Steinberg S, Hefner W, Shaikh M, Morris K, Fihn SD. Is quality of care for unstable angina comparable to that for acute myocardial infarction in the Veterans Health Administration? Presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2007 May 7; Washington, DC.


DRA: Health Systems
DRE: none
Keywords: Acute illness, Cardiovasc’r disease
MeSH Terms: Quality, Acute Disease

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