Heart attack patients are discharged without evidenced-based, guideline recommended, life-prolonging therapies

Jun 16 2004

Heart attack care is more likely to match recommended guidelines when health care providers use standardized forms and other reminders, and institutional systems reinforce goals for treatment and patient lifestyles, according to a new study in the June 16, 2004 issue of the Journal of the American College of Cardiology.

"Medicine by memory is unreliable. We need systems which surround the care to help all of us remember our top priorities," said Kim A. Eagle, MD, FACC with the University of Michigan Medical Center in Ann Arbor, Mich. Dr. Eagle is also a member of the American College of Cardiology Guidelines Applied in Practice Steering Committee.

The Guidelines Applied in Practice (GAP) Project is a collaborative effort to raise the quality of heart attack care. The project is led by the ACC and includes a group of Michigan hospitals and community stakeholders, such as major automobile companies and unions.

Although research has shown that certain steps, such as using aspirin and angiotensin-converting enzyme (ACE) inhibitors, beta blockers and statins; smoking cessation; improved diet and other lifestyle changes, can dramatically improve survival rates among heart attack patients, these evidence-based therapies often aren't applied in routine clinical practice.

The GAP pilot project demonstrated ways to improve adherence to evidence-based guidelines. Now this follow-up study shows how to boost the use of "tools," such as standard orders and discharge documents, and that these tools are linked to better care. One or more tools were used in 93 percent of patients, including standard orders for 82 percent of patients and discharge documents for 47 percent of patients. Tool use was associated with significantly higher adherence to measures of quality care, such as the use of aspirin and ACE inhibitors, as well as smoking cessation and dietary counseling.

Dr. Eagle said he hadn't expected to see such a high rate of use of standard orders. He said that putting these findings into practice could have a major payoff.

"We estimate that if GAP were implemented nationwide, the mortality of acute heart attack could drop by as much as 25 percent; this translates literally into tens of thousands of lives," Dr. Eagle said. He advised hospitals and health care practitioners to "embed guideline-based priorities right into the tools we use to care for patients, and involve the patients and nurses in an active attempt to be sure that a relatively short list of key priorities in acute heart attack care are considered in each and every patient, from admission to discharge. By doing this we can substantially improve care and therefore outcomes."

Dr. Eagle noted that since this study showed that the use of the standard "tools" was key to improving practice, health care institutions could measure tool use in order to track their quality improvement progress. Also, this study identified some specific areas where improvement is needed. For example, the researchers saw low rates of adherence to recommended care among heart bypass surgery patients.

Dr. Eagle said that they still need to find better ways to incorporate standard care tools into routine practice, but he added that their efforts involve more than just pushing the use of standard forms.

"The GAP methodology is not just about giving caregivers care tools, but rather a series of step-by-step processes and workshops designed to create the necessary teamwork, and steps that can bring about change in the hospital. Through hard work, deliberate attempts to break down barriers to change, and by strong leadership from physicians, nurses, and hospital leadership, it is possible to create care systems that repeatedly emphasize evidence-based care which then translate into better care," he said.

In an editorial in the journal, Ori Ben-Yehuda, MD, FACC from the University of California in San Diego, wrote that "the GAP project is an important step in the long road toward quality in medicine in general and cardiology in particular."

"Education is not enough. We need systems and checklists, "reminder tools;" just as pilots rely on checklists. The study in the Journal points to the efficacy of such tools in increasing compliance. Given recent trials which demonstrate that we need to be even more aggressive with cholesterol lowering, for example, in patients who have had a heart attack, the imperative of closing treatment gaps becomes even more urgent, and at the same time more difficult to achieve (because we now need even greater cholesterol reduction than before)," Dr. Ben-Yehuda said.

He added that the GAP project demonstrates the commitment of the ACC and the cardiology community to quality improvement.

Gregg C. Fonarow, MD, FACC at the University of California in Los Angeles, who has been deeply involved in quality improvement efforts, but was not connected with this study, said tens of thousands of lives could be saved each year if all hospitals used programs such as GAP.

"This study provides further evidence that a substantial proportion of patients receiving conventional care for acute coronary syndromes are discharged without evidenced-based, guideline recommended, life-prolonging therapies. As demonstrated in this study, use of simple reminder tools for clinicians such as preprinted orders and discharge checklists resulted in significant improvements in treatment rates," Dr. Fonarow said.

The American College of Cardiology, a 29,000-member nonprofit professional medical society and teaching institution, is dedicated to fostering optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and guidelines, and the formulation of health care policy.