Trends in the Quality of Care of Patients with Acute Myocardial Infarction:

1. Trends in the Quality of Care of Patients with Acute Myocardial Infarction: The National Registry of Myocardial Infarction from 1990 to 2006

2. Disclosures Bimal R. Shah None Eric D. Peterson Research grants from Bristol-Myers Squibb/Sanofi-Aventis, Merck/Schering-Plough Corporation. Lori Parsons Consultant for Genetech Charles V. Pollack Speakers bureau Schering-Plough Corporation, Sanofi-Aventis. Research support from GSK. Consultant for Genentech, Schering-Plough, Sanofi-Aventis, The Medicines Company, Bristol-Myers Squibb. William J. French None John G. Canto Research support from Pfizer, Schering-Plough, Bristol-Myers Squibb. Consultant for Pfizer, Sanofi-Aventis, Genentech (NRMI). Speaker's bureau for Pfizer, Sanofi-Aventi, Bristol-Myers Squibb, GSK. C. Michael Gibson Research support from Novartis, Pfizer, Eli Lilly, Genentech, Smith Kline Beecham, Astra Zeneca. Speaker's Bureau for Genentech, GSK, Schering-Plough. William J. Rogers None

3. Background The last two decades have seen rapid advancement in the therapeutic care of patients with acute myocardial infarction (AMI) This period has also seen the rise in �evidence-based� care as well as �provider profiling� The net impact of these trends on national AMI care, care disparities, and outcomes is unclear

4. National Registry of Myocardial Infarction National, voluntary, observational AMI registry with continuous enrollment since 1990 Five phases (NRMI 1 to 5) to address changes in elements of data collection Clinical characteristics Acute treatments (within 24 hrs of admission) In hospital treatments and outcomes Discharge therapies Established as a national AMI surveillance system NRMI 5 completed in 2006 2157 unique US hospitals2157 unique US hospitals

5. Objectives Assess temporal changes in the adherence to evidence-based therapies in 2.5 million patients with STEMI and NSTEMI since 1990 Determine if previously reported disparities in care for women, blacks, and the elderly (age = 75 years) have narrowed over time Examine if improved adherence to evidence-based therapies is associated with better outcomes

6. Methods Inclusions: AMI pts (ICD-9 410.X1) from 1990 to 2006 with at least one of the following: Elevated CK or CK-MB levels > 2 times ULN Elevation in other cardiac biomarkers (e.g. troponin) Typical ECG evidence of AMI Imaging or pathologic evidence of AMI Patients excluded if: Transferred out Transferred into NRMI hospital >24 hrs after symptom onset Died within 24 hours of admission STEMI: ST-segment elevation or LBBB (new or unknown), all others classified as NSTEMI

7. Methods Therapies recorded: Acute (e.g., aspirin, beta blockers, anticoagulants given within 24 hours of presentation) In hospital procedures (e.g., cardiac catheterization, PCI, CABG) Discharge (e.g., aspirin, beta blockers, lipid lowering agents) In hospital outcomes captured

8. Statistical Analysis Trends analyses were weighted to account for differences in site participation over time Multivariate logistic regression used for mortality analysis Time was primary indicator with key demographic, medical history, and hospital characteristics as covariates in the model Mortality reduction attributable to the use of evidence-based therapy was assessed by adding these covariates to the model Same models run separately for STEMI and NSTEMI patients

9. Baseline Characteristics: STEMI 1990-1993 1994-1996 1997-1999 2000-2002 2003-2006 (n=287,251) (n=572,248) (n=701,542) (n=605,313) (n=347,286) STEMI 64% 54% 46% 36% 34% Age 65 �13 65 �14 66 �14 67 �14 66 �14 = 75 25% 26% 30% 32% 30% Female 34% 36% 36% 37% 35% Race White - 87% 86% 85% 85% Black - 6% 6% 6% 6% Other - 7% 8% 9% 9%

10. Baseline Characteristics: NSTEMI 1990-1993 1994-1996 1997-1999 2000-2002 2003-2006 (n=287,251) (n=572,248) (n=701,542) (n=605,313) (n=347,286) NSTEMI 26% 42% 52% 63% 66% Age 68 �13 68 �13 69 �14 70 �13 69 �13 = 75 34% 34% 37% 42% 41% Female 39% 39% 41% 42% 41% Race White - 86% 85% 83% 84% Black - 7% 7% 8% 8% Other - 7% 8% 9% 8%

11. Acute Therapy Trends

12. Procedure Trends

13. Discharge Therapy Trends

14. Adjusted Treatment Disparities

15. Adjusted Treatment Disparities

16. Adjusted Treatment Disparities

17. Mortality Reduction with Improved Evidence-based Therapy Use

18. Limitations Participating NRMI hospitals may not be representative of entire population of U.S. hospitals Contraindications to evidence-based therapies were not captured Mortality reductions represent best estimates, yet may be confounded by unmeasured variables

19. Conclusions Overall AMI care in the U.S. has improved between 1990 and 2006 Evidence-based acute, procedural, and discharge therapy use have all steadily increased Disparities in care for key under-treated sub-groups have generally not changed Improvements in AMI care has been associated with reduced in-hospital mortality Future QI and performance measures should address continued, and in some cases widening, gaps in care for select populations