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CHICAGO – Heart attack patients treated at hospitals that are less likely to follow established treatment guidelines have almost twice the mortality rate as those treated at hospitals whose practices have been proven effective by clinical trials, Duke Medical Center cardiologists have found.
"The study underscores the importance of following clinical practice guidelines to improve patient outcomes," said Eric Peterson, M.D., who with his colleagues conducted the study. "Some physicians may balk at being held accountable to guidelines-based medicine, but this study demonstrates that adhering to guidelines saves lives."
In their review of more than 250,000 patients who suffered a heart attack in the U.S. in the past two years, Peterson and his colleagues found that the death rate at hospitals that adhere the most to established guidelines have mortality rates of 8.3 percent, compared to 15.3 percent for those hospitals least likely to adhere to the guidelines. The researchers measured how many of the patients died while in the hospital.
Peterson, who presented the results of the analysis today (Nov. 17, 2002) at the 75th annual scientific session of the American Heart Association (AHA), said that theirs is one of the first studies actually demonstrating that following guidelines established by such organizations as the AHA and American College of Cardiology can improve the outcomes for heart attack patients.
For his analysis, Peterson and his colleagues sought to determine how often hospitals followed 15 different guidelines for the immediate and discharge care of heart attack patients. The immediate care guidelines included the use of specific drugs and procedures within the first 24 hours of a heart attack, while the discharge guidelines covered use of medications, smoking cessation and rehabilitation.
In order to determine what effects these actions had on actual patient outcomes, the researchers consulted the National Registry of Myocardial Infarction 4 (NRMI-4), which has collected data on 257,482 heart attack patients seen at 1,247 U.S. hospitals between June 2000 and June 2002. They specifically examined how often each hospital followed each of the 13 guidelines and the effect those actions had on outcomes.
To compare how the best, or "leading" hospitals, compared to the worst, or "lagging" hospitals, the researchers ranked the 1,247 hospitals based on their adherence to the guidelines. They then divided this ranking into the 312 hospitals at the top of the list, and compared them to the 312 hospitals at the bottom of the ranking, and found that as a group, the leading hospitals reported significantly better mortality rates.
The researchers also found marked variation nationally in the treatments given to patients with heart attack. As one would expect, the larger hospitals and academic medical centers tended to more consistently follow the guidelines, Peterson said, adding however, that the results of the analysis still show room for improvement at even the top hospitals.
"Even for well-accepted treatments, such as giving beta-blockers within the first 24 hours of a heart attack, patients treated at lagging hospitals have only a 50-50 chance of getting the drugs," Peterson said. "In contrast, at leading US centers, nearly 82 percent of patients were given beta blockers. This degree of variation in care seems unacceptable."
In addition to giving acute heart attack patients beta-blockers within the first 24 hours, other immediate quality measures included:
- clot-busting treatment within 30 minutes of arrival at the hospital and angioplasty within 90 minutes
- aspirin within 24 hours
- heparin within 24 hours
- ACE inhibitors within 24 hours
- echocardiogram (ECG) within 10 minutes., and
- glycoprotein IIbIIIa inhibitors within 24 hours of admission.
The discharge quality measures used were the continued use of aspirin, beta-blockers, ACE inhibitors and cholesterol-lowering therapy; smoking cessation counseling; and physical activity, such as cardiac rehabilitation.
As another example of the disparity in care, the use of aspirin within 24 hours is commonly accepted standard of care, yet only 72 percent of patients at lagging hospitals, compared to 91 percent at leading hospitals, received aspirin.
Variation among hospitals in giving smoking cessation advice was especially discouraging, said Peterson. In the hospitals that lagged behind, only 24 percent of patients were given this advice, while 68 percent of patients in leading hospitals were advised to stop smoking.
The researchers also found variation in the numbers of patients prescribed lipid-lowering drugs, such as statins. At lagging hospitals, 58 percent of patients were discharged with these prescriptions, compared to 78 percent at the leading hospitals.
For Peterson, this analysis provides one of the clearest snapshots at the state of acute heart attack care in the U.S.
"This registry includes all patients with heart attack, unlike most clinical trials that only enroll specific types of heart attack patients," Peterson said. "This represents what is seen in the real world every day."
Additionally, Peterson said this study demonstrates the importance of programs such as the NRMI-4, which routinely feeds care practice information back to health care providers. The gap between guidelines recommendations and actual care is also a strong argument for programs such as the American Heart Association's "Get With The GuidelinesTM program" and the CRUSADE National Quality Improvement Program, whose aims are to disseminate clinical practice guidelines and encourage adherence to them.
The NRMI-4 databank is supported by grants from Genentech, South San Francisco, Calif.
Other members of the team included Lori Parsons, Ovation Research Group; Charles Pollack, M.D., University of Pennsylvania Hospital; Kristin Newby, M.D., Duke; and Katherine Littrell, Ph.D., Genentech.