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Original Contribution |

Improving Quality of Care for Acute Myocardial Infarction:  The Guidelines Applied in Practice (GAP) Initiative FREE

Rajendra H. Mehta, MD, MS; Cecelia K. Montoye, MSN; Meg Gallogly, BA; Patricia Baker, MS; Angela Blount, MPH; Jessica Faul, MPH; Canopy Roychoudhury, PhD; Steven Borzak, MD; Susan Fox, MSN; Mary Franklin, CNS; Marge Freundl, MSN; Eva Kline-Rogers, MSN; Thomas LaLonde, MD; Michele Orza, ScD; Robert Parrish, MM; Martha Satwicz, MSN; Mary Jo Smith, MSN, MPH; Paul Sobotka, MD; Stuart Winston, DO; Arthur A. Riba, MD; Kim A. Eagle, MD; for the GAP Steering Committee of the American College of Cardiology
[+] Author Affiliations

Author Affiliations: Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor (Drs Mehta and Eagle, and Ms Kline-Rogers); American College of Cardiology, Bethesda, Md (Mss Montoye and Gallogly, and Dr Orza); Michigan Peer Review Organization, Plymouth (Mss Baker, Blount, and Faul, Dr Roychoudhury, and Ms Satwicz); Division of Cardiology, Department of Internal Medicine, Henry Ford Health System, Detroit, Mich (Dr Borzak, Ms Fox); Division of Cardiology, Department of Internal Medicine, St John Hospital and Medical Center, Detroit, Mich (Dr LaLonde); Disease Management, St John Health System, Warren, Mich (Ms Freundl); Greater Detroit Area Health Council, Detroit, Mich (Mr Parrish); Division of Cardiology, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Mich (Ms Smith, Dr Winston); Department of Internal Medicine, Division of Cardiology, Detroit Medical Center, Detroit, Mich (Dr Sabotka); and Department of Internal Medicine, Division of Cardiology, Dearborn, Mich (Ms Franklin, Dr Riba).


JAMA. 2002;287(10):1269-1276. doi:10.1001/jama.287.10.1269.
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Published online

Context Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals.

Objective To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI.

Design and Setting The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan.

Patients A random sample of Medicare and non-Medicare patients at baseline (July 1998–June 1999; n = 735) and following intervention (September 1–December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January–December 1998; n = 513) and at remeasurement (March–August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group.

Intervention The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators.

Main Outcome Measures Differences in adherence to quality indicators (use of aspirin, β-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group.

Results Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P = .02) and β-blockers (65% vs 74%; P = .04) on admission and use of aspirin (84% vs 92%; P = .002) and smoking cessation counseling (53% vs 65%; P = .02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators.

Conclusions Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.

Despite considerable investment in the development and dissemination of national guidelines for the management of acute myocardial infarction (AMI),1 the Center for Medicare and Medicaid Services' (CMS) Cooperative Cardiovascular Project recently reported that quality of care for Medicare beneficiaries with AMI was far from optimal.2 Many subsequent studies have shown similar disappointing adherence to the therapies recommended in published guidelines.36 Furthermore, quality of care of patients with AMI varies with age, sex, race, geographic location, physician specialty, and hospital teaching status.2,3,716 This variation in care is likely linked to outcomes.11,13,17 Although recent analyses of care patterns over time have suggested steady improvement in the use of key therapies in patients with AMI,18,19 there remain important opportunities to improve adherence to evidence-based therapies.1820

In this report, we describe the initial impact of the Guidelines Applied in Practice (GAP) initiative of the American College of Cardiology (ACC) in southeast Michigan. Conceptually, the program sought to incorporate national guidelines into care processes, focused on both caregivers (physicians and nurses) and patients, in part by creating tools and systems that reinforce adherence to key evidence-based therapies.

Ryan TJ, Antman EM, Brooks MH.  et al.  ACC/AHA guidelines for management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction).  J Am Coll Cardiol.1999;34:890-911.
Ellerbeck EF, Jencks SF, Radford MJ.  et al. for the Cooperative Cardiovascular Project.  Quality of care for Medicare patients with acute myocardial infarction: a four-state pilot study.  JAMA.1995;273:1509-1514.
Gurwitz JH, Goldberg RJ, Chen Z, Gore JM. β-blocker therapy in acute myocardial infarction: evidence for underutilization in the elderly.  Am J Med.1992;93:605-610.
McLaughlin TJ, Soumerai SB, Wilson DJ.  et al.  Adherence to national guidelines for drug treatment of suspected acute myocardial infarction.  Arch Intern Med.1996;156:799-805.
Mehta RH, Ruane TJ, McCargar PA, Eagle KA, Stalhandske EJ. The treatment of elderly diabetic patients with acute myocardial infarction.  Arch Intern Med.2000;160:1301-1306.
Alexander KP, Peterson ED, Granger CB.  et al.  Potential impact of evidence-based medicine in acute coronary syndromes: insights from GUSTO-IIb.  J Am Coll Cardiol.1998;32:2023-2030.
Yarzebski J, Col N, Pagley P, Savangeau J, Gore J, Goldberg R. Gender differences and factors associated with receipt of thrombolytic therapy in patients with acute myocardial infarction: a community-wide perspective.  Am Heart J.1996;131:43-50.
Gurwitz JH, Gore JM, Goldberg RJ. Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction.  Ann Intern Med.1996;124:283-291.
Vaccarino V, Horwitz RI, Meehan TP, Petrillo MK, Radford MJ, Krumholz HM. Sex differences in mortality after myocardial infarction: evidence for a sex-age interaction.  Arch Intern Med.1998;158:2054-2062.
Allison JJ, Kiefe CI, Centor RM, Box JB, Farmer RM. Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction.  J Gen Intern Med.1996;11:736-743.
O'Connor GT, Quinton HB, Traven ND.  et al.  Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project.  JAMA.1999;281:627-633.
Pilote L, Califf RM, Sapp S.  et al. for the GUSTO-1 Investigators.  Regional variation across the United States in the management of acute myocardial infarction.  N Engl J Med.1995;333:565-572.
Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA.for the National Cooperative Cardiovascular Project.  National use and effectiveness of β-blockers for the treatment of elderly patients after acute myocardial infarction.  JAMA.1998;280:623-629.
Ayanian JZ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction.  N Engl J Med.1994;331:1136-1142.
Casale PN, Jones JL, Wolf FE, Pei Y, Eby LM. Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction.  J Am Coll Cardiol.1998;32:885-889.
Allison JJ, Kiefe CI, Weissman NW.  et al.  Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI.  JAMA.2000;284:1256-1262.
Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Golman L. Adverse outcomes of underuse of β-blockers in elderly survivors of acute myocardial infarction.  JAMA.1997;277:115-121.
Rogers WJ, Bowlby LJ, Chandra NC.  et al.  Treatment of myocardial infarction in the United States (1990-1993): observations from the National Registry of Myocardial Infarction.  Circulation.1994;90:2103-2114.
Marciniak TA, Ellerbeck EF, Radford MJ.  et al.  Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project.  JAMA.1998;279:1351-1357.
Jencks SF, Cuerdon T, Burwen DR.  et al.  Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels.  JAMA.2000;284:1670-1676.
Mehta RH, Das S, Tsai TT, Nolan E, Kearly G, Eagle KA. Quality improvement initiative and its impact on the management of patients with acute myocardial infarction.  Arch Intern Med.2000;160:3057-3062.
Mehta RH, Das S, Nolan EM.  et al.  Improving screening and management of hyperlipidemia in patients with acute myocardial infarction.  Prev Med Manag Care.2001;2:15-22.
Soumerai SB, McLaughlin TJ, Gurwitz JH.  et al.  Effect of local medical opinion leaders on quality of care of acute myocardial infarction: a randomized controlled trial.  JAMA.1998;279:1358-1363.
Weingarten S, Agocs L, Tankel N, Sheng A, Ellrodt AG. Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders.  Am J Cardiol.1993;71:259-262.
Hiss RG, MacDonald R, Davis WK. Identification of physician educational influence in small community hospitals. In: Proceedings of the Association of American Medical Colleges Annual Conference on Research in Medical Education; October 21-26, 1978; New Orleans, La: 283-288.
Thomson MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes [Cochrane Review on CD-ROM]. Oxford, England: Cochrane Library, Update Software; 2001; issue 1.
Grimshaw JM, Russel IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations.  Lancet.1993;342:1317-1322.

Figures

Tables

References

Ryan TJ, Antman EM, Brooks MH.  et al.  ACC/AHA guidelines for management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction).  J Am Coll Cardiol.1999;34:890-911.
Ellerbeck EF, Jencks SF, Radford MJ.  et al. for the Cooperative Cardiovascular Project.  Quality of care for Medicare patients with acute myocardial infarction: a four-state pilot study.  JAMA.1995;273:1509-1514.
Gurwitz JH, Goldberg RJ, Chen Z, Gore JM. β-blocker therapy in acute myocardial infarction: evidence for underutilization in the elderly.  Am J Med.1992;93:605-610.
McLaughlin TJ, Soumerai SB, Wilson DJ.  et al.  Adherence to national guidelines for drug treatment of suspected acute myocardial infarction.  Arch Intern Med.1996;156:799-805.
Mehta RH, Ruane TJ, McCargar PA, Eagle KA, Stalhandske EJ. The treatment of elderly diabetic patients with acute myocardial infarction.  Arch Intern Med.2000;160:1301-1306.
Alexander KP, Peterson ED, Granger CB.  et al.  Potential impact of evidence-based medicine in acute coronary syndromes: insights from GUSTO-IIb.  J Am Coll Cardiol.1998;32:2023-2030.
Yarzebski J, Col N, Pagley P, Savangeau J, Gore J, Goldberg R. Gender differences and factors associated with receipt of thrombolytic therapy in patients with acute myocardial infarction: a community-wide perspective.  Am Heart J.1996;131:43-50.
Gurwitz JH, Gore JM, Goldberg RJ. Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction.  Ann Intern Med.1996;124:283-291.
Vaccarino V, Horwitz RI, Meehan TP, Petrillo MK, Radford MJ, Krumholz HM. Sex differences in mortality after myocardial infarction: evidence for a sex-age interaction.  Arch Intern Med.1998;158:2054-2062.
Allison JJ, Kiefe CI, Centor RM, Box JB, Farmer RM. Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction.  J Gen Intern Med.1996;11:736-743.
O'Connor GT, Quinton HB, Traven ND.  et al.  Geographic variation in the treatment of acute myocardial infarction: the Cooperative Cardiovascular Project.  JAMA.1999;281:627-633.
Pilote L, Califf RM, Sapp S.  et al. for the GUSTO-1 Investigators.  Regional variation across the United States in the management of acute myocardial infarction.  N Engl J Med.1995;333:565-572.
Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA.for the National Cooperative Cardiovascular Project.  National use and effectiveness of β-blockers for the treatment of elderly patients after acute myocardial infarction.  JAMA.1998;280:623-629.
Ayanian JZ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction.  N Engl J Med.1994;331:1136-1142.
Casale PN, Jones JL, Wolf FE, Pei Y, Eby LM. Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction.  J Am Coll Cardiol.1998;32:885-889.
Allison JJ, Kiefe CI, Weissman NW.  et al.  Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI.  JAMA.2000;284:1256-1262.
Soumerai SB, McLaughlin TJ, Spiegelman D, Hertzmark E, Thibault G, Golman L. Adverse outcomes of underuse of β-blockers in elderly survivors of acute myocardial infarction.  JAMA.1997;277:115-121.
Rogers WJ, Bowlby LJ, Chandra NC.  et al.  Treatment of myocardial infarction in the United States (1990-1993): observations from the National Registry of Myocardial Infarction.  Circulation.1994;90:2103-2114.
Marciniak TA, Ellerbeck EF, Radford MJ.  et al.  Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project.  JAMA.1998;279:1351-1357.
Jencks SF, Cuerdon T, Burwen DR.  et al.  Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels.  JAMA.2000;284:1670-1676.
Mehta RH, Das S, Tsai TT, Nolan E, Kearly G, Eagle KA. Quality improvement initiative and its impact on the management of patients with acute myocardial infarction.  Arch Intern Med.2000;160:3057-3062.
Mehta RH, Das S, Nolan EM.  et al.  Improving screening and management of hyperlipidemia in patients with acute myocardial infarction.  Prev Med Manag Care.2001;2:15-22.
Soumerai SB, McLaughlin TJ, Gurwitz JH.  et al.  Effect of local medical opinion leaders on quality of care of acute myocardial infarction: a randomized controlled trial.  JAMA.1998;279:1358-1363.
Weingarten S, Agocs L, Tankel N, Sheng A, Ellrodt AG. Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders.  Am J Cardiol.1993;71:259-262.
Hiss RG, MacDonald R, Davis WK. Identification of physician educational influence in small community hospitals. In: Proceedings of the Association of American Medical Colleges Annual Conference on Research in Medical Education; October 21-26, 1978; New Orleans, La: 283-288.
Thomson MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes [Cochrane Review on CD-ROM]. Oxford, England: Cochrane Library, Update Software; 2001; issue 1.
Grimshaw JM, Russel IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations.  Lancet.1993;342:1317-1322.

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