News:AMI:Fixing the GAP-Quality Improvement Program for AMI Shown to be Effective

August 26, 2007 By Grendel Burrell [mailto:grendel.burrell@gmail.com]

The American College of Cardiology’s Guidelines Applied in Practice (GAP) program for AMI in Michigan in conjunction with the Michigan Peer Review Organization (MPRO), the Greater Detroit Area Health Council, and the Greater Flint Health Coalition is a quality improvement program incorporating ACC/AHA national AMI guidelines into practice in the hospital. GAP focuses on the implementation of hospital-based clinical care tools including standard admission orders and a standard discharge contract. GAP was implemented in 33 hospitals throughout southeastern Michigan and demonstrated an increase use of the ACC/AHA guideline-recommended therapies during and after hospitalization for AMI.

The objectives of this study were to determine if the use of hospital discharge contracts positively correlated with the prescription rate of guideline-recommended medications and to determine the association between increased hospital use of the discharge contact and 1-year mortality in AMI patients. For this analysis, both pre-GAP initiative Medicare patients and post-GAP implementation Medicare patients were followed for 1 year post AMI.

The actual discharge contract used in the study is short and divided into six topics-medications, smoking cessation, diet, exercise, knowledge about heart disease, and follow up. The discharge contract is completed in the presence of a nurse or physician, and thus provides an opportunity for patient education and for the patient to take an active role in self-care. Both patient and physician signed the contract. The overall proportion of post-GAP discharge contract use was calculated for each participating institution. Discharge contract rates were divided into tertiles based on the percentage rates by hospitals (<8.4%, 8.41-38.0%, and >38.0%). Within each tertile, differences in selected patient characteristics and frequency of guideline recommended medication prescriptions were assessed pre- and post-GAP initiative.

Of the hospitals in the study, 85-90% performed cardiac catheterizations, 50-60% performed PCI and CABG, and 27 hospitals were classified as teaching institution. All hospitals were “nonprofit” except for 3 government hospitals. The average number of staffed beds was 304-351, and the average number of cardiology admissions/year ranged from 950-1215 across the tertiles.

There were 1368 patients in the pre-GAP cohort and 1489 in the post-GAP cohort. Average age was 76.3 years. Medical history, in hospital treatments, demographics, and impaired functional status were consistent across the tertiles with a few exceptions. Patients post-GAP in tertile 2 were more likely to be female (P<0.05). Post-GAP patients in tertiles 1 and 3 were more likely to have hypertension (p<0.05). Patients in tertile 1 had a higher likelihood of having COPD (P < 0.05). Post-GAP patients in tertile 3 were more likely to have had CABG during the AMI hospitalization (P<0.05).

The data from this analysis showed an increase rate of use of the discharge contract in all tertiles after GAP was initiated. Prescription rates of aspirin, beta-blockers, ACE inhibitors, and lipid lowering agents were higher in the post GAP samples compared with pre GAP across all tertiles. There was a significant improvement in the rate of aspirin use in tertile 1 (82.1% pre-GAP vs 93.0% post-GAP, P=0.009) and in tertile 3 (79.9% pre-GAP vs 95.3% post GAP, P=0.001).

All patients who died during the hospitalization were excluded from the 1-year mortality analysis. Post-GAP mortality at 1 year decreased by 6.0% in tertile 3 (29.0% vs 23.0%, P=0.03) compared to the pre-GAP cohort. In tertiles 1 (32.5% vs 31.3%, P=0.71) and 2 (23.8% vs 22.6%, P= 0.68), mortality at 1 year decreased by 1.2% post GAP compared with pre-GAP.

In the hospitals where the discharge contract was most frequently used, the mortality was 6.0% lower for AMI patients. Of note, none of the 33 hospitals that participated in GAP achieved >61.1% utilization rate for the contract. The authors state, “The potential mortality improvement at 1 year could be larger than 6.0% with higher rates of discharge contract use.”

In this study, hospitals with the highest rates of discharge contract use showed a trend toward greater improvements in the prescription of guidelines-recommended therapies when comparing pre and post GAP rates. The authors conclude, “These data lend support to the hypothesis that hospitals with increased discharge contract use may achieve higher rates of medication adherence among patient populations, which in turn are associated with improved patient outcomes.”

While this study was not a randomized, controlled trial, there are multiple strengths. Patients were randomly selected and charts were sent to a data abstraction service for extraction of critical data. Additionally, the time elapsed between the data collection periods from baseline and post-GAP were minimal in that baseline data were collected ruing the 6-12 months preceding BAP implementation, and each CAP project was initiated over a 6-15 month period. Post BAP data collection was completed within 4 months of the project’s completion.

Resources: The clinical care tool templates are available at (www.acc.org/qualityandscience/gap/gap/htm).