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From the Institute for Clinical Evaluative Sciences (Austin, Tu, Ko, Alter); the Department of Public Health Sciences (Austin) and the Department of Health Management, Policy and Evaluation (Austin), University of Toronto; the Schulich Heart Centre and Division of Cardiology, Department of Medicine (Tu, Ko), Sunnybrook Health Sciences Centre; the Department of Medicine, Faculty of Medicine (Tu, Ko), University of Toronto; the Division of Cardiology and the Li Ka Shing Knowledge Institute (Alter), St. Michael's Hospital; The Cardiac and Secondary Prevention Program of the Toronto Rehabilitation Institute (Alter), Toronto, Ont.
Correspondence to: Dr. Peter C. Austin, Institute for Clinical Evaluative Sciences, Rm. G1 06, 2075 Bayview Ave., Toronto ON M4N 3M5; fax 416 480-6048; peter.austin{at}ices.on.ca
Background: In an accompanying article, we report moderate between-hospital variation in the postdischarge use of β-blockers, angiotensin-modifying drugs and statins by elderly patients who had been admitted to hospital with acute myocardial infarction. Our objective was to identify the characteristics of patients, physicians, hospitals and communities associated with differences in the use of these medications after discharge.
Methods: For this retrospective, population-based cohort study, we used linked administrative databases. We examined data for all patients aged 65 years or older who were discharged from hospital in 2005/06 with a diagnosis of myocardial infarction. We determined the effect of patient, physician, hospital and community characteristics on the rate of postdischarge medication use.
Results: Increasing patient age was associated with lower postdischarge use of medications. The odds ratios (ORs) for a 1-year increase in age were 0.98 (95% confidence interval [CI] 0.97–0.99) for β-blockers, 0.97 (95% CI 0.97–0.98) for angiotensin-converting-enzyme inhibitors and angiotensin-receptor blockers and 0.94 (95% CI 0.93–0.95) for statins. Having a general or family practitioner, a general internist or a physician of another specialty as the attending physician, relative to having a cardiologist, was associated with lower postdischarge use of β-blockers, angiotensin-modifying agents and statins (ORs ranging from 0.46 to 0.82). Having an attending physician with 29 or more years experience, relative to having a physician who had graduated within the past 15 years, was associated with lower use of β-blockers (OR 0.71, 95% CI 0.60–0.84) and statins (OR 0.81, 95% CI 0.67–0.97).
Interpretation: Patients who received care from noncardiologists and physicians with at least 29 years of experience had substantially lower use of evidence-based drug therapies after discharge. Dissemination strategies should be devised to improve the prescribing of evidence-based medications by these physicians.
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  J. Chen MD MPH and S.-L. T. Normand PhD Myocardial infarction and quality of care Can. Med. Assoc. J., October 21, 2008; 179(9): 875 - 876. [Full Text] [PDF]
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