Better Care, Better Outcomes


The experience of any patient suffering a heart attack can be described as a ‘pathway’, along which there are numerous opportunities to receive individual items of care. The provision of all these items, as a ‘bundle of care’, can be looked on as optimal treatment as described in Clinical Guidelines – recommendations that interpret or translate the results of research within carefully selected groups of patients into general clinical practice for all patients.

Clinical audits have tended to report the proportion of patients who receive individual components of care rather than on the proportion of patients who receive all the components for which they are eligible.

In their article published in European Heart Journal: Acute Cardiovascular Care, Simms and colleagues described 9 components along the pathway of care – some delivered in the early stages of treatment (before, or immediately on, arrival at hospital) and others delivered later on (by the time of discharge). They then defined, for each patient, a measure called the Cumulative Missed Opportunity for Care (CMOC), which represents the number of each of these nine components that were not provided. So for example, a patient receiving all components of care had a CMOC score of 0, while one receiving 7 of the 9 components had a CMOC score of 2.

Using the MINAP database, they calculated a CMOC score for patients discharged alive from hospital in England and Wales following ST-elevation myocardial infarction between Jan 2007 and Dec 2010. They performed sophisticated analysis to determine predictors of CMOC and the relationship between missed opportunities for care (CMOC) and the risk of death 30 days and 1 year after the admission to hospital.

Almost half of patients (44.5%) were judged by the admitting clinicians to be ineligible for one or more of the components of care. Of the remaining patients, who were eligible for all 9 components, half (50.6%) failed to receive at least 1 component. There was a clear relationship between higher CMOC (ie more missed opportunities for care) and higher death rates up to 1 year after admission. The authors also define a ‘domino-effect’ of missed opportunity, whereby failed opportunities to provide one of the early components of care was associated with subsequent failures to deliver one or more of the later components.

The authors call on clinicians to reduce their threshold for judging patients’ eligibility for treatment. Their study confirms the importance in routine clinical practice of delivering as many of the individual components of care as possible and suggests that outcomes for patients with heart attack could improve still further by adhering to guideline-recommended treatments.

Mortality and missed opportunities along the pathway of care for ST-elevation myocardial infarction: a national cohort study.

Simms at el. European Heart Journal: Acute Cardiovascular Care 2014. DOI: 10.1177/2048872614548602