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J Am Coll Cardiol, 2001; 38:587-594
© 2001 by the American College of Cardiology Foundation
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Presidential address: quality of cardiovascular care in the U.S.

George A. Beller, MD, MACCa

a Cardiovascular Division, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA



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  		Figure 1 Four silos representing locales of care for a hypothetical patient with cardiovascular disease. Presently, there is no common repository of medical information for such a hypothetical patient that can be easily accessed electronically by physicians or other hospital personnel in each of these locales. Such inability to easily share medical information contributes to overall lower quality care and increased chance for medical errors.

 


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  		Figure 2 Percentage of patients receiving various discharge medications that have a proven value for enhancing survival after acute myocardial infarction (MI). Note that only 65% of patients were discharged with a beta-blocker, despite knowledge for more than 10 years that beta-blocker therapy in post-MI patients reduces subsequent mortality. ACE = angiotensin-converting enzyme. ASA = aspirin.

Data from the National Registry of Myocardial Infarction-3, http://www.med.ucla.edu/champ/NRMI.htm. Reprinted with permission from Gregg C. Fonarow, MD.

 


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  		Figure 3 Percentage of post-myocardial infarction (MI) patients receiving beta-blockers at discharge in various geographic regions (each represented by a solid circle) across the U.S. Note the marked variability in the percentage of "ideal" patients receiving beta-blockers. If practice guidelines were more effectively and uniformly applied to practice, this variability would be far less, and more than 80% of all post-MI patients would be receiving beta-blockers.

Copyright the Trustees of Dartmouth College 1999. Reprinted with permission, from Wennberg DE, Birkmeyer JD. The Dartmouth Atlas of Cardiovascular Health Care. Chicago, IL: The American Hospital Association Press, 1999 (10).

 


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  		Figure 4 Usage of aspirin, heparin and beta-blockers in patients with AMI relative to whether patients were cared for by cardiologists, internists or general practice physicians.

Prepared, with acknowledgment of the authors, from data contained in Jollis JG, DeLong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med 1996;335:1880–7 (14).

 


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  		Figure 5 Percentage of patients with congestive heart failure (HF) who had documentation of a measurement of left ventricular function (LVF), and the percentage use of angiotensin-converting enzyme (ACE) inhibitors in HF patients, relative to whether cardiologists or family physicians were responsible for their care. Note that cardiologists assessed LVF and used ACE inhibitors more than noncardiologists in HF patients with depressed LVF.

Prepared, with acknowledgment of the authors, from data contained in Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol 1997;30:518–26 (25).

 


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  		Figure 6 Percentage of coronary artery disease (CAD) patients with either previous myocardial infarction, prior bypass surgery or a percutaneous coronary intervention who had a low-density lipoprotein (LDL) cholesterol level ≤130 mg/dl. Note that even the 90th percentile of performance in this survey yielded only 64.4% of patients achieving an LDL cholesterol of ≤130 mg/dl. In actuality, the National Cholesterol Education Program guidelines indicated that such patients with documented CAD need to have their LDL cholesterol levels lowered to <100 mg/dl.

Reprinted with permission from the National Committee for Quality Assurance. The State of Managed Care Quality. 2000:23. ©2000 by NCQA (27).

 


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  		Figure 7 Percentage of patients with diabetes who had a low-density lipoprotein cholesterol of ≤130 mg/dl (left) and percentage of patients with diabetes who had a lipid profile documented in their record (right). Surprisingly, the 90th percentile in performance achieved only a 48.5% lowering of cholesterol to this level in the diabetic population. An average of only 69.1% of diabetics had a lipid profile even obtained. These data from the National Committee for Quality Assurance indicate that lipid management is markedly suboptimal in diabetics.

Reprinted with permission from the National Committee for Quality Assurance. The State of Managed Care Quality Report. 2000:24. ©2000 by NCQA (27).

 


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  		Figure 8 Improvement in treatment rates for beta-blocker therapy and post-myocardial infarction (MI) patients from 1996 to 1999 in National Committee for Quality Assurance-accredited health plans, where quality indicators are made public and health systems have an incentive to improve. Note that the rate of post-MI beta-blocker use increased from 62.2% to 85% over this four-year period.

Reprinted with permission from the National Committee for Quality Assurance. The State of Managed Care Quality Report. 2000:30. ©2000 by NCQA (27).

 




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