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November 5, 1997

Thrombolytic Therapy for Elderly Patients With Myocardial Infarction-Reply

JAMA. 1997;278(17):1402. doi:10.1001/jama.1997.03550170032018

To the Editor.  —Previous work has clearly demonstrated that severe comorbidity has a negative impact on the receipt of thrombolytic therapy in patients with acute myocardial infaction who are eligible for treatment. In a study of 37 Minnesota hospitals from October 1992 to July 1993, McLaughlin et al1 observed that, after controlling for other factors reported to influence use of thrombolysis, the odds of receipt of thrombolytic therapy among patients with severe comorbidity were 0.49 (95% confidence interval, 0.27-0.88), when compared with individuals without this characteristic. These findings have implications for the measurement of physician adherence to evidence-based treatment guidelines. Apparent noncompliance with guidelines is commonly interpreted as reflecting gaps in knowledge or lack of acceptance of guideline recommendations. However, nonuse of an indicated treatment may reflect a conscious decision to withhold a therapy, based on other clinical considerations. Functional status is another important patient characteristic to consider in regard to decisions