1. Trends in the Quality of Care of Patients with Acute Myocardial Infarction: The National Registry of Myocardial Infarction from 1990 to 2006 Bimal R. Shah, MD, MBA Eric D. Peterson, MD, MPH, FACC,, Lori Parsons, BS, Charles V. Pollack, Jr., MA, MD, William J. French, MD, FACC, John G. Canto, MD, FACC, C. Michael Gibson, MS, MD, FACC, and William J. Rogers, MD, FACC, for the NRMI Investigators

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

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

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

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

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

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

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

9. Baseline Characteristics: STEMI 1990-19931994-19961997-19992000-20022003-2006 (n=287,251)(n=572,248)(n=701,542)(n=605,313)(n=347,286) STEMI64%54%46%36%34% Age65 ±13 65 ±14 66 ±14 67 ±14 66 ±14 ≥ 7525%26%30%32%30% ≥ 7525%26%30%32%30% Female34%36%36%37%35% Race White-87%86%85%85% White-87%86%85%85% Black-6%6%6%6% Black-6%6%6%6% Other-7%8%9%9% Other-7%8%9%9%

10. Baseline Characteristics: NSTEMI 1990-19931994-19961997-19992000-20022003-2006 (n=287,251)(n=572,248)(n=701,542)(n=605,313)(n=347,286) NSTEMI26%42%52%63%66% Age68 ±13 68 ±13 69 ±14 70 ±13 69 ±13 ≥ 7534%34%37%42%41% ≥ 7534%34%37%42%41% Female39%39%41%42%41% Race White-86%85%83%84% White-86%85%83%84% Black-7%7%8%8% Black-7%7%8%8% Other-7%8%9%8% Other-7%8%9%8%

11. Acute Therapy Trends STEMISTEMI NSTEMINSTEMI % Adherence Aspirin Beta blockers Any heparin

12. Procedure Trends % Adherence STEMISTEMI NSTEMINSTEMI Catheterization PCI CABG

13. Discharge Therapy Trends % Adherence STEMISTEMI NSTEMINSTEMI Aspirin Beta blockers Lipid-lowering agent

14. Adjusted Treatment Disparities 1994-1996 1997-1999 2003-2006 2000-2002 1994-1996 1997-1999 2003-2006 2000-2002 Women Acute Beta Blocker Acute Beta Blocker PCI/CABG Men more likely 1.0 0.5 0.2 1998-1999 2000-2002 2003-2006 Lipid Therapy Lipid Therapy

15. Adjusted Treatment Disparities Women Acute Beta Blocker Acute Beta Blocker PCI/CABG Men more likely 1.0 0.5 0.2 Lipid Therapy Lipid Therapy Blacks 1.0 0.5 0.2 Whites more likely 1994-1996 1997-1999 2003-2006 2000-2002 1994-1996 1997-1999 2003-2006 2000-2002 1998-1999 2000-2002 2003-2006

16. Adjusted Treatment Disparities Women Acute Beta Blocker Acute Beta Blocker PCI/CABG Men more likely 1.0 0.5 0.2 Lipid Therapy Lipid Therapy Blacks 1.0 0.5 0.2 Whites more likely 1994-1996 1997-1999 2003-2006 2000-2002 1994-1996 1997-1999 2003-2006 2000-2002 1998-1999 2000-2002 2003-2006 1.0 0.5 0.2 Young more likely Elderly

17. Mortality Reduction with Improved Evidence-based Therapy Use ‡ Mortality reduction attributable to treatment: (1- OR for clinical factors) – (1 – OR for clinical factors and acute therapies)/ (1- OR for clinical factors) ‡ Mortality reduction attributable to treatment: (1- OR for clinical factors) – (1 – OR for clinical factors and acute therapies)/ (1- OR for clinical factors) Annual Decline in Mortality Odds Ratio Attributable Relative Reduction‡ Adjustment for Baseline Factors Only Adjustment for Baseline Factors and Acute Therapies NSTEMI Patients 0.968 (0.963 – 0.972) 0.980 (0.975 – 0.984) 37% STEMI Patients 0.954 (0.950 – 0.958) 0.957 (0.953 – 0.962) 7%

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

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