Use of Evidence-Based Therapy at Discharge: DISCUSSION
In this study of patients treated in hospital for acute myocardial infarction, the prescribing rates at discharge for the 4 classes of medications were higher than established benchmark values. One-third to one-half of the patients were already receiving one or more of the medications of interest at admission. This finding is clinically significant, as improvements in morbidity and mortality after acute myocardial infarction have been linked to the use of these classes of medications. The results indicate awareness on the part of the health care team of the importance of adhering to current standards of therapy. Another retrospective Canadian study published in 2005 reported rates of discharge prescribing for “ideal” patients after acute myocardial infarction of 85% for ASA, 78% for fi-blockers, 72% for ACE inhibitors, and 61% for statins, all lower than the rates reported here. The demographic characteristics of our sample were similar to those in the earlier study.
In the current study, 28.9% of patients had a history of acute myocardial infarction at the time of admission. For this subgroup of patients, the percentages receiving ASA, fi-blockers, ACE inhibitors, and statins at the time of admission were lower than the stated benchmarks. However, we did not determine the timeframe of the prior myocardial infarction, and it is possible that for at least some of these patients, the CCORT/CCS quality indicators for acute myocardial infarction, published in 2003, were not available at the time of the prior infarction. As well, this study examined only one type of inpatient process of care, i.e., the prescribing rate at discharge for 4 classes of medications. In particular, we did not measure rates of adherence to therapy after discharge. Rates of adherence to medications after discharge following acute myocardial infarction have been shown to decrease, especially within the first 2 years. This may explain, at least in part, why the subset of patients with a history of acute myocardial infarction had lower use of these classes of medications on admission. levitra 10 mg
During the study period, there was no formal process (e.g., preprinted forms) for prescribing of medications at discharge after acute myocardial infarction, yet the prescribing rates for the medications of interest were above the benchmarks. This may have been due to the conduct of the study at 2 teaching centres for medical and allied health students, and the organization’s promotion of a team approach to patient care. This appears to have created an environment in which multiple opportunities existed for health care providers to avail themselves of information about guideline-recommended therapies. In addition, given the relatively small group of specialist physicians, nurses, residents, and pharmacists caring
for these patients, care providers were able to meet and discuss treatment options through activities such as continuing education, journal clubs, and patient care rounds. The retrospective nature of the study allowed a snapshot of “real world” practice in the care of patients with acute myocardial infarction at the authors’ institution.
The CCORT/CCS document listed exclusion criteria for each class of medication, and we relied on documentation in the medical records to determine whether patients met these exclusion criteria; however, we could not always identify a reason why a medication had not been prescribed for a particular patient. Documentation in hospital medical records has been shown in previous studies to be less than optimal.10 In theory, there might have been more patients in the current study who had undocumented contraindications to the medications of interest than we were able to identify. This would have led to overestimation of the number of “ideal” patients and underestimation of prescribing rates.
This study was carried out several years ago, and the data may therefore not be entirely applicable or relevant today. However, the practice model of care for patients with acute myocardial infarction has remained consistent at these 2 acute care sites, and we therefore believe that these results reflect the appropriateness of this aspect of care.
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At the authors’ institution, rates of prescribing of ASA, fi-blockers, ACE inhibitors, and statins for “ideal” patients discharged after acute myocardial infarction exceeded published Canadian benchmarks. These results indicate that it is possible to meet the CCORT/CCS benchmarks for this aspect of post-infarction care, even without a formal initiative focused on discharge prescribing. Nonetheless, periodic monitoring will be required to ensure that Eastern Health continues to meet these standards.