Patients' narratives of their patient participation in the myocardial infarction pathway

A number of trends, pressures and policy shifts can be identified that are promoting greater patient involvement in health care delivery through consultations, treatments and continuing care. However, while the literature is growing fast on different methods of involvement, little attention has been given so far to the role which patients themselves wish to play, nor even of the conceptual meanings behind involvement or participation. This article reviews the current models of involvement in health care delivery as derived from studies of professional views of current and potential practice, prior to examining the empirical evidence from a large-scale qualitative study of the views and preferences of citizens, as patients, members of voluntary groups, or neither. Individual domiciliary interviews were carried out with 44 people recruited from GP practices in northern England. These respondents were then included in a second phase of 34 focus groups in 6 different localities in northern and southern England, of which 22 were with individuals unaffiliated to any voluntary/community groups, 6 related to local voluntary/community groups with specific interests in health or health care, and 6 related to groups without such specific interests. A final set of 12 workshops with the same samples helped to confirm emergent themes. The qualitative data enabled a taxonomy of patient-desired involvement to be derived, which is contrasted with professional-determined levels of involvement identified from the literature. Participation is seen as being co-determined by patients and professionals, and occurring only through the reciprocal relationships of dialogue and shared decision-making. Not everyone wanted to be involved and the extent to which involvement was desired depended on the contexts of type and seriousness of illness, various personal characteristics and patients' relationships with professionals. These levels are seen to provide basic building blocks for a more sophisticated understanding of involvement within and between these contexts for use by professionals, managers, policy-makers and researchers.

Worldwide, each year more than 7 million people experience myocardial infarction, in which one-year mortality rates are now in the range of 10%, but vary with patient characteristics. The consequences are even more dramatic: among patients who survive, 20% suffer a second cardiovascular event in the first year and approximately 50% of major coronary events occur in those with a previous hospital discharge diagnosis of ischaemic heart disease.The people behind these numbers spur this call for action. Prevention after myocardial infarction is crucial to reduce risk and suffering. Evidence-based interventions include optimal medical treatment with anti-platelets and statins, achievement of blood pressure, lipid and blood glucose targets, and appropriate lifestyle changes.The European Society of Cardiology and its constituent bodies are determined to embrace this challenge by developing a consensus document in which the existing gaps for secondary prevention strategies are reviewed. Effective interventions in relation to the patients, healthcare providers and healthcare systems are proposed and discussed. Finally, innovative strategies in hospital as well as in outpatient and long-term settings are endorsed.

To characterise management of suspected acute coronary syndrome (ACS) in Australia and New Zealand, and to assess the application of recommended therapies according to published guidelines. All patients hospitalised with suspected or confirmed ACS between 14 and 27 May 2012 were enrolled from participating sites in Australia and New Zealand, which were identified through public records and health networks. Descriptive and logistic regression analysis was performed. Rates of guideline-recommended investigations and therapies, and inhospital clinical events (death, new or recurrent myocardial infarction [MI], stroke, cardiac arrest and worsening congestive heart failure). Of 478 sites that gained ethics approval to participate, 286 sites provided data on 4398 patients with suspected or confirmed ACS. Patients' mean age was 67 2013s (SD, 15 2013s), 40% were women, and the median Global Registry of Acute Coronary Events (GRACE) risk score was 119 (interquartile range, 96-144). Most patients (66%) presented to principal referral hospitals. MI was diagnosed in 1436 patients (33%), unstable angina or likely ischaemic chest pain in 929 (21%), unlikely ischaemic chest pain in 1196 (27%), and 837 patients (19%) had other diagnoses not due to ACS. Of the patients with MI, 1019 (71%) were treated with angiography, 610 (43%) with percutaneous coronary intervention and 116 (8%) with coronary artery bypass grafting. Invasive management was less likely with increasing patient risk (GRACE score 200, 36.1%; P < 0.001). The inhospital mortality rate was 4.5% and recurrent MI rate was 5.1%. After adjusting for patient risk and other variables, significant variations in care and outcomes by hospital classification and jurisdiction were evident. This first comprehensive combined Australia and New Zealand audit of ACS care identified variations in the application of the ACS evidence base and varying rates of inhospital clinical events. A focus on integrated clinical service delivery may provide greater translation of evidence to practice and improve ACS outcomes in Australia and New Zealand.