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Collaborative led to 10% drop in mortality rates
Cardiovascular diseases are once again the leading focus of the Health Care Financing Administration’s (HCFA) quality improvement program, with new projects beginning this year on acute myocardial infarction (MI), heart failure, and stroke.
In its initial Cooperative Cardiovascular Project (CCP), which ended last year, peer review organizations nationwide worked with hospitals to improve on indicators such as aspirin and beta-blocker use, timing to reperfusion, and use of ACE inhibitors. (For a complete list of indicators, see box on p. 56.)
A study of the first four states to launch the CCP showed that mortality rates dropped by 10% while performance on all indicators improved.1 Hospitals used a variety of interventions, from changing standing orders to improving communication among emergency and primary care physicians and cardiologists. (For sample interventions to improve thrombolytic therapy, see p. 57.)
"Shining a light on this problem has heightened people’s awareness of the impact of these relatively simple interventions," says Martha Radford, MD, FACC, Deputy Director of the Center for Outcomes Research and Evaluation at Yale-New Haven (CT) Health. She is also associate clinical coordinator at Qualidigm, a peer review organization (PRO) in Connecticut, one of the CCP pilot states. Qualidigm also has been designated the Clinical Area Support PRO, which means it helps coordinate the national Acute Myocardial Infarction Clinical Project.
The CCP also illuminated problems and solutions associated with heart attack treatment. Use of various therapies varied widely across the nation and even within locales. Prescription of beta-blockers at discharge among ideal candidates, for example, ranged from 36% to 62%. On average, 33% of ideal candidates failed to receive reperfusion, either from thrombolytic therapy or angioplasty.2
Yet hospitals showed that they could make dramatic progress through targeted interventions — particularly if a physician leader championed the process and physicians worked to eliminate barriers to appropriate care, Radford says.
"The most successful QI project I saw was so successful because it was championed by a chief," she says. "It became part of their monthly medical staff meeting to go over the data. They improved more than I’ve ever seen anyone improve in any project."
A Best Practices Working Group from four PROs surveyed 36 hospitals to determine which interventions were most successful.3 When hospitals examined their systems of care from admission to discharge, "[they] really found a lot of room for improvement," says Dale Bratzler, DO, MPH, principal clinical coordinator for the Oklahoma Foundation for Medical Quality in Oklahoma City and a member of the group.
Here are some of the major strategies that helped hospitals improve their care for patients with acute MI:
Although the CCP focused on hospital-level improvement, "it’s the individual physicians who have to change what they’re doing at the bedside to actually impact patient care," says Bratzler, who is also vice chairman of the medical affairs section of the American Health Quality Association in Washington, DC.
For example, Stratis Health of Bloomington, MN, a PRO, developed an advisory board of physicians and other clinicians. Cardiologists led the CCP presentations at hospitals to discuss the indicators and methods of improving outcomes. In fact, research shows that the use of well-respected opinion leaders can influence physicians to increase their use of therapies such as beta-blockers and aspirin among acute myocardial infarction patients.4
Improved communication among physicians also played a role in many interventions. In some cases, confusion over responsibility for different aspects of care led to delays in thrombolytic therapy or gaps in use of appropriate medication at discharge.
"Timing is everything here," says Bratzler. "The data are really clear that the longer the delay until you give the [thrombolytic] drug, the poorer the patient’s prognosis is. Someone needs to make that decision and do it quickly. The national goal is 30 minutes from the door to the time the drug starts. In some cases, the cardiologist insisted on being called first, which builds inherent delays in the system," he says. "The reason some of the cardiologists wanted to be called is because sometimes they want to take patients up to the catheterization lab and do angioplasty."
Some community hospitals use a rotation system of area physicians who work in the emergency department. To ensure uniformity in their training, one hospital established a credentialing program for emergency physicians who administer thrombolytics. Others arranged for physicians to discuss communication issues and focused on the development of clinical pathways.
Meanwhile, the increased use of angioplasty presents a new challenge for many hospitals and physicians. "Some of these hospitals are making a change toward more reliance on PTCA [angioplasty] rather than thrombolytics," says Tom Arneson, MD, MPH, associate medical director for health care quality improvement at Stratis Health. "They’re concerned that their timing on thrombolytics for patients who get [that therapy] may get worse."
One strategy involves speeding up information flow, such as ordering ECGs more quickly and allowing nurses to start ECGs.
At its inception, the CCP represented a "sea change" for HCFA in the way it approached national quality improvement, says Radford. Instead of sending dunning letters to physicians or hospitals based on data from retrospective chart reviews, the PROs restructured to collaborate with providers.
"We’re always open to the suggestions of our collaborators — hospitals, physicians, nurses, quality assessment staff," says Radford. "Every-body realizes the centrality of the physician community here."
Physicians and others have been responsive to the new approach and the feedback it provides. Collecting detailed information for quality improvement would be expensive without HCFA’s support.
Best practice hospitals also commented on the importance of inclusive QI teams. "You had to have a team put together that crossed disciplines and looked at the barriers to providing effective care," Bratzler says. The teams included medical staff, nursing, pharmacy, and emergency department staff, he says.
It’s not enough just to remind physicians of current guidelines on treating patients with acute MI. After all, they generally know what is appropriate care. "You’ve got good people doing the best they can working in an imperfect system. Look at your system," says Arneson.
About half of the hospitals in the "best practices" study changed standing orders to include such items as prescribing aspirin on admission. The Mayo Clinic in Rochester, MN, provided pocket cards for physicians as easy reminders. Hospitals also looked for barriers in their systems that led to unnecessary delays.
Almost half of the "best practices" hospitals went beyond the retrospective data review and feedback from HCFA. Instead, they set goals, tracked indicators, and made swift changes to their interventions, using concurrent data collection, says Bratzler. "If you wait for retrospective data, it’s tougher to know whether your interventions are working or not."
For example, at Tulsa Regional Medical Center where Bratzler is director of education, "when a patient is dismissed, that case is automatically reviewed. Every quarter we get data. We have nurses that will look at the cases before the patient goes home to make sure we’ve done certain things. We’re looking at our own care as it occurs," he says.
Monthly or bimonthly meetings allow a QI team to make adjustments, he says. "You don’t have to collect 250 cases like HCFA did to see if you had a problem," he says.
In fact, a QI review of cases should become a normal part of health care, says Radford. "It is my hope that examining what we do in some critical detail will become some part of our medical culture in a more systematic way than we’ve seen before."
1. Marciniak TA, Ellerbeck EF, Radford MJ, et al. Improving the quality of care for Medicare patients with acute myocardial infarction. JAMA 1998; 279:1,351-1,357.
2. 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.
3. The Cooperative Cardiovascular Project Best Practices Working Group. Improving care for acute myocardial infarction: Experience from the Cooperative Cardiovascular Project. Jt Comm Jl on Qual Improv 1998; 24:480-490.
4. Soumerai SB, McLaughlin TJ, Gurwitz JH, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: A randomized controlled trial. JAMA 1998; 279:1,358-1,363.