November 17, 2002
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.
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).
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."
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
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
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
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
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
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."
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.
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.
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.
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.
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.
Lori S. Parsons; Charles V. Pollack, M.D.; L. Kristin Newby,
M.D.; and Katherine A. Littrell, Ph.D.