Transcript Document

Quality of Care and In-Hospital Outcomes in Patients With Coronary Heart
Disease in Rural and Urban Hospitals (from Get With the Guidelines–
Coronary Artery Disease Program)
Amrut V. Ambardekar, MD, Gregg C. Fonarow, MDc, David Dai, PhD,
Eric D. Peterson, MD, MPH, Adrian F. Hernandez, MD, MHS, Christopher P.
Cannon, MD, and Mori J. Krantz, MD
Background
Previous reports have demonstrated that
participation in Get With The GuidelinesCoronary Artery Disease(GWTG-CAD), a
national quality initiative of the American
Heart Association, is associated with
improved guideline adherence for patients
hospitalized with CAD. We sought to
establish whether these benefits from
participation in GWTG-CAD were sustained
over time.
Introduction
Previous studies have suggested that patients
with coronary artery disease (CAD) in rural areas
may have worse outcomes due to limited
availability of specialists, fewer resources, and
less institutional funding. Based on 2000 US
census data, 6.4% of the US population resides in
rural areas within towns of 10,000 residents and
another 10.1% live in areas of 10,000 to 50,000
residents.
Objective
The present study sought to
determine
the
characteristics,
treatments, quality of care, and inhospital outcomes of patients with
CAD treated in rural versus urban
hospitals participating in the Get
With
the
Guidelines–Coronary
Artery Disease Program (GWTGCAD).
Methods
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Data were collected from 22,096 patients at 71 rural centers and
329,938 patients at 477 urban centers from January 2000 to
December 2008.
The hospitals were participating in the Get With the Guidelines–
Coronary Artery Disease Program (GWTGCAD)
In-hospital outcomes and quality of care were stratified by care
at rural versus urban hospitals.
Multivariate logistic regression analysis was used to determine
the association of rural locale with in-hospital mortality, length
of stay, and compliance with the GWTG-CAD performance
measurements.
These performance measurements include:
(1) early aspirin use,
(2) smoking cessation counseling and discharge prescriptions
(3) aspirin,
(4) ACE-I, or ARBs for left ventricular systolic dysfunction,
(5) -blockers, and
(6) lipid-lowering therapy and a composite of all 6
measurements.
Results
• Unadjusted rates of compliance with
performance measurements were lower in rural
(range 82.4% to 90.5%) compared to urban
(range 81.3% to 95.0%) hospitals including
the composite (74.7% vs. 80.6%, p <0.0001).
• In multivariate analysis, rural status was
not independently associated with lower
compliance with any of the performance
measurements.
• Unadjusted mortality rates were higher in rural
versus urban hospitals (5.7% vs. 4.4%, p
<0.0001), but this was not significant in
multivariate analysis (odds ratio 1.05, 95%
confidence interval 0.87 to 1.26).
Limitations
• The GWTG-CAD is a voluntary program and could overrepresent high-performing hospitals.
• Data were collected by chart review and thus depend on the
accuracy and completeness of documentation.
• Rural centers were defined as being located outside a CBSA,
so only areas of 10,000 residents were considered rural in
this analysis. CBSAs are based on population density, and
data regarding physician practice patterns, patient transfer
patterns, and per-capita specialist availability are lacking.
• Critical-access hospital status was not determined. Criticalaccess hospitals have very limited resources and are only
beginning the accreditation process, so greater disparities
could exist in this setting.
• The GWTG-CAD database does not track inpatient provider
specialty, and this may influence mortality, length of stay, and
quality of care.
Conclusion
Within the GWTG-CAD quality
improvement initiative, patients
with CAD treated at rural hospitals
receive similar quality of care and
have similar outcomes as those at
urban centers.