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Study shows best practices do improve outcomes
Randomized study shows where improvement needed
One of the most challenging issues for quality managers is demonstrating that best QI practices can actually improve outcomes. Demonstrating such success requires a good deal of time and resources. In light of this challenge, the results of a new study published in JAMA should be good news, indeed.
The article, based on data from the Global Registry of Acute Coronary Events (GRACE) study, which has collected data from 44,372 patients treated at 113 hospitals in 14 countries, shows a correlation between a period during which hospitals increased use of certain drugs, tests, and procedures that have been proved to help reduce the immediate and long-term impact of acute heart problems, and a significant drop in the rate of heart failure and death. People who suffer a heart attack or severe chest pain today are much less likely to die or to experience long-lasting effects than their counterparts even a few years ago, according to the study.1
All of the patients studied had suffered either an ST-elevated myocardial infarction (STEMI) or had acute coronary syndrome (ACS), which includes non-STEMI heart attack and unstable angina. Between 1999 and 2006, the use of drugs such as aspirin, statins, glycoprotein IIb/IIIa inhibitors, clopidogrel and heparin, and ACE inhibitors increased markedly. At the same time, the use of angiography and angioplasty as an emergency or secondary treatment to reopen blockages increased by more than 30% in STEMI patients and about 20% in ACS patients.
"I think the most significant finding was the magnitude of improvement in both inpatient and six-month outcomes that reflect the global effort to provide more rapid reperfusion for ST-elevation MI and a steady migration to using acute angioplasty as an approved method to open occluded arteries, and the remarkable impact on inpatient heart failure and stroke that was maintained after six months by getting patients on evidence-based therapies after leaving the hospital," says Kim Eagle, MD, FACC, a co-author of the paper and co-chair of the publication committee for GRACE, and director of the University of Michigan Cardiovascular Center in Ann Arbor.
A 'remarkable transformation'
Eagle notes these findings mirror a recent progression toward greater use of evidence-based practices. "Professional societies began creating guidelines 30 years ago, and 20 years ago we started having important randomized trials that suggested improved outcomes, but as recently as 15 years ago, studies said doctors were not using their own guidelines," he notes. "In the last 10 years we've seen a multi-faceted effort at trying to make sure these key therapies are available to every patient we treat."
Today, he continues, "we are being asked to show this through core measures, and, in some cases, it affects the way reimbursements are parceled out. This reflects quite a remarkable transformation that we're in."
While he was careful about calling this paper one of the first studies to show that following best practices leads to better outcomes, Eagle offered that: "This is one of the largest studies [of its kind] in the world. This is observational, taking the average patient who presented to one of 115 hospitals [with one of these conditions] and a six-month follow-up. It suggests if we do a good job at the point of discharge, we will do better downstream as well, and that is very gratifying."
Eagle says the study also underscores that in the early treatment of ACS "the evidence that reperfusion with balloon whenever available is beneficial is compelling. And this study shows that in real-world experience, the benefit may even exceed what we saw in the trials. Second, we cannot underestimate the additional benefit on other outcomes, such as heart failure and stroke."
Making failure impossible
Despite the encouraging results, there were also disappointments. For example, the percentage of patients receiving reperfusion therapy has not increased significantly over time. Eagle also notes that only 85% of STEMI patients and 83% of ACS patients in the study received a statin in 2006, when virtually all such patients should receive the cholesterol-lowering drug.
"I'm convinced all cardiovascular caregivers want to give the best care, but the ideal solution is to create systems where we can't fail; build into your systems reminders of those things you always want do," says Eagle. "If we get more systematic, it's amazing what we can do.''
So, for example, at the point of discharge the University of Michigan has created a system where every quality measure is gone over and explained. "For example, if the patient is not on blood pressure medicine, we have documented why they are not," Eagle explains.
Tracking the patient's experience is also important, he continues. "For example, if a patient's heart rate is 50 when they are admitted, they would not get a beta-blocker; but when they are discharged and it is 80, they are now eligible. However, this could potentially get omitted unless there is a system of review."
There could be simple human errors, such as forgetting to tell a patient they need to stay on aspirin or not writing a prescription because it can be purchased over the counter. "Those kinds of simple little omissions can have a big impact when you are treating a large population," Eagle notes.
The program at the University of Michigan starts with standardized orders, key early strategies, and at the point of discharge, a document called a contract that both the nurse and the patient sign. "It basically goes over key lifestyle goals, key pharmacological drug goals, and tries to ensure a clear follow-up plan that includes the patient knowing what to do if they get recurrent symptoms,'' Eagle explains.
When the chart is coded, the discharge coders also review the notes and if they pick something up, the doctor is immediately notified and can call the patient to correct the information.
"So, we have three levels of correction," says Eagle. "We've shown when we use this layered redundancy we substantially improve quality indicators to almost 100% of patients, and we have a significant impact on six-month recurrent MI and death."
The three keys to success, he continues, are clear quality goals, a simple way to track performance, and a feedback loop to make sure they are adhered to. "We send a quality measures report card to our doctors and nurses every month," he reports. "The future of quality is to guarantee, rather than say we are trying."
A few years ago, he notes, "We stopped asking the question, 'How can we get better?' We started asking, 'How can we make sure we never miss?'"
[For more information, contact Kim Eagle, MD, FACC, Director, University of Michigan Cardiovascular Center, Ann Arbor, MI. Phone: (734) 936-5275.]