Acute Myocardial Infarction Setting Priorities for Effectiveness Research (1990) / Chapter Skim
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Key Patient Management Topics for Effectiveness Research in Acute Myocardial Infarction
Key Patient Management Topics for Effectiveness Research in Acute Myocardial Infarction
Pages 29-42
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From page 29... ...
with existing HCFA administrative data of the sort on which the preliminary analyses presented at the workshop were based; (2) with existing HCFA data augmented by clinical data from medical records abstracted by PROs or from specially conducted patient surveys and follow-up studies; and (3)
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From page 30... ...
TABLE ~ Provisional Patient Management Topics Relating to Acute Myocardial Infarction Risk Stratification after AMI Timing related to MI: early versus late Use of diagnostic or therapeutic procedures to stratify risk Guidelines for stratification based on existing administrative data Prospective study to validate stratification testing and criteria High-risk versus low-risk treatment plans Patients appropriate for no stratification Available data on effectiveness of stratification over age 65 Procedures in Early Diagnosis and Treatment Catheterization, angioplasty, and surgical procedures Echocardiography; positron emission tomography scans Defibrillation Use of coronary care unit (CCU) Aggressive (invasive)
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From page 31... ...
; individual physicians and groups; specific hospitals Relationship to outcomes Implications for cost Value as "natural e~cperunents" Post-AMI Issues Prognosis for different risk categories Cardiac rehabilitation Sudden death Prudery Prevention Role of pre-event risk identification Concem for neglect of this area, as primary prevention occurs before Medicare age Prehospital Care Precipitating events Recognition, initial treatment out of hospital Emergency room Physician Education Guidelines for patient management Comparative Analyses of Differem Modalities Aggressive versus nonaggressive management Angiaplasty versus CABG Value of ~rombolytic treatment Additional diagnostic tests
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From page 32... ...
(By "aggressive," the committee referred to invasive diagnostic, therapeutic, and surgical interventions, and by "nonaggressive," to conservative medical and pharmacologic management.) Other patient management issues receiving attention in the discussion and in the second round of committee voting on key topics included primary prevention, prehospital care, rehabilitation, and physician education about clinical management.
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From page 33... ...
The committee recommended the development of methods that will more accurately identify acute myocardial infarction patients for any effectiveness studies. These would involve both the nature and the extent of damage to the heart.
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From page 34... ...
The committee was convinced that such access to data files would allow creative investigators to identify new projects and important issues and problems Hat might not overwise be examined. Improvement of Risk Stratification Methods The committee recommended the funding of extramural research to validate stratification and triage decision methods that would permit determination of effectiveness in clinically important subsets of patients.
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From page 35... ...
As noted with the angioplasty example, this research could begin with an analysis of existing data sets, identify "natural experiments" in the differing risk stratification methods that exist in practice, and then generate relevant clinical hypotheses that could be tested by ongoing surveillance or more targeted research, such as one or more "pilot" studies. The committee was convinced, however, that a prospective study will eventually be needed to provide a sufficiently reliable, valid, and practical method for stratifying AMI patients that will allow appropriate and unambiguous interpretation of effectiveness data.
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From page 36... ...
The committee recommended that the Department of Health and Human Services solicit outside expert opinion to define an adequate, appropriate set of outcome measures and to propose instruments for measuring these outcomes in effectiveness research both generally and for acute myocardial infarction. Consensus is emerging ~at, for health status and quality-of-life measurement, use of reliable and valid "generic" measures of health status coupled win selected "disease-speciD'c" measures is an appropriate, desirable, and practical research strategy.
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From page 37... ...
Thus, the committee strongly urged DHHS support to extramural work that will produce reliable and valid instruments for functional assessment and quality of life in the Medicare population not only win regard to acute myocardial infarction, but also as part of a broader charge to define outcomes satisfactorily for all projects carried out under the aegis of effectiveness. Examination of Variations in the Patterns of Care and Use of Treatment Modalities in Different Settings The committee recommended that work on understanding patterns of care be supported and be linked to issues relating to the three high priority patient management topics identified for the Effectiveness Initiative.
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From page 38... ...
Differences in practices of different types of physicians may also prove instructive, particularly the care provided by generalists such as family physicians and internists compared with that rendered by cardiologists. Group practices, particularly those that try to influence clinical practices or that use formal clinical guidelines and specialty cardiology practices that use advanced technology, may demonstrate marked differences in patterns of care, patient outcomes, and costs relative to other types of practices.
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From page 39... ...
This adds a further complexity to the patient management topics warranting investigation through electiveness research.
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From page 40... ...
One useful tactic might be to identify cohorts of elderly AMI patients who received no interventions, those who receive only thrombolysis, those who received only invasive or other procedures, and those who received bow thrombolytic drugs and procedures. Another might be to obtain specific data on the extent to which thrombolytic therapy is used in the Medicare population.
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From page 41... ...
Use of Diagnostic Tests and Guidelines to Stratify Risk and Guide Treatment The committee recommended that explicit attention be directed at ways to assign or stratify risk to individual patients with AM] as an element in the choice of diagnostic and therapeutic interventions.
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From page 42... ...
In short, proven risk stratification methods are essential for appropriate decision making about patient care. Because such methods are not well established, the committee concluded that developing such approaches was, in fact, a critical patient management issue both amenable to and necessary for effectiveness research.
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