Original Research
Older Emergency Department Patients With Acute Myocardial Infarction Receive Lower Quality of Care Than Younger Patients

https://doi.org/10.1016/j.annemergmed.2004.12.012Get rights and content

Study objective

We assessed the independent relationship between age and the quality of medical care provided to patients presenting to the emergency department (ED) with acute myocardial infarction.

Methods

We conducted a 2-year retrospective cohort study of 2,216 acute myocardial infarction patients presenting urgently to 5 EDs in Colorado and California from July 1, 2000, through June 30, 2002. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from the ED record and ECG review. Patients were divided into 6 groups based on their age at the time of their ED visit: younger than 50 years, 50 to 59 years, 60 to 69 years, 70 to 79 years, 80 to 89 years, and 90 years or older. Hierarchic multivariable regression was used to assess the independent association between age and the provision of aspirin, β-blockers, and reperfusion therapy (fibrinolytic agent or percutaneous coronary intervention) in the ED to eligible acute myocardial infarction patients.

Results

Of ideal candidates for treatment in the ED, 1,639 (80.5%) of 2,036 received aspirin, 552 (60.3%) of 916 received β-blockers, and 358 (77.8%) of 460 received acute reperfusion therapy. After adjustment for demographic, medical history, and clinical factors, older patients were less likely to receive aspirin (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.77 to 0.93), β-blockers (OR 0.79, 95% CI 0.71 to 0.88), and reperfusion therapy (OR 0.30, 95% CI 0.18 to 0.52).

Conclusion

Older patients presenting to the ED with acute myocardial infarction receive lower-quality medical care than younger patients. Further investigation to identify the reasons for this disparity and to intervene to reduce gaps in care quality will likely lead to improved outcomes for older acute myocardial infarction patients.

Introduction

Morbidity and mortality after acute myocardial infarction is particularly high for older patients.1 Previous studies have shown that hospitalized elderly acute myocardial infarction patients receive lower-quality medical care than younger patients, which may partly explain age-related differences in outcomes.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 However, little is known about the degree to which age-related disparities in care occur in the emergency department (ED) because existing studies have not differentiated between care provided in the ED and in the inpatient setting.

The ED is a critical setting in which to evaluate acute myocardial infarction care because most hospital-based cardiac care starts in the ED. The early administration of key therapies (eg, acute reperfusion) has been associated with improved patient outcomes.29, 30, 31, 32, 33, 34, 35, 35 Furthermore, care initiated in the ED (eg, aspirin or β-blockers) may be more likely to be continued during hospitalization and after discharge.

The objective of this study is to assess age-related rates of aspirin, β-blocker, and reperfusion therapy use for ED acute myocardial infarction patients. We hypothesized that eligible older acute myocardial infarction patients would be less likely to receive effective therapies than younger patients independent of demographic, medical history, and clinical characteristics. The results of this study may identify an important gap in ED-care quality and could identify a population that might benefit from a directed quality-improvement intervention.

Section snippets

Study Design and Setting

The Emergency Department Quality in Myocardial Infarction Project is a 2-year retrospective cohort study focusing on the quality of care for ED acute myocardial infarction patients. The study was conducted at 5 community EDs in Colorado and California from July 1, 2000, through June 30, 2002.

Selection of Participants

Patients were included in the study if they presented urgently to the ED, had elevated cardiac markers diagnostic for acute myocardial infarction in the ED or within 24 hours of ED arrival, and had a

Characteristics of the Study Subjects (Table 1)

Of the 2,216 patients in the study population, 177 (8.0 %) were younger than 50 years, 329 (14.8%) were aged 50 to 59 years, 432 (19.5%) were aged 60 to 69 years, 667 (30.1%) were aged 70 to 79 years, 508 (22.9%) were aged 80 to 89 years, and 103 (4.6%) were aged 90 years or older. The population was 38.3% women and 61.7% white. Cardiac risk factors and comorbidities were common.

With increasing age, there was an increase in the proportions of patients who were women, white, and had a history of

Limitations

Several potential limitations should be addressed. First, this study was conducted in 5 community hospital EDs. Although our results may not be generalizable to all EDs, our findings are consistent with studies evaluating the relationship between age and quality of care for hospitalized acute myocardial infarction patients in other patient populations.8, 13, 26 Second, we conducted a retrospective study that relied on data available from medical record review. The findings are subject to

Discussion

The objective of this study was to determine whether older ED patients receive guideline-recommended treatments for acute myocardial infarction as frequently as younger patients. We found that eligible older patients with acute myocardial infarction were less likely to receive aspirin, β-blockers, and reperfusion therapy than eligible younger patients. Differences in treatment rates by age persisted after adjustment for other demographic, medical history, and clinical characteristics and were

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    Supervising editor: Brent R. Asplin, MD

    Author contributions: DJM conceived the study, obtained funding, and supervised the conduct of the study. DJM, DRV, TMV, TGP, JSR, EEL, and ASG contributed to the design of the study. DRV, TMV, TGP, AJT, FAM, PMH, JSR, and ASG contributed to the data collection. EEL, LC, and DWB managed the data. EEL provided statistical advice on study design, and EEL and LC analyzed the data. DJM drafted the manuscript, and all authors contributed substantially to its revision. DJM takes responsibility for the paper as a whole.

    Funding and support: This project was funded by a grant from the Garfield Memorial Fund. Dr. Masoudi is supported by the National Institute on Aging National Institutes of Health Research Career Award K08-AG01011. Dr. Rumsfeld is supported by VA Health Services Advanced Research Career Development Award RCD-98-341-2.

    Presented at the American College of Emergency Physicians Scientific Assembly, October 2004, San Francisco, CA.

    Reprints not available from the authors.

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