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Cars, computer chips… and heart attacks?


Study shows quality-improvement effort saves lives

The same philosophy used to make better cars and computer chips can also save the lives of heart attack patients, a new study finds. In fact, 26 percent fewer patients died in the first year after their heart attack when hospitals used quality-improvement tactics to prevent crucial heart-care steps from "slipping through the cracks" -- in much the same way a car company ensures that a car is made well before it leaves the factory.

The steps included a checklist that doctors, nurses and patients in 33 Michigan hospitals had to complete before each patient could leave the hospital. The checklist, based on national heart-care guidelines, helped make sure that patients got crucial drugs, tests and lifestyle advice that could help prevent another heart attack. And that’s what appears to have saved the lives of many patients, compared with those treated before the quality-improvement effort started. The study involved 2,857 patients, 1,489 of whom were treated after the effort started.

In general, the chance that a patient would die within a month or a year of going home from the hospital was 21 percent to 26 percent lower after the quality-improvement effort. The findings, published in the October issue of the Journal of the American College of Cardiology, come from a study led by University of Michigan Cardiovascular Center co-director Kim Eagle, M.D., FACC and sponsored by the American College of Cardiology as part of their Guidelines Applied in Practice (GAP) initiative.

Eagle and his colleagues aren’t suggesting that hospitals should become factories or treat every heart patient the same. But they point to their findings as an example of how health care professionals can learn from the quality movement that has transformed manufacturing, and how patients can benefit.

"Medicine based on memory alone is unreliable," Eagle says. "Guidelines for care, when embedded into a system used by doctors, nurses and patients alike, can improve care and translate into improved outcomes for patients. This kind of professional commitment to never-ending improvement, which industry has used to great effect, is needed in health care."

The GAP study began as a pilot project at the U-M Health System’s University Hospital, and grew to involve more hospitals in southeastern Michigan as part of the ACC’s effort to foster "evidence based" heart care that reaches all patients. The collaborative project aims to improve use of aspirin, ACE inhibitor, beta-blocker and cholesterol-lowering drugs, which all help prevent further heart problems.

The project also made sure that before they left the hospital, patients were educated about their disease, their medications, and the need to change their smoking, eating and exercise habits to decrease their chances of another heart attack -- and pledged that they understood all of this. The checklist also made sure that patients knew what to do in the event of recurrent cardiac symptoms, and knew what their plan for a follow-up appointment was once they went home.

The new results are the first to show that this increased use of proven therapy and patient-involvement techniques can actually reduce the risk of death soon after patients leave the hospital.

"We know more than ever about what it takes to help heart attack patients do well after they go home, but the fast pace of hospital care and the lack of coordination has kept many from getting all those proven therapies in the past," says Eagle, the Albion Walter Hewlett Professor of Cardiology in the U-M Medical School. "Now, we’ve shown that standardizing care really makes a difference."

Eagle says he hopes the new data will help convince hospitals across the nation to implement measures like those that helped the GAP hospitals improve their adherence to guidelines. And, he hopes that soon, forgetting to give a patient a guideline-recommended medication or to educate them about the need to stop smoking or start exercising will be seen as a medical error. "We need to flip this system completely over, and create ways to absolutely guarantee guideline-based care," he says. "The cup is half empty, and we need to fill it to the brim."

He notes that both the ACC GAP project, and the American Heart Association’s "Get With the Guidelines" initiative to encourage doctors to follow standards for heart care, will help give patients better care and a chance at a longer, healthier life. But this will happen, he warns, only if hospital administrators, physicians and nurses take the effort seriously.

GAP involved 383 cardiologists at hospitals around southeast Michigan. It was led by 105 nurses and physicians who championed the project at their hospitals. Cecelia Montoye, MSN, consultant to the ACC, served as project manager.

In addition to the ACC, the study partners are the Michigan chapter of the ACC, the Michigan Peer Review Organization, the Greater Detroit Area Health Council through its Southeast Michigan Quality Forum for Cardiovascular Care, and the Greater Flint Health Coalition. The study hospitals were of all different sizes and types, from small community facilities to major urban and tertiary-care medical centers. Both teaching and non-teaching hospitals were included, and patients had various forms of insurance – about 70 percent were on Medicare.

All hospitals were offered a "toolkit" of reminders, checklists, stickers, standard orders, reference cards and educational materials that helped doctors, nurses and patients follow ACC’s guidelines. The new data come from a random sample of half the heart attack patients treated at each hospital before the GAP project was implemented there, and a random sample of nearly all the patients treated in the time after the GAP rollout at each hospital.

The patients were elderly and not very healthy, with an average age around 76 years and high rates of smoking, heart failure, high blood pressure, diabetes and previous heart attack. A large percentage had invasive procedures -- angiographies, angioplasties or bypass operations -- during their post-heart attack hospital stay.

Overall, 21.6 percent of patients in the pre-GAP group died within a month of leaving the hospital, as documented on their Medicare records. That percentage dropped to 16.7 percent in the post-GAP group. At one year, 38.3 percent of the pre-GAP patients had died, compared with 33.2 percent of those treated after GAP was implemented.

Eagle acknowledges that more can be done. "The degree of improvement we’ve demonstrated in Michigan is at least matched by the opportunity that remains," he says. "We need to move from a culture of missed opportunity to a system that guarantees quality and accountability."

Kara Gavin | EurekAlert!
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