European Heart Journal Advance Access originally published online on June 7, 2006
European Heart Journal 2006 27(13):1539-1549; doi:10.1093/eurheartj/ehl066
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction
1 Institute for Clinical Evaluative Sciences, G106-2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5
2 University of Toronto Clinical Epidemiology and Health Care Research Program, Sunnybrook Health Science Centre, Canada
3 Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Science Centre, and the, University of Toronto, Canada
4 Department of Health Policy, Management, and Evaluation, University of Toronto, Canada
Received 26 January 2006; revised 1 May 2006; accepted 12 May 2006; online publish-ahead-of-print 7 June 2006.
* Corresponding author. Tel: +1 416 480 5838; fax: +1 416 480 6048. E-mail address: david.alter{at}ices.on.ca
See page 1513 for the editorial comment on this article (doi:10.1093/eurheartj/ehl007)
Aims To determine the relative impact of time to hospital arrival, baseline cardiovascular risk (i.e.TIMI mortality risk index), intracerebral haemorrhage risk, and comorbid disease burden on the likelihood of not receiving reperfusion therapy among ST-segment elevation myocardial infarction (STEMI) patients without contraindications to treatment.
Methods and results Retrospective population-based cohort of 3994 patients admitted to 103 acute care hospitals with chest pain and STEMI within 12 h of symptom onset in Ontario, Canada, between 1999 and 2001. Patients with one or more documented absolute or relative contraindication (n=909) were excluded from the analyses. Reperfusion therapy was defined as the receipt of either fibrinolysis or primary percutaneous coronary intervention. Multivariable analysis and likelihood 
2 was used to quantify the importance of each factor in predicting the non-utilization of therapy. In total, 23.1% of patients received no reperfusion therapy. Listed in order from greatest to least importance, predictors of non-utilization of reperfusion therapy included increasing time to hospital presentation (likelihood 2 31.6, P<0.001), higher intracerebral haemorrhage risk (likelihood 2 27.1, P<0.001), higher baseline cardiovascular risk (likelihood 2 25.4, P<0.001), and greater number of chronic comorbid conditions (likelihood 2 15.4, P<0.001). The importance of each factor on non-utilization was independent, additive, not explained by age effects alone, or driven by subgroups traditionally under-represented in clinical trials.
Conclusion Care gaps in the use of reperfusion therapy widen with both increasing baseline cardiovascular risk and increasing intracerebral haemorrhage risk. Future studies should examine whether the implementation of clinical decision tools which allow for more accurate risk–benefit tradeoff predictions improve the treatment gaps when using life-saving therapies in this patient population.
Key Words: Reperfusion therapy • ST-segment elevation acute myocardial infarction • Utilization
CiteULike 
Connotea 
Del.icio.us What's this?
Related articles in EHJ:
- Gaps in myocardial infarction care: how might we best EFFECT change?
- Vivek Rajagopal and Deepak L. Bhatt
EHJ 2006 27: 1513-1514.[Extract] [Full Text]
This article has been cited by other articles:
|
|
 |
|
  H. M. Krumholz and F. A. Masoudi The Year in Epidemiology, Health Services Research, and Outcomes Research J. Am. Coll. Cardiol., December 4, 2007; 50(23): 2254 - 2262. [Full Text] [PDF]
|
|
|
|
 |
|
 V. Rajagopal and D. L. Bhatt Gaps in myocardial infarction care: how might we best EFFECT change? Eur. Heart J., July 1, 2006; 27(13): 1513 - 1514. [Full Text] [PDF]
|
|