A quality guarantee in acute coronary syndromes: the American College of Cardiology's Guidelines Applied in Practice program taken real-time

Smit Vasaiwala, Elizabeth Nolan, Vijay S Ramanath, Jiaming Fang, Gwen Kearly, Sharon Van Riper, Eva Kline-Rogers, Richard Otten, Robert A Cody, Kim A Eagle
American Heart Journal 2007, 153 (1): 16-21

BACKGROUND: Wide variation exists in the management of acute coronary syndromes (ACSs), which includes an apparent underutilization of evidence-based therapies. We have previously demonstrated that application of the American College of Cardiology Guidelines Applied in Practice (GAP) tools can improve quality indicator rates and outcomes of patients hospitalized with ACS.

OBJECTIVE: To determine whether a real-time system for monitoring key quality-of-care indicators using GAP would improve both process indicators and outcomes beyond those of the initial implementation of GAP.

DESIGN: Prospective patient identification, prospective chart coding, retrospective data abstraction.

PATIENTS: All patients with ACS admitted (N = 3189) to our institution between January 1, 1999, and December 2004; 2019 studied before real-time implementation from January 1, 1999, to June 30, 2002, and 1170 studied during real-time implementation from July 1, 2002, to December 31, 2004.

MAIN OUTCOME MEASURE: The effect of real-time monitoring of key quality indicators on inhospital therapy and outcomes, and 6-month outcomes in patients admitted with ACS.

RESULTS: The real-time GAP implementation correlated with more frequent use of inhospital angiotensin-converting enzyme inhibitors (72.7% vs 63.7%, P < .0001), beta blockers (93.0% vs 89.7%, P = .0016), statins (81.2% vs 65.9%, P < .0001), antiplatelet agents (69.2% vs 22.5%, P < .0001), and glycoprotein IIb/IIIa inhibitors (35.5% vs 26.7%, P < .0001). There were fewer episodes of inhospital congestive heart failure (3.85% vs 8.77%, P < .0001) and major bleeding events (3.2% vs 7.9%, P < .0001) after the real-time system was adopted. Real-time GAP also resulted in higher discharge rates of aspirin (92.1% vs 86.5%, P < .0001), beta blockers (86.8% vs 79.1%, P < .0001), statins (81.2% vs 64.7%, P < .0001), and angiotensin-converting enzyme inhibitors (67.1% vs 55.5%, P < .0001). Real-time GAP implementation was associated with fewer rehospitalizations for heart disease (19.8% vs 25.2%, P = .0014), myocardial infarction (3.5% vs 5.4%, P = .0243), and combined death/cerebrovascular accident/myocardial infarction (9.5% vs 13.9%, P = .0009) during the first 6 months after discharge.

CONCLUSION: The institution of a formal system to review and "guarantee" key quality-of-care indicators real time in the hospital is associated with improved outcomes in patients admitted with ACS. The combination of American College of Cardiology's GAP program and its real-time implementation leads to higher use of evidence-based therapies and correspondingly better outcomes than those associated with the initial GAP implementation.

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