Purchasing for quality: the providers' view. Purchasing care for patients with acute myocardial infarction.

Patients with suspected myocardial infarction (MI) now account for a considerable proportion of acute medical admissions, whose number seems to be rising inexorably. Figure 1 shows the rise in such admissions to the Nottingham hospitals since 1982.1 No sensible provider is going to agree anything with a purchaser, based on the previous year's figures, even though we might have hoped that the number of patients admitted with heart attacks each year would level off and eventually decline. Both purchaser and provider clearly want all patients with suspected MI to receive the best possible quality of care, but with the high and increasing admission rate it is unlikely that all patients will receive "ideal" management. The purchaser and provider will have to agree on acceptable and attainable targets, taking into account local facilities and budgets. The problem is to define those aspects of care that are "ideal," "acceptable," and "attainable." Figure 1 also shows that the increase in admissions has been due to patients with unconfirmed MI. These patients would "ideally" not have been admitted or extensively investigated, but unfortunately it is not easy initially to predict which patients have had an infarction. A normal electrocardiogram on admission certainly does not exclude this diagnosis, and, although patients with a normal initial electrocardiogram have a good prognosis, some do die. Junior doctors are, very properly, hesitant about not admitting patients with chest pain just because there is no clear diagnosis of infarction. Most of the patients admitted without a proved infarction do have coronary disease, but eventually the investigations do not confirm that a new event