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Trabalho sobre : Utilization patterns and effectsof acute myocardial infarction pharmacological management in Rio de Janeiro, Brazil

( Resumo do estudo apresentado na 17a International Conference da International Society for Quality in Health Care. Conference Abstracts. 2000. pg 22. Dublin, Irlanda: ISQua Ed. )

Escosteguy C. C., Portela, M. C., Vasconcellos, M.T. L., Medronho, R. A.

OBJECTIVE

To analyze utilization patterns of acute myocardial infarction (AMI) pharmacological management and corresponding effects on inpatient mortality in hospitalizations covered by the Brazilian Unified Health System (SUS) in Rio de Janeiro City, Brazil.

METHODS

A stratified random sample of 391 hospitalizations was selected, without reposition, from 1936 AMI admissions registered by SUS Information System in Rio de Janeiro City in 1997. The sample was stratified by hospital unit, being representative of all admissions covered by SUS in the study area. Logistic regression was employed to evaluate the impact of different interventions; odds ratio (OR) and 95% confidence intervals (95%CI) were estimated.

RESULTS

We reviewed 384 patient charts corresponding to the sampled hospitalizations, having a loss of 1,8%. AMI diagnosis was confirmed in 91.7% of the cases. Thrombolytic treatment was used in 19.5% (95%CI=15.8-23.9) of the cases; there were 35 untreated patients with no apparent reason for withholding thrombolysis (shortfall of 32.4%), and 76 for whom the reason for withholding was ignored. Aspirin was used in 86.5% (95%CI=82.5-89.6) of the cases; beta-blocker in 49% (95CI%=43.8-54.1); angiotensin-converting-enzime inhibitor in 63.3% (95%CI=58.2-68.1); intravenous nitrate in 18.8% (95CI%=15-23.1); oral nitrate in 79.2% (95%CI=74.7-83); calcium-channel blocker in 30.5% (95%CI=26-35.4); intravenous heparin in 25.5% (95%CI=21.3-30.2); subcutaneous heparin in 71.9% (95%CI=67-76.3); lidocaine in 9.1% (95%CI=6.5-12.6). Inpatient mortality was 20.6%. There was significant hospital variation in the use of thrombolytics, beta-blockers, angiotensin-converting-enzime inhibitors, calcium-channel blockers and heparin. Although there was no significant variation in the aspirin use, which was in general similar to that registered by other countries, we considered that it could have been broader, as the register of contraindication, usually peptic disease, occurred only in eight patients. Thrombolytic, beta-blocker and intravenous nitrate use were lower than related by other countries; oral nitrate use was similar and angiotensin-converting-enzime inhibitor higher. The pharmacological technologies presenting significant negative impact upon inpatient mortality were: aspirin (OR=0.30 95%CI=0.12-0.79), beta-blocker (OR=0.31 95%CI=0.41-0.70) and angiotensin-converting-enzime inhibitor (OR=0.44 95%CI=0.20-0.95); this impact was estimated through a logistic regression model including explanatory variables related to severity, coronary care unit admission and coronary angiography, angioplasty and bypass surgery use. The thrombolytic treatment odds ratio was 0.70, non significant.

CONCLUSION

These findings indicate the need of implementing the use of those technologies with evidence-based efficacy in Rio de Janeiro, especially thrombolytics, beta-blockers and aspirin, in inpatient AMI care. They also illustrate the greater impact of technologies with broader use in the study district, such as aspirin, beta-blockers and angiotensin-inhbitors, comparing to the underused thrombolytic treatment, even though the last one has higher efficacy as documented by randomized clinical trials.