Correspondence |
Availability bias in the management of myocardial infarction
Sir,Variable and suboptimal treatment of myocardial infarction are both common. Whether cognitive biases1 such as the perceived availability of a treatment might affect the quality of care, is not known.
We prospectively evaluated the quality of management for myocardial infarction at Hadassah Medical Center (a major teaching institution in Jerusalem, Israel), which operates at two sites: the Ein-Kerem campus, which has the angiographic facilities, and the Mt Scopus hospital, which has the cardiac rehabilitation unit. Both are under the same division of Cardiology. In addition to various quality indicators, we measured (in both sites) the rate of reperfusion treatments and their time delays, and the proportion of patients referred to cardiac rehabilitation after discharge. Patients were included if they had suspected diagnosis of ST-elevation myocardial infarction (defined as clinical symptoms of angina-like pain and ST elevation), a new left bundle branch block on electrocardiography, or cardiogenic shock attributed to coronary ischaemia. The study was approved by the Institutional Review Board.
From February to August 2003, 145 consecutive patients with ST elevation myocardial infarction were enrolled (81 in Ein-Kerem, 64 in Mt Scopus). At each site, about half of patients received any reperfusion modality (either percutaneous coronary intervention (PCI) or thrombolysis), and only about a quarter of them went to cardiac rehabilitation, suggesting under-use of proven therapies.2 Table 1 presents the rates of referral to treatment modalities at the two hospitals: primary PCI was used in the majority of cases at the site with the angiography suite (Ein-Kerem). By contrast, at the other site (Mt Scopus), half of the patients received thrombolysis, even though the time delay for transfer to PCI was short: for patients transferred, an ambulance drive from Mt Scopus to Ein-Kerem lasted only 15 ± 1 min (mean ± SD). At both sites, time delays to PCI (door to balloon) were higher than the 90 min recommended,3 and delays were shorter in Ein-Kerem by only half an hour. On the other hand, patients discharged from Mt Scopus (the site with cardiac rehabilitation) were more likely to be referred to rehabilitation. Confounding variables (such as patient age, ethnicity and cardiac disease severity) did not explain the differential referral between the two hospitals. At each site, over 80% of patients received PCI during the course of their hospitalization.
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Although patient transfer to a referral center for primary PCI is an accepted option,3 physicians at Mt Scopus appeared reluctant to use it, despite short transport delays. Although cardiac rehabilitation has been repeatedly shown to be effective,2 this modality was largely under-used at both hospitals, and perhaps more so at the Ein-Kerem site, remote from the rehabilitation facility. Differential referral to therapies may relate to a cognitive bias1 regarding their perceived availability by physicians. Furthermore, costly modalities such as primary PCI may be especially prioritized because of their inherent financial incentives, even when actual benefit is being questioned,4 in comparison to under-used, low-cost, low-tech options such as cardiac rehabilitation, as reported in the US.5 Interventions aimed at improving the quality of treatment need to understand and address the cognitive biases that may influence a physician's choice of therapy.
School of Public Health Faculty of Medicine Hebrew University of Jerusalem
Cardiac Intensive Care Unit Ein-Kerem Hospital
Cardiac Intensive Care Unit Mt Scopus Hospital
Center for Clinical Quality & Safety Hadassah Medical Organization Hebrew University Jerusalem Israel
email: brezis{at}vms.huji.ac.il
Acknowledgments
This work was published in a thesis for the degree of Masters of Public Health at the School of Public Health of the Hebrew University.
References
1. Kahneman D, Slovic P, Tversky A. Judgment under uncertainty: heuristics and biases. Cambridge, New York, Cambridge University Press, 1982.
2. Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005; 143:659–72.
3. Jacobs AK. Primary angioplasty for acute myocardial infarction—is it worth the wait? N Engl J Med 2003; 349:798–800.
4. Van de Werf F, Gore JM, Avezum A, et al. Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study. Br Med J 2005; 330:441–6.
5. Ayala C, Orenstein D, Greenlund KJ, Croft JB, Neff LJ, Mensah GA. Receipt of cardiac rehabilitation services among heart attack survivors—19 states and the District of Columbia, 2001. Morb Mortal Wkly Rep 2003; 52:1072–5.[Medline]
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