Implementation of Evidence-Based Therapies for Myocardial Infarction and Survival

Cardiovascular disease remains the most common cause of morbidity and mortality in the United States, and each year an estimated 785 000 US residents will have a new myocardial infarction (MI), and approximately 470 000 will have a recurrent MI.¹ ST-segment elevation myocardial infarction (STEMI) constitutes a subset of MI presentation, defined by characteristic symptoms of myocardial ischemia and associated with ST-segment elevation or new or presumed new left bundle-branch block. Among patients presenting with an MI, the percentage of cases with STEMI varies in different registries and databases. According to the National Registry of Myocardial Infarction 4 (NRMI-4), among all patients with MI, approximately 29% present with STEMI.²

The optimal treatment of STEMI has significantly changed during the last decade with the incorporation of evidence from multiple clinical trials into clinical practice guidelines that emphasize the importance of rapid reperfusion and the use of evidence-based therapies to reduce morbidity and mortality. Multiple studies have suggested that improving trends in survival after an acute MI are associated with increasing use of evidence-based treatments and timely reperfusion therapies during the initial admission to the hospital.^{3 - 4}

In this issue of JAMA, Jernberg and colleagues⁵ report that in a national Swedish registry of patients with STEMI, between 1996 and 2007, there was an overall increase in the use of evidence-based treatments. This increase coincided with a decrease in 30-day and 1-year mortality that was sustained during long-term follow-up. Although causality between increase in evidence-based therapies and decreased mortality cannot be established given the study design, the study does provide valuable insights into STEMI management. One important finding is the large variation in the implementation of evidence-based and guideline-recommended treatments between different hospitals, and another is the inherently gradual and slow adoption of such therapies.

The results have significant clinical implications for clinicians, hospitals, and patients. They point to an opportunity to improve the quality of care provided to patients with STEMI by decreasing the lag time for adoption of life-saving therapies and improving adherence to evidence-based care across hospitals. The difficulty in disseminating and implementing new technology as reported in the current study⁵ is not unique to health care; the slow adoption of innovation has been documented in fields as different as agriculture, education, and communication.⁶ Successful training of clinicians in implementing new therapies requires a balance of both didactic training, defined as the methods used for information transfer such as written materials, lectures, and workshops, and competence training, defined as the process of acquiring skills necessary to administer a treatment skillfully and with fidelity.⁶ Quality improvement exercises that promote the use of systems that embed guideline knowledge into the care process are often more successful than simple dissemination of information.⁷

The creation of systems and the inclusion of the patient, nurse, and physician in a review of care priorities are methods that promote improvement in quality of health care. Three strategies that define successful quality improvement initiatives include involvement of all stakeholders (such as physicians, patients, nurses, pharmacists, and hospital administrators), emphasis on standard orders and discharge tools that remind clinicians to consider evidence-based therapies for every patient from admission to discharge, and rapid or concurrent and continuous feedback to physicians on use of appropriate evidence-based therapies.⁸

Any intervention aiming to modify physician behavior also must be effective in supporting the adoption of changes into clinical practice. In a review assessing the relative success of interventions in clinical practice, Tamblyn and Battista⁹ grouped the factors that affect change into predisposing, enabling, and reinforcing factors. The authors found that interventions designed to modify the enabling and reinforcing factors seem to be more effective than those aimed at changing the predisposing factors that constitute clinical competence. Their results showed that changes in practice were more likely when the interventions were aimed toward changing the practice setting (eg, practice aids or audit programs) or the reimbursement policy (the fee allowed for a service) than at attempting to change physician knowledge or skill. The authors attributed this success to the greater relevance of these interventions for the individual physician and to the opportunities provided for practicing them and for feedback. A similar insight regarding the effectiveness of different types of interventions was reported by Oxman et al.¹⁰ Comparisons of trials that used single or multifaceted interventions showed that combinations of strategies were more effective than single strategies. These findings demonstrate that interventions to improve performance are complex, with a range of strategies that can be used.¹⁰

In the United States, the ACTION Registry–Get With The Guidelines (GWTG) program was created by the merger of the National Cardiovascular Data Registry (NCDR)–ACTION Registry from the American College of Cardiology Foundation and the GWTG program from the American Heart Association to improve the quality of care for patients with MI. The registry joined the robust data collection and quality reporting features of the ACTION Registry with the collaborative models, unique tools, and quality improvement techniques of the GWTG program. With the collective strengths of these 2 programs, the data from registry may help empower clinical teams to treat patients with MI more consistently and according to the most current, science-based guidelines. The registry provides weekly key measures reports such as use of evidence-based therapies and risk-adjusted quarterly benchmark reports that compare an institution's performance with that of volume-based peer groups and national experience. Such ongoing feedback may help improve adherence to the clinical guidelines recommendations. A recent report from this registry demonstrated significant improvements in the receipt and timeliness of reperfusion therapy for STEMI, in the dosing of antithrombotic therapies, in the safety and results of PCI procedures, and in composite measures of acute MI care using tools available in the registry.¹¹

The appropriate use of evidence-based therapy for patients presenting with STEMI and other cardiovascular conditions has significant health outcome and policy implications. For individual patients and society in general, to fully realize the benefits from optimal therapies, such treatment protocols will need to be adopted quickly and at all hospitals with little variation in care across institutions. In the future, substantial national funding and support for quality measurement and improvement initiatives will be needed to implement the accumulating evidence of effective medical therapies into routine clinical practice and translate efficacy into effectiveness.¹² To ensure that all hospitals are included, regulatory agencies and national societies should encourage hospital participation in regional or national registries to receive key measures reports such as use of evidence-based therapies on a regular and frequent basis and benchmark their performance against their peers. Physicians treating STEMI patients must continue to partner with nurses, patients, hospitals, practice managers, insurance providers, employers, national health care organizations, and information technology in a constructive manner to successfully implement evidence-based therapies quickly, safely, and effectively to serve patients in the best way possible.