Quality-improvement improves mortality in hospital

Heart attack death rates dropped significantly at hospitals that participated in a quality-improvement process that increased the use of evidence-based therapies, according to a new study in the Oct. 4, 2005, issue of the Journal of the American College of Cardiology.

"This study shows that the Guidelines Applied in Practice Project improves not just process indicators, but also mortality in hospital, and especially at 30 days and a year later," said Kim A. Eagle, M.D., F.A.C.C., from the University of Michigan Cardiovascular Center in Ann Arbor, Michigan.

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 American College of Cardiology and includes a group of Michigan hospitals, health systems and insurers, as well as community stakeholders and coalitions, including major automobile companies and unions. Previous reports from the project showed that a systems approach and tools such as standardized admission and discharge documents and "contracts" between physicians and patients could boost adherence to recommended therapies, including aspirin and ACE inhibitors, as well as smoking cessation and dietary counseling. The use of recommended therapies was higher at GAP hospitals than at similar hospitals that did not participate in the project.

Now the researchers report that the GAP hospitals saw heart attack death rates drop. Deaths in the hospital declined from 13.6 percent to 10.4 percent. At 30 days after hospital discharge, the death rate dropped from 21.6 percent to 16.7 percent. After one year, the death rate declined from 38.3 percent to 33.2 percent. After statistical adjustments for a variety of factors, the authors report that when a standard discharge document was used as recommended, the risk of a patient dying within one year was cut almost in half (1-year mortality, odds ratio 0.53; 95% CI 0.36 to 0.76; p = 0.0006).

"The differences are very real. The absolute reduction in one-year death rates was 5 percent, that is, one additional life saved for every 20 patients treated. And if the hospitals used the standardized tools, the impact looked far greater," Dr. Eagle said.

He said the GAP project helps hospitals, caregivers, and patients to put into practice a variety of lifestyle interventions and medical treatments that have been proven effective in clinical trials.

"The system makes sure that patients, nurses and doctors are in agreement. The patients sign discharge contracts saying they understand the goals; so by having a system which helps caregivers and patients to remember to pay attention to these priorities in care every time, we insure that the patients get them. In particular, by involving the patients with the discharge document, we increase the chance that the best care will be realized in the long term," Dr. Eagle said.

Although this was an observational study that was not designed to definitely prove that the GAP changes caused the declines in patient deaths, Dr. Eagle noted that a previous study did show that GAP hospitals adhered to treatment guidelines better than a group of control hospitals. He says this new study ties those improvements in care to higher rates of survival.

"I hope that every acute care hospital in the country will use a system to guarantee the key priorities of care for every patient with an acute coronary syndrome, such as early reperfusion and correct medical treatment, the use of aspirin, beta blockers, statins, and ACE inhibitors among all eligible patients at discharge, a clear follow-up plan, lifestyle goals, and plans for what to do in the event of recurrent symptoms," he said.

Joseph V. Messer, M.D., M.A.C.C., from Rush University Medical Center in Chicago, Illinois, who was not connected with this study, said the GAP project shows that modern medical care requires a systems approach.

"The complexity of optimal health care can no longer depend solely on human memory and individual execution. This study demonstrates that improved patient care requires the combined efforts of individual health care providers and improvements in the systems in which we practice. We await long term results from the GAP project and additional analyses of cost effectiveness," Dr. Messer said.

Raymond McKay, M.D., F.A.C.C., from the Hartford Hospital in Hartford, Connecticut, who also was not connected with this research, pointed out that many patients currently do not receive the kind of care that clinical research results indicate they should.

"Given this background, the article provides a useful framework for how hospitals can begin to achieve the quality outcomes that will be necessary to achieve for all patients. There is no question that the article can only show an association with the Michigan GAP program. However, regardless of whether the results were achieved because of this program or simply related to the widespread dissemination of guidelines and the knowledge that outcomes were being monitored, clinical outcomes did improve. The science here is less important than the actual results," Dr. McKay said.