Can a guideline-oriented intervention increase effective treatment for heart attack patients in the hospital?

Medicare heart attack patients at 10 southeast Michigan hospitals were more likely to receive evidence-based treatment after the hospitals engaged in a structured intervention that included implementing customized, guideline-oriented tools, engaging local physician and nurse opinion leaders, conducting grand rounds educational programs, and measuring quality performance.

Why is this important?

The American College of Cardiology and the American Heart Association first published evidence-based guidelines for the management of heart attack patients in 1996. Many patients still do not receive all the therapies recommended in the guidelines. Better adherence to evidence-based therapy could help prevent many of the 300,000 recurrent heart attacks that occur annually (AHA 2005).

Interventions

Ten acute-care hospitals in southeast Michigan (members of the 32-hospital Southeast Michigan Heart Consortium) were selected to implement the American College of Cardiology's Guidelines Applied in Practice (GAP) quality improvement project, which is designed to incorporate national heart attack treatment guidelines into care practice. The one-year GAP intervention consisted of the following components:

• customizing guideline-based tools (e.g., standard admission orders, clinical pathways, and standard discharge forms),
• assigning local physician and nurse opinion leaders,
• performing educational "grand rounds" site visits, and
• measuring quality indicators among random samples of patients who were ideal candidates for therapy.

The control group consisted of 11 consortium hospitals that volunteered for but were not selected to participate in the intervention, although they were encouraged to undertake improvements in heart attack treatment (Mehta et al. 2002).

Findings

Three GAP-promoted tools were documented for about one-quarter of patients in GAP-participating hospitals. Among Medicare patients for whom GAP tools were used, five of six quality indicators showed significant improvement compared with control hospitals from before to after the intervention:

• aspirin administration within 24 hours of admission and smoking cessation counseling increased by 16 and 58 percentage points, respectively, and
• prescription of aspirin, beta blockers, and ACE inhibitors at discharge increased by 16, 13, and 10 percentage points, respectively.

In a comparison of death rates among all Medicare beneficiaries before and after GAP implementation, GAP was associated with a lower risk of in-hospital, 30-day, and one-year mortality (Eagle et al. 2005). This effect was especially pronounced among patients for whom the standardized discharge tool was used, although the tool was not used as often among women as among men (Jani et al. 2006).

The intervention effect tended to be greatest among older patients (ages 75 and older), who are less likely to receive such treatment (Mehta et al. 2002).

Implications

The authors attributed the success of the GAP intervention to several factors including:

• development of tools that reinforce the key goals of heart attack therapy,
• identification and targeting of implementation barriers,
• support of the patient-doctor-nurse relationship,
• flexibility of the intervention to be adapted to the local environment,
• readiness for change among participating institutions, and
• involvement of community stakeholders including insurers, employers, the professional society, and a Medicare Quality Improvement Organization.

Because tool use was associated with the greatest improvements in quality, the authors recommend that future initiatives emphasize a longer implementation period with insistence on routine tool use (Eagle et al. 2005; Mehta et al. 2002).

Improvement Ideas and Resources

Additional resources are available from the Web site of American College of Cardiology.

Measure:

The Guidelines Applied in Practice (GAP) Pilot Project was a comparative before-and-after study that included Medicare and non-Medicare patients treated for acute myocardial infarction (AMI) at 10 acute-care hospitals in southeastern Michigan. The chart is based on a subgroup analysis of results for Medicare beneficiaries identified from Medicare claims data (N = 515 at baseline; N = 663 at follow-up). Baseline data were collected from a random sample of medical records for patients discharged from July 1998 to June 1999. Follow-up data were collected from medical records for all Medicare patients discharged from Sept. to Dec. 2000. Medical record abstraction was performed by a central center. The denominator for a quality indicator included only eligible patients who did not have a documented contraindication for the specific treatment. Follow-up rates shown in the chart, which represent a subset of patients for whom there was chart documentation of GAP-promoted tool use, were significantly greater than rates at follow-up for a control group of Medicare patients at 11 nonparticipating hospitals. Data for the control group were collected for a public profiling project among southeast Michigan hospitals from Jan. to Dec. 1998 at baseline (N = 513) and from Mar. to Aug. 2001 at follow-up (N = 388) (Mehta et al. 2002).

Limitations:

The study was not a randomized controlled trial; the analysis does not permit definitive conclusions to be made about the effectiveness of the intervention.

Source:

The Guidelines Applied in Practice (GAP) Pilot Project used random samples of medical records and was conducted by a multicenter team including the University of Michigan, Ann Arbor, participating southeastern Michigan hospitals and stakeholders, and the American College of Cardiology and its GAP Steering Committee (Eagle et al. 2002; 2005; Jani et al. 2006; Mehta et al. 2002).

References:

* Indicates source of data used in the chart(s).AHA (American Heart Association). 2005. Heart Disease and Stroke Statistics, 2005 Update. Dallas, Tex.: American Heart Association.

Eagle, K. A., M. Gallogly, R. H. Mehta et al. 2002. Taking the National Guideline for Care of Acute Myocardial Infarction to the Bedside: Developing the Guideline Applied in Practice (GAP) Initiative in Southeast Michigan. The Joint Commission Journal on Quality Improvement 28 (1): 5–19.

Eagle, K. A., C. K. Montoye, A. L. Riba et al. 2005. Guideline-Based Standardized Care Is Associated with Substantially Lower Mortality in Medicare Patients with Acute Myocardial Infarction: The American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan. Journal of the American College of Cardiology 46 (7): 1242–8.

Jani, S. M., C. Montoye, R. Mehta et al. 2006. Sex Differences in the Application of Evidence-Based Therapies for the Treatment of Acute Myocardial Infarction: The American College of Cardiology's Guidelines Applied in Practice Projects in Michigan. Archives of Internal Medicine 166 (11): 1164–70.

* Mehta, R. H., C. K. Montoye, M. Gallogly et al. 2002. Improving Quality of Care for Acute Myocardial Infarction: The Guidelines Applied in Practice (GAP) Initiative. Journal of the American Medical Association 287 (10): 1269–76.