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New study points to postcode lottery in heart attack care

14 July 2016

BHF-funded research shows urgent need for improvement in aftercare for heart attack patients

The care received by patients after suffering a life-altering type of heart attack varies widely across the country, with some regions only providing optimal care in just over 10 percent of cases, according to a 10-year study funded by the British Heart Foundation (BHF) looking at the frequency of missed opportunities to treat people after a heart attack.

Chris Gale, with a BHF-funded team of researchers from the University of Leeds and colleagues at Farr London, used data from the UK National Heart Attack Register to analyse the 357,228 cases of non-ST elevation myocardial infarction (NSTEMI), the most common type of heart attack, in 232 hospitals in England between 1 Jan 2003 and 30th Jan 2013.

The researchers looked at 13 treatments that guidelines recommend be considered for patients who have suffered from an NSTEMI, where blood supply to the heart is limited rather than completely cut off. They assessed how often these treatments were given and compared this with whether guidelines at that time suggested that they were appropriate.

They then mapped each patient record to individual Strategic Clinical Networks (SCNs), Clinical Commissioning Groups (CCGs) and hospitals across the country. The team found that the standard of care varied widely across the country, with the highest percentage of people receiving optimal care (defined as the person receiving all appropriate treatments) being in the North East and North Cumbria (20 percent) and the lowest percentage being in the East Midlands (10.3 percent). Most of the variation in care was due to differences in the delivery of heart attack treatments between hospitals.

The researchers also found that the level of care received by patients in a specific region rose and fell over time, meaning that no one region consistently delivered a dependable standard of care. The research did, however, show that overall there were substantial improvements in care over time.

The study is the first to look at variations in NSTEMI care across a whole healthcare system. However, the study does have limitations in that it relies on the accuracy of the UK Heart Attack Register which depends upon clinicians and healthcare managers recording the care given. Deficits in smoking cessation and dietary advice may partly be explained as this advice is given when patients attend cardiac rehabilitation programmes.

Previous research conducted by the researchers has shown that almost 87 per cent of patients did not receive at least one of the interventions that they should have been given. The most frequently missed were dietary advice, advice to help people to stop smoking and the prescription of a type of anticlotting drug known as P2Y12 inhibitors, such as clopidogrel, and that was associated with potentially avoidable deaths.

Someone suffers a heart attack approximately every three minutes in the UK (1), with nearly 200 people of working age dying every week of a heart attack in the UK.

Dr Chris Gale, Associate Professor of Cardiovascular Health Sciences at the Leeds institute of Cardiovascular and Metabolic Medicine, who led the research, said:

“What we’ve shown in this study is that patients across the country who have suffered from a life-changing type of heart attack are not receiving equal treatment or consistent care. We know from our earlier BHF research that these missed care opportunities are associated with unfavourable patient outcomes.

The variations in the level of heart attack treatments that we’ve seen have remained the same even after accounting for differences in how the disease affected people differently. This would seem to suggest that they were caused by differences in hospital infrastructure or the availability of specialist care, both of which are possible to address.

2The good news is that hospitals are certainly improving their standards of care for people who’ve had an NSTEMI, however they still have some way to go to provide optimal care consistently across the country and therefore reduce unwarranted premature death from heart attack..“

Professor Peter Weissberg, Medical Director at the British Heart Foundation, which funded the research, said:

“This study shows that many people in the UK are receiving suboptimal care after a heart attack and that lives are being lost as a consequence.

“Over the years the BHF has invested millions of pounds of donated money on research that demonstrates how best to identify and treat people who have had a heart attack. Hospitals need to apply the lessons learnt from this research and we’re committed to working with the NHS to improve patient care.

“Applying clinical guidelines in heart disease costs little and in the long-term saves money and, most importantly, saves lives.”

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. Geographic variation in the treatment of non-ST-segment myocardial infarction in the English National Health Service: a cohort study. BMJ Open 2016; 6:e011600 (published online 12 July). doi: 10.1136/bmjopen-2016-011600