A regional quality improvement effort aimed at increasing the use of preoperative beta-blocker (BB) usage to help prevent postoperative myocardial infarction (POMI) was revealed today at the 64th Vascular Annual Meeting® presented by the Society for Vascular Surgery®.
This quality improvement effort was implemented at 11 centers participating in participating in the Vascular Study Group of New England (VSGNE) from 2003 through 2008. Prospective data were collected from BB usage of less than one month preoperative (P) vs. chronic (C), from 926 patients undergoing open abdominal aortic aneurysm repair (AAA) and 2,123 patients having a lower extremity bypass (LEB). Their affect on POMI rates were also measured.
A 90 percent target was set and feedback was presented at VSGNE bi-annual meetings. "Overall BB utilization was 86 percent (AAA 90 percent, LEB 84 percent) and in-hospital POMI occurred in 5.5 percent of patients (AAA 7.6 percent, LEB 4.6 percent)," said Philip Goodney, MD, MS, who worked with Drs. Brian Nolan, and Jens Eldrup-Jorgensen on the project, all vascular surgeons and members of the Vascular Study Group of New England. "The P-BB usage increased in low risk and C-BB usage increased in medium and high risk patients, by over 10 percent in each category."
However, despite successfully increasing the use of BB, POMI rates did not change over time. Independent predictors of POMI included people 70 years of age and older (OR 2.1), positive stress test (OR 2.2), congestive heart failure (OR 1.7), C-BB (OR 1.7), resting heart rate of less than 70 (OR 1.8) and diabetes (1.6). Resting heart rate was 67, for patients on C-BB; and 70 for patients on P-BB or on no BB. Researchers noted that predictors of POMI were determined using multivariate logistic regression. Rates of BB utilization and POMI were analyzed over time across strata of patient risk based on a multivariate model.
"Overall, we were quite pleased at the success of our quality improvement effort, in terms of increasing the utilization of BB. However, we are unsure as to why the increase in preoperative BB utilization failed to decrease or change the POMI rate. This may have been because BB doses were not high enough to adequately decrease heart rate, or because the increases in BB utilization occurred primarily in low risk patients," said Dr Goodney. "Our future work will aim to explore both of these questions."
The VSGNE is a regional voluntary consortium which collects and exchanges information in an effort to continuously improve the quality, safety, effectiveness, patient selection algorithms, costs and care for patients with vascular disease. Its quality improvement registry has prospectively collected data on more than 12,000 patients undergoing certain vascular procedures including carotid endarterectomy, carotid stenting, lower extremity arterial bypass, and open and endovascular repair of AAA.
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