Now, combined results from three studies conducted in 33 Michigan hospitals show it’s possible to improve the care provided to heart attack patients after admission.
By incorporating a system of reminders, standing orders and checklists into routine care, the study shows, hospitals significantly improved the percentage of patients receiving certain proven treatments and lifestyle counseling. After the system was put in place, the study shows, there were jumps in the use of individual treatments that ranged in size from 5.6 percentage points to 34.8 percentage points.
The new results come from the latest phase of a study sponsored by the American College of Cardiology and led by members of the Michigan ACC chapter under the direction of researchers at the University of Michigan Cardiovascular Center. They will be presented at the ACC’s 52nd Annual Scientific Session meeting in Chicago. Note to editors: An ACC press conference will be held at 12:30 p.m. CT on 3/30.
“These results leave no doubt that if hospitals and caregivers adopt tools that can help them improve care, and create systems to make sure those tools are used, they can improve their performance on quality indicators – which means better care for patients,” says study leader Kim A. Eagle, M.D., the Albion Walter Hewlett Professor of Internal medicine and chief of clinical cardiology at the U-M Health System.
The study, called ACC AMI GAP for the ACC’s Acute Myocardial Infarction Guidelines Applied in Practice, seeks to find ways to help doctors and hospitals deliver the care outlined in heart attack care guidelines developed by the ACC and the American Heart Association. The guidelines are based on the best available evidence of what drugs, tests and lifestyle changes (such as smoking cessation and diet modification) work best for patients, preventing complications and recurrences.
The new results of the three projects conducted between the years 2000 and 2003 compare the care given to 1,892 heart attack patients treated at the 33 hospitals before the studies began, and 2,065 heart attack patients treated while the system was in place. The study measured use of aspirin, beta blockers and ACE inhibitors early and late in a patient’s care; cholesterol tests and cholesterol-lowering drugs; and counseling on diet and smoking cessation.
“These are all proven therapies that, while not indicated for every single patient, have been shown to reduce the risk of death, additional heart attacks, and other complications in the vast majority of patients who receive them,” says Eagle. “Even though we know what works, it hasn’t been easy to make sure that knowledge benefits every patient. This study aimed to close the gap between what experts recommend and what patients receive.”
The new results combine the data collected in three stages of the GAP project: a pilot study in 10 hospitals in southeast Michigan, a phase II study in five hospitals in the Flint/Saginaw region of Michigan, and a phase III study in 19 more southeast Michigan hospitals including UMHS.
The study hospitals were of all different sizes and types, from small community facilities to major urban and tertiary-care medical centers. Both teaching and non-teaching hospitals were included, and patients had various forms of insurance – about 70 percent were on Medicare.
The ACC Michigan Chapter team is leading the GAP project for acute myocardial infarction, or heart attack; other national projects focus on heart failure in Oregon and unstable angina in Alabama. The ACC chose Eagle and ACC AMI GAP project manager Cecelia Montoye, RN, MSN, CPHQ, to co-direct the heart attack study. In addition to the ACC, which sponsored the project, the study’s partners are the Michigan chapter of the ACC, the Michigan Peer Review Organization, the Greater Detroit Area Health Council, through its Southeast Michigan Quality Forum for Cardiovascular Care, and the Greater Flint Health Coalition.
All hospitals were offered a “toolkit” of reminders, checklists, stickers, standard orders, reference cards and educational materials that made it easier for doctors, nurses and patients to follow the ACC’s guidelines.
The degree to which the care system was incorporated into each hospital varied. Some improvement was seen even in the hospitals that didn’t use the toolkit very often – for instance, an increase of about 7 percentage points was seen in prescriptions for aspirin and beta blockers that were written before patients left the hospital.
But in hospitals that consistently used the tools, the gains were much greater. Use of aspirin and beta blockers early in a patient’s hospital stay increased 6.6 points and 5.6 points, respectively. Pre-discharge prescriptions for the same drugs rose 12.4 points and 6.3 points, respectively. There was also a 7.7 percentage point increase in prescriptions for ACE inhibitor drugs given before patients went home. And a 9.6 percentage point jump in cholesterol tests was also seen.
The biggest gains were in the area of diet and smoking-cessation counseling, and in prescriptions for cholesterol-lowering drugs, which rose by 14.3 points. A 34.8 point jump in the proportion of patients who got advice about stopping smoking, and a 21.6 point rise in the percentage who saw a dietitian or nutritionist before they went home, show how far hospitals have to go in helping patients understand the lifestyle changes that can help their health.
Eagle notes that none of the therapies was used in 100 percent of patients – the highest percentage achieved was 94 percent, for pre-discharge aspirin. But not every patient needs every therapy – for instance, non-smokers don’t need advice on stopping smoking, and patients who are already taking blood-thinning drugs should generally not take aspirin, too.
Eagle emphasizes that the ACC guidelines, and the GAP toolkit that incorporates them, aren’t a “cookbook” for cookie-cutter medicine. “These tools, and the processes that lead to their consistent use, simply function as a reminder system,” he says. “These are key things that need to be thought about and either ordered or ruled out because of a contraindication. We want to help doctors, nurses, and patients consider the priorities and follow them if indicated.”
Based on the success seen in the new results, Eagle says, there’s momentum for the project to expand into other states, and to incorporate additional care guidelines. Eagle and Montoye have recently helped a group of hospitals in Montana adopt the GAP toolkit, and similar programs have begun in Kansas, West Virginia and Ohio. The concept is also taking hold overseas – hospitals in Italy have initiated a GAP project, and another effort is being planned in Spain.
In addition to Eagle and Montoye, the authors of the new study include Anthony DeFranco, Arthur Riba, Robert Parrish, Jessica Paul, Patricia L. Baker, and Rajendra Mehta, M.D., a clinical assistant professor of cardiology who has helped lead the study.
The hospitals in the study were:
Southeast Michigan pilot: Bi-County, Harper, Henry Ford Wyandotte, Mt. Clemens General, Oakwood Dearborn, Oakwood Heritage, Providence, Sinai-Grace, St. Joseph Mercy, St. John.
Flint/Saginaw phase: Genesys, McLaren, Hurley, Covenant Health System, St. Mary-Saginaw.
Southeast Michigan phase: Botsford, Beaumont, Chelsea, Crittenton, Henry Ford, Huron Valley-Sinai, McPherson, North Oakland, Oakwood-Annapolis, Oakwood-Seaway, Pontiac Osteopathic, Port Huron, Riverside Osteopathic, St. John-Macomb, St. John-River District, St. Joseph Mercy-Oakland, St. Mary Mercy-Livonia, University Hospital (U-M).
Background on heart attack and heart attack treatment:
Heart attack, or acute myocardial infarction (AMI) is a leading killer of Americans, striking 1.1 million people each year and killing about 45 percent of them within one year of their attacks. With recent advances in treatment and preventive measures, survival rates have improved – leaving 7.5 million American heart attack survivors alive today.
The quality of care that patients receive in the minutes, hours, days and months after their heart attacks varies widely from hospital to hospital, state to state, and person to person. The result: wide variation in patients’ survival, complication and recurrence rates, and quality of life. Sizable variations by age, sex, race and geographic location have been seen.
The ACC developed its heart attack guidelines in collaboration with the American Heart Association to address such disparities. Based on solid medical evidence about the effectiveness of drugs, tests, interventions and other techniques, and updated regularly, the guidelines serve as a “gold standard” for emergency, hospital and follow-up care. Available on the Internet, the guidelines give recommendations for the treatments, tests and advice that patients should get based on their age, sex, medical history and the severity of their condition.
Tools in the GAP Initiative “Tool Kit” (available online at www.acc.org):
- Standing orders for medication and tests
- Pocket cards of medications and guidelines for medical staff
- A “clinical pathway” that guides nurses through their daily activity
- A special patient information form
- Stickers for the patient’s chart
- A chart that shows the hospital’s overall performance
- A discharge checklist for doctors or selected nurses to review with patients
- Patient education materials -- written and verbal instruction on therapy and lifestyle
Guideline-recommended therapies, tests and counseling measured in the study:
- Aspirin in the emergency room and before discharge to prevent clotting
- Beta-blockers to reduce heart rhythm problems
- Angiotensin-converting enzyme (ACE) inhibitors, to aid the heart’s recovery
- Blood cholesterol tests and, in appropriate patients, drugs to lower cholesterol
- Smoking cessation counseling (smoking doubles the long-term risk of heart attack)
- Diet counseling, with emphasis on low-fat diets