First evidence that guidelines for drugs, tests and lifestyle changes save lives
NEW ORLEANS -- Heart attack patients have a 25 percent lower risk of dying within a year of leaving the hospital if their doctors and nurses follow standard national guidelines for their care, and teach them how to stick to those standards at home.
This major effect on mortality rates, seen in 2,800 Medicare patients treated at 33 Michigan hospitals, is the first evidence that standardized heart care saves lives.
The University of Michigan Cardiovascular Center physician who helped lead the project will present the results here today in a late-breaking session and press conference at the Annual Scientific Session of the American College of Cardiology.
Kim Eagle, M.D., FACC, will describe how the ACC's Guidelines Applied in Practice (GAP) Project improved the chances that heart attack patients received all the recommended tests, drugs and lifestyle advice. The project also made sure that before they left the hospital, patients pledged that they understood their disease, their medications, and the need to change their smoking, eating and exercise habits.
This improved care led to a 25 percent lower death rate at 30 days and one year for patients treated after the hospitals in the study implemented the GAP guidelines, compared with those treated before the project began.
"We're thrilled to be able to show this strong link between guidelines-based care and lower mortality," says Eagle. "This proves the benefit of working to close the gap between what we know works for patients and what we deliver on a daily basis."
The GAP Project was previously shown to increase the chances that hospitalized heart attack patients would get proven medications to prevent complications and future problems, such as aspirin and beta blockers. Prior GAP results had also shown that reminder stickers on patient charts, and a checklist and contract that must be completed by both the nurse and the patient before discharge from the hospital, made it more likely that patients would get risk-reducing lifestyle advice.
But the new results are the first to show that this increased use of proven therapy and patient-involvement techniques can actually reduce the risk of patients dying soon after they leave the hospital.
"We know more than ever about what it takes to help heart attack patients do well after they go home, but the fast pace of hospital care and the lack of coordination has kept many from getting all those proven therapies in the past," says Eagle. "Now, we've shown that standardizing care really makes a difference."
Eagle says he hopes the new data will help convince hospitals across the nation to implement measures like the standard orders, pocket guides, chart stickers, discharge checklists and performance reports that helped the 33 GAP hospitals improve their adherence to guidelines.
And, he hopes that soon, forgetting to give a patient a guideline-recommended medication or to educate them about the need to stop smoking or start exercising will be seen as a medical error. "We need to flip this system completely over, and create ways to absolutely guarantee guideline-based care," he says. "The cup is half empty, and we need to fill it to the brim."
He notes that both the ACC GAP toolkit, and the American Heart Association's "Get With the Guidelines" initiative to encourage doctors to follow standards for heart care, will help give patients better care and a chance at a longer, healthier life. But this will happen, he warns, only if hospital administrators, physicians and nurses take the effort seriously.
GAP involved 383 cardiologists at hospitals around southeast Michigan. It was led by 105 nurses and physicians who championed the project at their hospitals. In addition to the ACC, the study 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.
Cecelia Montoye, MSN, consultant to the ACC, served as project manager. "One cannot say enough about the hard work that each hospital's physician- and nurse-leaders did to identify and overcome barriers during project implementation," she says. "Their efforts have allowed us to document the lessons learned to apply to all quality improvement projects."
The idea for the project originally grew out of a U-M Health System initiative aimed at improving adherence to ACC heart attack guidelines. A pilot group of 10 hospitals joined the project in 1999 after the ACC selected U-M as the lead institution, and the list grew to 33 by 2002. The study hospitals were of all different sizes and types, from small community facilities to major urban and tertiary-care medical centers.
The new data come from a random sample of half the heart attack patients treated at each hospital before the GAP project was implemented there, and a random sample of nearly all the patients treated in the time after the GAP rollout at each hospital.
The patients were elderly and not very healthy, with an average age around 76 years and high rates of smoking, heart failure, high blood pressure, diabetes and previous heart attack. A large percentage had invasive procedures -- angiographies, angioplasties or bypass operations -- during their post-heart attack hospital stay.
The GAP effort made a big difference in the prescriptions they received both early and late in their hospital stay. Before GAP, only 19.8 percent of the patients were treated using standard orders that guide doctors and nurses on care. But after GAP was implemented, this percentage approached 46 percent.
Even better was the improvement in use of the discharge tool that is designed to help patients understand and take charge of their care. Written in simple language, with a place for patients to sign a pledge to take care of themselves, the discharge tool brings the patient into the triangle of care along with the doctor and nurse. It emphasizes adherence to medication regimens, the importance of regular follow-up visits, and the vast increase in heart risk posed by smoking.
Overall, 21.6 percent of patients in the pre-GAP group died within a month of leaving the hospital, as documented on their Medicare records. That percentage dropped to 16.7 percent in the post-GAP group.
At one year, 38.3 percent of the pre-GAP patients had died, compared with 33.2 percent of those treated after GAP was implemented.
When Eagle and his colleagues looked more closely at the group of patients who received the discharge tool and contract, the effect was even greater. They were nearly 50 percent less likely to die within a month or year of discharge than those treated before GAP was implemented.
Eagle acknowledges that opportunities to improve remain even in the hospitals that have been using the GAP toolkit the longest. But he's hopeful that as the work of GAP's beneficial effect on mortality grows, doctors and nurses will miss fewer and fewer chances to treat patients well, and patients will take their responsibilities more seriously.
"The degree of improvement we've demonstrated in Michigan is at least matched by the opportunity that remains," he says. "We need to move from a culture of missed opportunity to a system that guarantees quality and accountability."
Source: Eurekalert & othersLast reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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-- Ralph Waldo Emerson