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Death rates lower in hospitals that follow heart attack guidelines
November 17, 2002

CHICAGO, IL (AHA) Ė Heart attack patients at hospitals that lag behind in following treatment guidelines had a one-third greater risk of dying before discharge than patients at "leading" hospitals, according to a study reported at the American Heart Associationís Scientific Sessions 2002.

Death rates ranged from 17.6 percent at "lagging" hospitals (those with low guideline adherence) to 11.9 percent among "leading" hospitals (those with the highest overall guideline adherence).

"The study underscores the importance of following clinical practice guidelines to improve patient outcomes," says Eric D. Peterson, M.D., lead author of the study and associate professor of medicine at Duke University School of Medicine in Durham, N.C. "Some physicians balk at being held accountable to guidelines-based medicine, but this study demonstrates that adhering to guidelines saves lives."

Quality measures recommended jointly by the American Heart Association and the American College of Cardiology for emergency heart attack treatment include: clot-busting treatment within 30 minutes of arrival at the hospital; angioplasty within 90 minutes; aspirin within 24 hours; beta-blockers within 24 hours; heparin within 24 hours; and glycoprotein IIb/IIIa inhibitors within 24 hours of admission.

Other recommendations include: aspirin, beta-blockers, ACE inhibitors and cholesterol-lowering therapy prescribed at hospital discharge; blood pressure below 140/90 mm Hg by discharge; smoking cessation counseling; and physical activity counseling (education on or referral to cardiac rehab or outpatient exercise program).

This is one of the first studies to examine how variation in treatment affects patient outcomes, Peterson says. In a hospital, quality-of-care indicators refer to how a patient is treated while ill in the hospital.

When treatments are backed by randomized, controlled trial data showing an impact on death rates, they are considered Class I recommendations, the strongest evidence for recommendations. The researchers examined adherence to Class I guidelines and reported the median performance on seven care protocols at 1,085 U.S. hospitals that treated 86,735 patients between July 2000 and March 2001. Hospitals were divided into quartiles based on their performance, and a composite quality of care was derived. In this study, 271 leading hospitals were compared with 271 lagging hospitals.

Protocols measured include the percentage of heart attack patients who received aspirin within 24 hours, the percentage given beta-blockers within 24 hours and the percentage discharged with an ACE inhibitor, cholesterol-lowering therapy and smoking cessation advice.

Nationally, Peterson found marked variation in treatment for patients with heart attack, even for well-accepted standards of care, such as giving a beta-blocker within 24 hours. "Patients treated at lagging hospitals had only a 50-50 chance of getting it," he says. "In contrast, at leading U.S. centers, 86 percent of patients were given beta-blockers. This degree of variation in care is unacceptable."

Giving aspirin within 24 hours is another commonly accepted standard of care, yet only 73 percent of patients in the lowest performing hospitals were prescribed aspirin, in contrast with 93 percent in the leading hospitals.

ACE-inhibitors were prescribed for 70 percent of patients at leading hospitals, while just 40 percent of patients at lagging hospitals received this medicine at discharge. ACE-inhibitors expand blood vessels and decrease resistance, allowing blood to flow more easily. This makes the heartís work easier and more efficient.

The researchers also found variation in the numbers of patients prescribed cholesterol-lowering drugs. Fifty-eight percent of patients left the hospital with these prescriptions in the lowest performance quartile compared to 80 percent in the highest quartile.

Variation in giving smoking cessation advice was especially discouraging, Peterson says. In lagging hospitals, only 7 percent of patients were given this advice. In contrast, 65 percent of patients in leading hospitals were advised to stop smoking.

Peterson says this study demonstrates the importance of programs such as the National Registry of Myocardial Infarction, which routinely gives care practice information to healthcare providers. The gap between guidelines recommendations and actual care is also a strong argument for programs like the American Heart Associationís Get With The GuidelinesTM program and the CRUSADE National Quality improvement program, which aim to disseminate clinical practice guidelines and encourage adherence to them.

Co-authors are Lori S. Parsons; Charles V. Pollack, M.D.; L. Kristin Newby, M.D.; and Katherine A. Littrell, Ph.D.

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