I attended a lecture on new treatments for STEMI and had a brief discussion with the lecturer afterwards regarding “Quality Measures” as determined by CMS.
He mentioned a study that I had not read that goes by the acronym “COMMIT” – the Clopidogrel and Metoprolol in Myocardial Infarction Trial. This was a HUGE study that enrolled more that 45,000 patients in 1250 different hospitals. Patients suspected of having an acute MI were randomized to receive clopridogrel, metoprolol or placebo and were then continued on the medication until discharge or until they had been in the hospital for a week.
Interesting point of the study was that patients who are given beta blockers “on arrival” had no difference in the primary endpoints of the study – death, reinfarction, or cardiac arrest. There was a 0.005 probability that the people receiving metoprolol would not experience ventricular fibrillation or reinfarction, but more than 1% of the patients receiving early beta blockers went into cardiogenic shock! As an aside, those on clopridogrel showed a significant improvement in the primary study endpoints.
By getting early beta blockers, initially the patients did worse than those getting placebos. Over time, the reduction in reinfarctions and in ventricular fibrillation caused study participants to break just about even in terms of adverse events. The conclusion of the COMMIT study was that “it might generally be prudent to consider starting beta-blocker therapy in hospital only when the haemodynamic condition after MI has stabilised.”
The COMMIT study results somewhat conflict with other studies cited by the American College of Cardiology and the American Heart Association in their joint 2004 guidelines for management of patients with acute ST-Elevation MI.
Yet one of the “Hospital Compare” indicators for “quality care” in heart attack patients that the patient receive a “beta-blocker at arrival.” Even though the ACC/AHA recommendations are for patients with ST elevation MI, the Hospital Compare site does not make that distinction.
Hospitals all over the nation brag about their statistics giving beta blockers at arrival. Cedars-Siani Hospital, Henry Ford Hospital, the Mayo Clinic, the Indiana Community Health Network, St. Luke’s Hospital in Missouri, and the University Health Care System in Georgia are just a few of the hospitals that I found posting their beta-blocker stats online. Is there conclusive evidence that we are helping, and not harming, patients by giving them beta blockers at arrival?
I spent an hour online researching on PubMed, eMedicine, and MD Consult. I couldn’t find any studies showing a significant improvement in outcomes with “beta blockers at admission” for acute MI patients. I’m hoping that someone out there can post a link or two. The Beta Blocker Heart Attack Trial showed a significant improvement in outcomes when beta blockers were started 5-21 days after hospital admission, not “at arrival.”
Even if there are some studies out there that do show a benefit, how do we reconcile the potential harm shown in the COMMIT study? If there is disagreement in the literature about the possible harm of a therapy, should hospitals get a bad “grade” for not giving that therapy?
I would love to see data comparing the rates of death, reinfarction, etc. AFTER all of the CMS quality care measures were instituted. Couldn’t find that online, either.
CMS is already making things worse for patients with pneumonia care. Now a huge study shows it may also be wrong with recommending early beta blocker administration.
And there is no quality care measure for giving clopridogrel (Plavix) — a medicine that is proven to reduce morbidity and mortality in acute MIs.
Isn’t one of the tenets of medicine to “first do no harm“?