CLINICAL RESEARCH: TREATMENT STANDARDS FOR ACUTE INFARCTION
Guideline-Based Standardized Care Is Associated With Substantially Lower Mortality in Medicare Patients With Acute Myocardial Infarction
The American College of Cardiology’s Guidelines Applied in Practice (GAP) Projects in Michigan
Kim A. Eagle, MD, FACC*,*,
Cecelia K. Montoye, MSN*, ,
Arthur L. Riba, MD, FACC ,
Anthony C. DeFranco, MD, FACC ,||,
Robert Parrish, MM¶,#,
Stephen Skorcz, MPH**,
Patricia L. Baker, MS,
Jessica Faul, MPH,,
Sandeep M. Jani, MPH*,
Benrong Chen, PhD,
Canopy Roychoudhury, PhD,
Mary Anne C. Elma, BA,
Kristi R. Mitchell, MPH and
Rajendra H. Mehta, MD, MS, FACC*,||||
* University of Michigan Cardiovascular Center, Ann Arbor, Michigan
St. Joseph Mercy Hospital, Ann Arbor, Michigan
Oakwood Hospital and Medical Center, Dearborn, Michigan
McLaren General Hospital, Flint, Michigan
|| Cardiology Associates, PSC, Edgewood, Kentucky
¶ Greater Detroit Area Health Coalition, Detroit, Michigan
# Future Directions in Health Care Inc., West Bloomfield, Michigan
** Greater Flint Health Coalition, Flint, Michigan
MPRO, Farmington, Michigan
University of Michigan Health System, Ann Arbor, Michigan
American College of Cardiology Foundation, Bethesda, Maryland
|||| Duke University, Durham, North Carolina
Manuscript received October 19, 2004;
revised manuscript received November 23, 2004,
accepted December 6, 2004.
* Reprint requests and correspondence: Dr. Kim A. Eagle, University of Michigan Cardiovascular Center, 300 North Ingalls, 8B02, Ann Arbor, Michigan 48109-0477. (Email: keagle{at}umich.edu).
OBJECTIVES: We sought to assess the impact of the American College of Cardiology’s Guidelines Applied in Practice (GAP) project for acute myocardial infarction (AMI) care, encompassing 33 acute-care hospitals in southeastern Michigan, on rates of mortality in Medicare patients treated in Michigan.
BACKGROUND: The GAP project increases the use of evidence-based therapies in patients with AMI. It is unknown whether GAP also can reduce the rate of mortality in patients with AMI.
METHODS: Using a before (n = 1,368) and after GAP implementation (n = 1,489) cohort study, 2,857 Medicare patients with AMI were studied to assess the influence of the GAP program on mortality. Multivariate models tested the independent impact of GAP after controlling for other conditions on in-hospital, 30-day, and one-year mortality.
RESULTS: Average patient age was 76 years, 48% were women, and 16% represented non-white minorities. The rate of mortality decreased after GAP for each interval studied: hospital, 10.4% versus 13.6%; 30-day, 16.7% versus 21.6%; and one-year, 33.2% versus 38.3%; all p < 0.02. After multivariate adjustment, GAP correlated with a 21% to 26% reduction in mortality, particularly at 30 days (odds ratio of GAP to baseline 0.74; 95% confidence interval [CI] 0.59 to 0.94; p = 0.012) and one year (odds ratio 0.78; 95% CI 0.64 to 0.95; p = 0.013), particularly in the patients for whom a standard discharge tool was used (1-year mortality, odds ratio 0.53; 95% CI 0.36 to 0.76; p = 0.0006).
CONCLUSIONS: Embedding AMI guidelines into practice was associated with improved 30-day and one-year mortality. This benefit is most marked when patients are cared for using standardized, evidence-based clinical care tools.
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Abbreviations and Acronyms
| | ACC = American College of Cardiology | | AMI = acute myocardial infarction | | BCBSM = Blue Cross Blue Shield of Michigan | | CMS = Centers for Medicare and Medicaid Services | | GAP = Guidelines Applied in Practice |
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