ABC = Aspirin, Beta- blockers, Clot busters

NY concentrates its efforts on 3 indicators for AMI

Findings from the 1994 national Cooperative Cardiovascular Project (CCP) goaded New York state’s peer review organization (IPRO) in Lake Success, NY, toward an initiative that is already improving treatment for patients with acute myocardial infarction (AMI). The "ABC" project deals with three crucial measures that can lower in-hospital and 30-day mortality rates:

• providing aspirin on the day of the heart attack;

• administering beta-blockers to selected patients;

• administering thrombolytics within an hour of the AMI.

In 1994, CCP researchers examined records of all Medicare patients admitted for heart attack — 230,000 cases nationwide and 16,000 in 200 New York state hospitals.

"They looked at every case billed out as an AMI (ICD-9-CM code 410) over an eight-month period," says cardiologist Monte Malach, MD, clinical professor of medicine at New York University and State University of New York in Brooklyn and medical director at IPRO. The researchers looked at whether care was being provided according to nine standards developed by the American College of Cardiology (ACC) and American Heart Association (AHA). They found some room for improvement and told each of the PROs to do what they could to try to better outcomes.

As project leader, Malach conducted sessions around the state and pointed out significant problems in the Medicare population — gross underuse of aspirin and beta-blockers and less than timely use of reperfusion. During face-to-face meetings as well as teleconferences, administrators and researchers discussed study results, and hospitals were encouraged to develop quality improvement programs.

Two years later, IPRO went back and remeasured New York hospitals’ compliance with the CCP standards.

"When we remeasured for a four-month period in 1996," Malach says, "we saw significant improvement; but in three critical areas, much still needed to be done. We also saw that we needed to change our focus."

The initiative had been directing its efforts at the general hospital staff — internists, cardiologists, and family physicians — but now it had to refocus on the EDs because that’s where the patients come in.

"We had meetings with EDs around the state to go over this," says Malach. "Because changing any form in a hospital involves a lot of red tape, we developed a stamp to put on the progress sheet."

The stamp says, "Aspirin, yes, no, and reasons for no; beta-blockers, yes, no, and reasons for no; and reperfusion, yes, no, and reasons for no."

Administering thrombolytics within an hour had increased from 60% in 1994 to 66% in 1996; administering beta-blockers at discharge increased from 60% in 1994 to 76% in 1996.

"Despite increases," he says, "the values were still thought to be too low."

The "C" of the ABC initiative has to do with the use of clot-busters and timing.

"You only have up to six hours from the moment of infarct to open arteries with these thrombolytics," says Malach. "The door-to-needle time standard nationally is one hour, and in New York state, most hospitals have it down to thirty minutes or faster by improving the process."

One of the original quality indicators of the CCP was administration of beta-blockers at discharge — the "B" of ABC.

"There’s significant documentation in the literature that beta-blockers should be given within 12 hours because of its remarkable benefit in reduced fatal ventricular arrhythmias and overall 30-day and one-year mortality rates," he says.

First-day aspirin use actually dropped to 53% in 1996 from 59% in 1994, but Malach says he thinks that’s a documentation issue. "Some patients don’t consider aspirin a drug and fail to document."

According to ACC/AHA guidelines, aspirin should be given on the day of the heart attack and continued on a daily basis thereafter. Beta-blockers should be given within 12 hours in order to reduce risk of ventricular fibrillation and tachycardia. Aspirin and beta-blockers also reduce the likelihood of a second attack. Thrombolytics should be given within an hour of arriving at the emergency department (ED). Fast therapy has been shown to reduce 35-day mortality by 18-21%.

"The [progress sheet] stamp has been actively accepted and aggressively used," says Malach. His team is in the process of remeasuring for a three-month period in 1998, but the numbers are not yet in.

"It’s gratifying to see how focusing on ABC’ as three quality indicators has made a difference," he says. "We have no hard information yet, but I’ve been making tours, and my observations are that improvements are being made."

Suggested reading

Marciniak TA, Ellerbeck EF, Radford MJ, et al. Improving the quality of care for Medicare patients with acute myocardial infarction: Results from the Cooperative Cardiovascular Project. JAMA 1998; 279:1,351-1,357.