Improving Quality of Care for Acute Myocardial Infarction : The Guidelines Applied in Practice (GAP) Initiative.
Mehta, Rajendra H. MD, MS; Montoye, Cecelia K. MSN; Gallogly, Meg BA; Baker, Patricia MS; Blount, Angela MPH; Faul, Jessica MPH; Roychoudhury, Canopy PhD; Borzak, Steven MD; Fox, Susan MSN; Franklin, Mary CNS; Freundl, Marge MSN; Kline-Rogers, Eva MSN; LaLonde, Thomas MD; Orza, Michele ScD; Parrish, Robert MM; Satwicz, Martha MSN; Smith, Mary Jo MSN, MPH; Sobotka, Paul MD; Winston, Stuart DO; Riba, Arthur A. MD; Eagle, Kim A. MD; for the GAP Steering Committee of the American College of Cardiology
[Article]
JAMA.
http://www.jama.com. 287(10):1269-1276, March 13, 2002.
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Context: Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals.
Objective: To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI.
Design and Setting: The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan.
Patients: A random sample of Medicare and non-Medicare patients at baseline (July 1998-June 1999; n = 735) and following intervention (September 1-December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January-December 1998; n = 513) and at remeasurement (March-August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group.
Intervention: The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators.
Main Outcome Measures: Differences in adherence to quality indicators (use of aspirin, [beta]-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group.
Results: Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P =.02) and [beta]-blockers (65% vs 74%; P =.04) on admission and use of aspirin (84% vs 92%; P =.002) and smoking cessation counseling (53% vs 65%; P =.02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators.
Conclusions: Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.
JAMA.2002;287:1269-1276
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