Acute myocardial infarction in nursing home residents: adherence to treatment guidelines reduces mortality, but why is adherence so low?

OBJECTIVES: To investigate the applicability of clinical practice guidelines (CPGs) to the care of nursing home (NH) residents who experience acute myocardial infarction (AMI).
DESIGN: Secondary examination of data from the national Cooperative Cardiovascular Project.
SETTING: 6684 US hospitals. PARTICIPANTS: A NH-dwelling (N = 8151) cohort and a community-dwelling cohort (N = 119,012). MEASUREMENTS: Adherence to AMI guidelines and associated mortality rates.
RESULTS: Mortality at 30 days and 1 year respectively was 39.5% and 65.4% in the NH cohort versus 17.5% and 31.1% in the community-dwelling cohort (P < .001). Among patients who were ideally eligible to receive aspirin, 58.8% of the NH cohort and 78.9% of the community-dwelling cohort actually received aspirin (P < .001). Among patients who were ideally eligible for beta-blockers, 43.8% of the NH cohort and 61.4% of the community-dwelling cohort received beta-blockers (P < .001). The 30-day mortality for NH patients who were ideally eligible for aspirin but did not receive aspirin was significantly higher compared with NH patients who were ideally eligible but did receive aspirin (49.2% versus 26.0%, P < .001). Similarly, mortality was significantly higher for NH patients who were ideally eligible for beta-blockers but did not receive a beta-blocker (35.3% versus 18.6%, P < .001).
CONCLUSION: Only half of NH patients who are ideally eligible for aspirin and beta-blockers received these medications, yet mortality was significantly lower in patients who were treated with these medications. These results demonstrate the effect of applying AMI guidelines to NH patients while also raising the question of what factors guided decisions not to provide these medications.