Adherence to treatment guidelines for patients with ACS associated with decreased in-hospital deaths

Receiving care at a hospital with higher adherence to guidelines for treatment of patients with acute coronary syndromes is associated with a decreased likelihood of in-hospital death, according to a study in the April 26 issue of JAMA.

Assessing quality in health care has become increasingly important in current medical practice, according to background information in the article. Government agencies, professional societies, accreditation organizations and major insurers have published performance guidelines. The American College of Cardiology/American Heart Association (ACC/AHA) have established national clinical practice guidelines for the appropriate care of patients with non – ST-segment elevation (NSTE - a certain pattern on an electrocardiogram) myocardial infarction (MI – heart attack) acute coronary syndrome (ACS - the development of chest pain of cardiac nature).

Eric D. Peterson, M.D., M.P.H., from Duke University Medical Center, Durham, N.C., and colleagues examined how well hospitals followed ACC/AHA guideline recommendations for treating patients with NSTE ACS using data from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) National Quality Improvement Initiative between Jan.1, 2001, and Sept. 30, 2003. The study included information on 350 academic and nonacademic U.S. medical centers and 64,775 patients.

The researchers found that overall, the nine ACC/AHA recommended treatments for patients with NSTE ACS were followed in 74 percent of treatment opportunities. However, composite adherence scores varied greatly among the hospitals. Hospitals in the highest adherence group (quartile 4) had a median adherence score of 82 percent, compared to 63 percent for hospitals in the lowest group (quartile 1). These guideline adherence rates were significantly associated with in-hospital deaths; death rates ranged from 6.31 percent in the lowest adherence group to 4.15 percent in the highest adherence group. After adjusting for risk, the researchers found that every 10 percent increase in composite adherence was associated with a 10 percent decrease in its patients' likelihood of in-hospital death.

"Quality of care has been defined as 'the degree to which health service for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge,'" the authors write. "Our work supports the central hypothesis of hospital quality improvement; namely, better adherence with evidence-based care practices will result in better outcomes for patients who are treated."

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(JAMA. 2006; 295: 1912 – 1920. Available pre-embargo to media at www.jamamedia.org.)

Editor's Note: This study was supported by CRUSADE, a National Quality Improvement Initiative of the Duke Clinical Research Institute, which was funded by the Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership and Millennium Pharmaceuticals provided additional funding support. Dr. Peterson is also the recipient of a grant from the National Institute on Aging. For the financial disclosures of the authors, please see the JAMA article.


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