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CLINICAL RESEARCH: MYOCARDIAL ISCHEMIA/INFARCTION

Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use

The American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw Expansion

Rajendra H. Mehta, MD, MS, FACC^*, Cecelia K. Montoye, MSN, Jessica Faul, MPH, Dorothy J. Nagle, BSN, James Kure, MD, FACC, Ethiraj Raj, MD, FACC^||, Peter Fattal, MD, FACC^¶, Shiraz Sharrif, MD, FACC^#, Mohamadali Amlani, MD^**, Hameem U. Changezi, MD, FACC, Stephen Skorcz, MPH, Nancy Bailey, MSN, Theresa Bourque, BSN^||, Mary LaTarte, MSN^#, Donna McLean, MBA^**, Suzanne Savoy, MN^¶, Paul Werner, MD^#, Patricia L. Baker, MS, Anthony DeFranco, MD, FACC^**, Kim A. Eagle, MD, FACC^*,* American College of Cardiology Guidelines Applied in Practice Steering Committee

^* University of Michigan, Ann Arbor, Michigan, USA
Consultant to the American College of Cardiology, Bethesda, Maryland, USA
MPRO, Farmington Hills, Michigan, USA
Genesys Regional Medical Center, Grand Blanc, Michigan, USA
^|| Hurley Medical Center, Flint, Michigan, USA
^¶ Covenant Health Care, Saginaw, Michigan, USA
^# St. Mary's Medical Center, Saginaw, Michigan, USA
^** McLaren Regional Medical Center, Flint, Michigan, USA
Greater Flint Health Coalition, Flint, Michigan, USA

Manuscript received March 10, 2003; revised manuscript received June 16, 2003, accepted August 5, 2003.

^* Reprint requests and correspondence: Dr. Kim A. Eagle, Albion Walter Hewlett Professor of Medicine, Chief of Clinical Cardiology, University of Michigan, 1500 East Medical Center Drive, 3910 TC, Ann Arbor, Michigan 48109, USA.
Keagle{at}umich.edu

OBJECTIVES: This project evaluated if by focusing on process changes and tool use rather than key indicator rates, the use of evidence-based therapies in patients with acute myocardial infarction (AMI) would increase.

BACKGROUND: The use of tools designed to improve quality of care in the American College of Cardiology AMI Guidelines Applied in Practice Pilot Project resulted in improved adherence to evidence-based therapies for patients, but overall, tool use was modest.

METHODS: The current project, implemented in five hospitals, was modeled after the previous project, but with greater emphasis on tool use. This allowed early identification of barriers to tool use and strategies to overcome barriers. Main outcome measures were AMI quality indicators in pre-measurement (January 1, 2001 to June 30, 2001) and post-measurement (December 15, 2001 to March 31, 2002) samples.

RESULTS: One or more tools were used in 93% of patients (standard orders = 82%, and discharge document = 47%). Tool use was associated with significantly higher adherence to most discharge quality indicator rates with increases in aspirin, angiotensin-converting enzyme inhibitors, and smoking cessation and dietary counseling. Patients undergoing coronary artery bypass grafting (CABG) had low rates of discharge indicators. Patients undergoing percutaneous coronary revascularization were more likely to receive evidence-based therapies.

CONCLUSIONS: These data validate the results of the pilot project that quality of AMI care can be improved through the use of guideline-based tools. Identifying and overcoming barriers to tool use led to substantially higher rates of tool use. The low rates of adherence to quality indicators in patients undergoing CABG suggest that these patients should be particularly targeted for quality improvement efforts.

Abbreviations and Acronyms   ACC = American College of Cardiology   ACE = angiotensin-converting enzyme   AMI = acute myocardial infarction   CABG = coronary artery bypass graft surgery   CMS = Center for Medicare & Medicaid Services   GAP = Guidelines Applied in Practice   GFHC = Greater Flint Health Coalition   MPRO = Michigan Peer Review Organization   PCI = percutaneous coronary intervention

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