Older patients treated for heart attack at teaching hospitals are more likely to survive and receive better quality care than those treated at hospitals that do not train physicians, according to a national study supported by the Agency for Healthcare Research and Quality (AHRQ; Rockville, Maryland). In the report, published in the Sept. 13 issue of the Journal of the American Medical Association, researchers at the University of Alabama at Birmingham (Birmingham, Alabama) found that Medicare patients 65 and older receiving care for myocardial infarction at teaching hospitals were more likely to be alive two years after being discharged – the maximum follow-up period studied – than similar patients treated at non-teaching hospitals.
Most of the teaching hospital patients' lower heart attack death rate was due to having received better quality of care, according to the research. "This study underscores the importance of vigorously evaluating the outcomes and effectiveness of how and where we deliver health care services," said John Eisenberg, MD, director of AHRQ. "This is just as critical to improving health care quality as studying the outcomes and effectiveness of different medical treatments."
Robert Centor, MD, a senior author of the study, called the research, "the most extensive and in-depth study to date of quality of patient care and mortality according to hospital teaching status." The researchers found that the patients at major teaching hospitals – defined as academic medical centers with more than one intern for every 10 patients – more often were given aspirin during their stays, if appropriate, than non-teaching hospitals' patients (91.2% vs. 81.4%). The major teaching hospital patients were also more likely to be given beta-blockers and angiotensin-converting enzyme inhibitors upon discharge, when appropriate (48.8% vs. 36.5% and 63.6% vs. 58%, respectively). Usage rates for these drugs at minor teaching hospitals – facilities with one or fewer interns for every 10 patients – were lower than those of major teaching hospitals but higher than the rates for non-teaching facilities. The study found no significant differences between teaching and non-teaching hospitals in the use of angioplasty or thrombolytic drugs.
The study was based on Medicare data on 114,129 randomly selected patients from all 50 states who were treated for heart attack from February 1994 to July 1995.
GRACE finding: holes in ACS treatment
Initial data from the Global Registry of Acute coronary Events (GRACE) suggest that acute coronary syndromes (ACS) are not being fully managed or treated with current therapies and that physicians are not using anti-thrombotics to their full potential. The findings were presented last month at the European Society of Cardiology (ECS) congress in Amsterdam, the Netherlands, by Keith Fox, MD, co-chair of the GRACE scientific steering committee, during the Euro Heart Survey Symposium and in various other presentations.
GRACE is considered the first comprehensive, multinational registry covering the spectrum of acute coronary syndromes. To date, data have been collected on 8,213 patients from 101 hospitals in 14 countries. The majority of the patients were male (66%), with a median age of 66. Only 8% to 10% of patients were included in the trials to capture data on real-world practice patterns on the full range of ACS, as opposed to trial data, which test hypotheses.
"Initial findings clearly demonstrate a need for better treatment practices," according to Fox, professor of cardiology at the Royal Infirmary of Edinburgh (Edinburgh, Scotland). "These results are a call to action for physicians worldwide to take advantage of new advances in ACS therapy."
The GRACE registry is run by an independent scientific committee and is supported by an educational grant from Aventis Pharma (Strasbourg, France).
Rhode Island passes blood filtration rule
Rhode Island has become the first state to implement a universal leukoreduction (ULR) blood filtration policy, and the Rhode Island Blood Center (Providence, Rhode Island), which collects about 68,000 units of blood each year, says it is leukoreducing all of its blood collections. Donor white blood cells can cause reactions in the patient at transfusion and can transmit disease and predispose recipients to infection, with longer and more expensive hospital stays and diminished patient outcomes the result.
While there is no national mandate to filter all blood products in the U.S., the FDA's Blood Products Advisory Committee (BPAC) has recommended that all donor blood be filtered to remove white cells. In 1998, BPAC said that "the benefit-to-risk ratio associated with leukoreduction is sufficiently great to justify routine leukoreduction of all non-leukocyte transfusion blood components." Since that recommendation, leukocyte reduction has increased in the U.S. from about 16% to nearly 50%, according to Eric Krasnoff, chairman and CEO of Pall (East Hills, New York), which makes blood filtration systems used by the center.
At least 22 other countries are also moving to filter all of their donor blood using leukocyte reduction technology, according to Pall. Many of them have mandated routine blood filtration of all blood components as a matter of public policy. Pall recently reported that it has been awarded a $6 million contract by the German Red Cross Transfusion Center, Lower Saxony, the second-largest blood center in Germany and one of the first in the country to implement total filtration voluntarily.
Task force develops statins consensus
Members of the International Task Force for Prevention of Coronary Heart Disease have developed a consensus on statin therapy and have confirmed the key role of LDL reduction in the prevention of cardiovascular events. In addition, the task force outlined new secondary effects and related disease states to provide new information for physicians.
Statins, such as cerivastatin, have now become cornerstones of the management of cardiovascular disease. Their ability to reduce cholesterol and the associated atherosclerosis is established, as is their ability to prevent cardiovascular mortality. Dr. John Katelein of the University of Amsterdam (Amsterdam, the Netherlands), a member of the task force faculty, commented, "At the start of the new century, it is time to take stock of what we know about statins and what else we need to learn in order to provide patients with better treatment options based on sound clinical results. The consensus that there is a class effect of statins on morbidity and mortality will increase their level of confidence with their prescribed medication."
The discovery of the statin class of drugs in the 1980s led to a series of debates in the medical community regarding the true value of lowering cholesterol. The first outcome trial, the 4S study, confirmed that statins do in fact reduce the risk of myocardial infarction and overall mortality in patients with coronary heart disease (CHD). The WOSCOPS trial showed that these benefits also apply to people with no established CHD who are apparently healthy. In this study, a 26% LDL reduction provided a 31% reduction in coronary events. The Paris consensus concluded that these results should be applicable across all the six statins on the market.
Within the consensus conference there was broad-based agreement on the need for further information to support treatment in currently under-treated groups, such as the elderly, women and diabetic patients. The extensive cerivastatin clinical outcome trial program, with more than 20,000 patients, specifically addresses these high-risk groups.