News Release

Study succeeds in closing gaps in heart attack care

Peer-Reviewed Publication

Michigan Medicine - University of Michigan

U-M leads team of hospitals in applying American College of Cardiology guidelines

ANN ARBOR, MI – As they rush to the hospital, today’s heart attack patients may assume they’ll get all of the best, most scientifically proven treatments available. But in reality, they may not. For a number of reasons, a large gap exists between what medical science has proven effective and what patients actually receive — a gap that can mean the difference between life and death.

Now, a team of hospitals, led by physicians from University of Michigan Health System, is reporting success in improving the odds that patients will get the medicines, tests, procedures, counseling and follow-ups that are proven to improve their chances of surviving and returning to a full life.

As reported in the March 13 issue of the Journal of the American Medical Association, the ten Detroit-area hospitals made the gains through a system of reminders, checklists, stickers, standard orders, reference cards and educational materials that made it easier for doctors, nurses and patients to follow the American College of Cardiology’s national heart attack guidelines.

When compared with their previous records, and with hospitals that did not use the system, the hospitals in the study significantly boosted the percentage of their patients that got aspirin, beta-blocker drugs and advice on stopping smoking. They also closed the gap for other treatments.

Fittingly, the ACC-sponsored study is called GAP, for Guidelines Applied in Practice. And even as the results from its first multi-center test are published, UMHS and other GAP hospitals are using the study’s tools in everyday care, and joining in an expanded study with more hospitals.

“The jump in the percentage of patients that received some of the recommended therapies was phenomenal, showing us that we can make positive change throughout hospitals of any size or type,” says GAP project director and senior author Kim Eagle, M.D., the Albion Walter Hewlett Professor of Internal Medicine and chief of clinical cardiology at UMHS. “But we still have a long way to go from this pilot project to getting all heart attack patients the care they deserve.”

Adds lead author and UMHS clinical assistant professor of cardiology Rajendra Mehta, M.D., M.S., “We hope that our results will form a foundation for hospitals everywhere to improve the quality of care they provide.” GAP’s guidelines and tools are available online at www.acc.org.

Heart attack is a leading killer of Americans, striking 1.1 million people each year and killing about 45 percent of them within one year of their attacks. With recent advances in treatment and measures to prevent complications and recurrence, survival rates have improved, leaving 7.5 million heart attack survivors alive today throughout the United States.

But the quality of care that patients receive in the minutes, hours, days and months after their attacks varies widely from hospital to hospital, state to state, and person to person. The result: a wide variation in patients’ survival, complication rates, recovery and quality of life — including sizable variations by sex, age, race and geographic location.

The ACC developed its heart attack guidelines to address such disparities. Based on solid medical evidence about the effectiveness of drugs, tests, interventions and other techniques, they have served for years as an evolving gold-standard for emergency, hospital and follow-up care for patients with acute myocardial infarction, or heart attack. Available on the Internet, the guidelines give recommendations for the treatments and advice patients should get, adjusted for age, sex, medical history and seriousness of their condition.

But research has shown that despite this effort to make current and proven knowledge available to physicians everywhere, preventable variations in care persist. The same is true for angina and heart failure, two other common heart conditions for which ACC has developed guidelines.

So, the ACC launched the GAP project to bring its guidelines directly into everyday hospital-based care. ACC selected Eagle to lead a Detroit-area multi-hospital heart attack study after seeing the positive results of a program developed and pilot-tested at UMHS over the previous five years. In the UMHS experience, substantial gains were made in adherence to guidelines.

For the multi-hospital study, hospitals of different sizes and types from the Southeast Michigan Heart Consortium were approached, and selected to be GAP study hospitals or control hospitals. Data and medical charts from 1649 Medicare and non-Medicare patients at the ten GAP hospitals, and 901 Medicare patients at 11 control hospitals, were analyzed.

In addition to the national ACC, which sponsored the project, the study’s partners are the Michigan chapter of the ACC, the Michigan Peer Review Organization, and the Greater Detroit Area Health Council, through its Southeast Michigan Quality Forum for Cardiovascular Care.

Overall, significant gains were made in the rates at which patients received aspirin and beta blockers upon admission to the hospital, and the rates at which they received aspirin and smoking cessation counseling upon discharge. Medicare patients also saw a gain in aspirin use.

For example, the percentage of patients receiving aspirin when they entered the hospital went fro 81 percent to 87 percent, and the proportion receiving aspirin therapy guidance before they left the hospital jumped from 84 percent to 92 percent. Beta blockers on admission went from 65 percent to 74 percent, and stop-smoking counseling rose from 53 percent to 65 percent. The highest levels of guideline adherence — more than 77 percent and up to 100 percent — were in the one-quarter of patients whose charts showed evidence that the GAP tools had been used.

Several key treatment indicators, such as the use of aspirin, ACE inhibitor drugs and proof that patients stopped smoking, rose faster in Medicare patients at GAP hospitals than in the Medicare population at the comparison hospitals, but not enough for statistical significance. This effect may be due to other quality-improvement projects under way at the control hospitals.

Despite the overall success of the GAP pilot project, there’s still much room for improvement in current and future tests of the toolkit, says Eagle. To take the project to the next level, UMHS is joining the 10 GAP hospitals, and additional hospitals throughout southern Michigan, to implement GAP more systematically.

“To reach higher rates will require a concerted effort to make every physician, nurse and resident aware of the guidelines and the importance of following them,” he says. “Too often, providers fail to give patients every therapy that’s indicated simply because they’re too busy to remember all the recommendations or haven’t received enough information on the guidelines and the evidence behind them. GAP is designed to combat that effect by identifying key priorities for care and creating easy-to-use reminders directed at doctors, nurses and even the patients themselves during the course of treatment.”

Information on the GAP heart attack project, and the heart failure and angina projects now under way in other regions, is available at www.acc.org. Samples of the toolkit items, including reference materials that physicians can print and keep in the pockets of their white coats, are all included in the web site.

GAP participating hospitals:

Bi-County, Harper, Henry Ford Wyandotte, Mt. Clemens General, Oakwood Dearborn, Oakwood Heritage, Providence, Sinai-Grace, St. Joseph Mercy and St. John.

Tools in the GAP Initiative “Tool Kit”:

• standing orders for medications and tests;
• pocket cards of medications and guidelines for medical staff;
• a “clinical pathway” that guides nurses through their daily activity;
• a special patient information form;
• stickers for the patient’s chart;
• a chart that shows the hospital’s overall performance;
• a discharge checklist for doctors or selected nurses to review with patients; and
• patient education materials, including written and verbal instruction on therapy and lifestyle.

Guideline-recommended therapies, tests and counseling used in the GAP Project:

• aspirin in the emergency room and after discharge to prevent clotting;
• beta-blockers to reduce arrhythmias;
• angiotensin converting enzyme, or ACE, inhibitors to aid the heart’s recovery from damage;
• blood cholesterol tests and, in appropriate patients, treatment to lower cholesterol;
• measurement of the pumping capacity of the heart’s left ventricle;
• cardiac catheterization or other heart imaging studies in certain patients;
• angioplasty or bypass surgery in selected patients to open or go around blocked arteries;
• smoking cessation counseling (smoking doubles the long-term risk of another heart attack)
• diet counseling, with emphasis on low-fat diets; and
• referral for outpatient rehabilitation.

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