Geographic variation in the treatment of non-ST-segment myocardial infarction in the English National Health Service: a cohort study

T B Dondo, M Hall, A D Timmis, A T Yan, P D Batin, G Oliver, O A Alabas, P Norman, J E Deanfield, K Bloor, H Hemingway, C P Gale, T B Dondo, M Hall, A D Timmis, A T Yan, P D Batin, G Oliver, O A Alabas, P Norman, J E Deanfield, K Bloor, H Hemingway, C P Gale

Abstract

Objectives: To investigate geographic variation in guideline-indicated treatments for non-ST-elevation myocardial infarction (NSTEMI) in the English National Health Service (NHS).

Design: Cohort study using registry data from the Myocardial Ischaemia National Audit Project.

Setting: All Clinical Commissioning Groups (CCGs) (n=211) in the English NHS.

Participants: 357 228 patients with NSTEMI between 1 January 2003 and 30 June 2013.

Main outcome measure: Proportion of eligible NSTEMI who received all eligible guideline-indicated treatments (optimal care) according to the date of guideline publication.

Results: The proportion of NSTEMI who received optimal care was low (48 257/357 228; 13.5%) and varied between CCGs (median 12.8%, IQR 0.7-18.1%). The greatest geographic variation was for aldosterone antagonists (16.7%, 0.0-40.0%) and least for use of an ECG (96.7%, 92.5-98.7%). The highest rates of care were for acute aspirin (median 92.8%, IQR 88.6-97.1%), and aspirin (90.1%, 85.1-93.3%) and statins (86.4%, 82.3-91.2%) at hospital discharge. The lowest rates were for smoking cessation advice (median 11.6%, IQR 8.7-16.6%), dietary advice (32.4%, 23.9-41.7%) and the prescription of P2Y12 inhibitors (39.7%, 32.4-46.9%). After adjustment for case mix, nearly all (99.6%) of the variation was due to between-hospital differences (median 64.7%, IQR 57.4-70.0%; between-hospital variance: 1.92, 95% CI 1.51 to 2.44; interclass correlation 0.996, 95% CI 0.976 to 0.999).

Conclusions: Across the English NHS, the optimal use of guideline-indicated treatments for NSTEMI was low. Variation in the use of specific treatments for NSTEMI was mostly explained by between-hospital differences in care. Performance-based commissioning may increase the use of NSTEMI treatments and, therefore, reduce premature cardiovascular deaths.

Trial registration number: NCT02436187.

Keywords: Clinical Commissioning Groups; Geographic variation; Inequalities; MINAP; NSTEMI; National Health Service.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
STROBE diagram of the derivation of the analytical cohort from the MINAP data set. MINAP, Myocardial Ischaemia National Audit Project; NSTEMI, non-ST-segment elevation myocardial infarction.
Figure 2
Figure 2
Geographic variation proportions of eligible patients who received guideline-indicated interventions, for each intervention and for optimal care, by CCG. ACEis, ACE inhibitors; ARB, angiotensin receptor blockers; CCGs, Clinical Commissioning Groups.
Figure 3
Figure 3
Optimal care variation in hospitals by SCNs. SCNs, Strategic Clinical Networks.

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