Efforts to improve the quality of post-heart attack care working better for men than for women

Mar 9 2005

Efforts to improve the quality of post-heart attack care in hospitals are working - but they appear to be working better for men than for women, new research shows.

That finding, presented at the Annual Scientific Session of the American College of Cardiology, comes from an analysis of records from 2,857 heart attack survivors treated at Michigan hospitals before and after a major quality improvement effort took place. All were insured under Medicare.

The researchers, led by a team from the University of Michigan Cardiovascular Center, found a significant difference between the treatment women received before and after the effort, and that received by men. The increased use of proven medications, for example, was much more pronounced in men.

Overall, both men and women treated in the four months after the quality effort began had a better chance of being alive a year after their hospital stay ended. But women didn't get as much mortality reduction benefit as men.

That difference may be in part because women patients were less likely than men to have a one-on-one session with doctors or nurses before they went home, to help them understand and "take charge" of the medicines and lifestyle changes that could improve their health. Both men and women who had this session, and signed a discharge contract with their doctors and nurses that included a pledge to stick to treatment and follow-up appointments, lived longer than those who didn't.

"We're troubled by the gender differences we found, though we remain encouraged by the overall effect of post-heart attack quality improvement efforts," says lead researcher Kim Eagle, M.D., clinical director of the U-M Cardiovascular Center.

Eagle is co-director of the Guidelines Applied in Practice (GAP) Project in Michigan. GAP is a project of the ACC that aims to help hospitals deliver proven medications, tests, and advice on diet, exercise, smoking cessation and weight loss to all patients.

At last year's ACC meeting, Eagle and his colleagues reported that the GAP project resulted in a 25 percent lower risk of dying within a year of leaving the hospital among heart attack patients whose doctors and nurses followed standard national guidelines for their care, and used the discharge tool and contract. This major effect on mortality rates was the first evidence that standardized heart care saves lives.

GAP tries to increase hospitals' use of aspirin and beta blocker drugs, and cholesterol testing, within 24 hours of a heart attack, and the prescribing of aspirin, beta blockers, cholesterol-lowering drugs and ACE inhibitor drugs for patients leaving the hospital. It also seeks to increase the number of patients who get counseling about diet and smoking before they leave the hospital.

Sandeep Jani, MPH, the researcher who will present the results, notes that on the whole, men treated after the quality effort were more likely to receive pre-discharge prescriptions for all four classes of recommended heart medications than were women. The quality effort significantly improved the use of only two of the drugs – beta blockers and aspirin -- in women. Jani is a former ACC intern and research assistant with the GAP project at U-M, and is now studying at the Wayne State University Medical School in Detroit.

The new analysis showing differences in the delivery of care to women and men, even after the quality improvement effort, raises an important question of how hospitals implement quality measures.

Although the new data do not give insights into the factors that caused the gender difference, Jani and Eagle note that the female patients were on average older and more seriously ill, with more co-existing health problems, than the male patients. This fits the known pattern of heart disease among women, who tend to develop the condition and its effects later in life. Cardiovascular disease is the number one killer of both men and women.

Some previous studies by other researchers have found that doctors are less likely to deliver evidence-based medical care -- the foundation of quality improvement efforts like GAP – to women compared with men. But the new study is the first to show a correlation between this failure and mortality.

"We owe women heart attack patients a full examination of the factors that might lead them to receive fewer of the proven drugs and lifestyle tips than men receive," says Eagle. "Now that we know that they get just as much mortality benefit as men when quality standards are applied to their care, we must find ways to ensure that they are all treated according to those standards."

Thirty-three hospitals across Michigan took part in the GAP-Heart attack study, and many more across the nation are joining the drive to improve the quality of health care.

In addition to Jani and Eagle, the study's authors are: Michigan GAP co-director and project coordinator Cecelia K. Montoye, MSN; Benrong Chen, Ph.D.; Canopy Roychoudhury, Ph.D.; Anthony D. DeFranco, M.D., and Arthur L. Riba, M.D. for the Michigan GAP Investigators and the ACC GAP Steering Committee.