Association of unstable angina guideline care with improved survival

Representations of clinical practice guidelines and health equity in healthcare literature: An integrative review

AIM

This paper reports an integrative review of international health literature that discusses health equity in relation to clinical practice guidelines (CPGs).

BACKGROUND

Healthcare professionals (HCPs), policy makers, and decision makers rely on sound empirical evidence to make fiscally responsible and appropriate decisions about the allocation of health resources and health service delivery. CPGs provide statements and recommendations that aim to standardize care with an implicit goal of achieving equity of care among diverse populations. Developers of CPGs must be careful not to exacerbate inequity when making recommendations. As such, it is important to determine how equity is discussed within the context of CPGs.

DESIGN

This integrative review was conducted according to integrative review methods as outlined by Whittemore and Knafl (2005), and Toronto and Remington (2020). These authors outlined a systematic process for the identification of relevant literature across health disciplines to examine the state of knowledge pertaining to a phenomenon such as health equity.

SEARCH METHODS

The computerized databases PubMed, CINAHL, Cochrane, Embase, Medline, and Web of Science were searched using a combination of keywords. Search parameters included international peer-reviewed published, full-text, English language articles, editorials, and reports over the last decade (January 2011 to February 2022). A reference search of included articles was conducted to identify any additional articles. Dissertations and theses were not included.

SEARCH OUTCOME

A total of 139 peer-reviewed English language articles were identified.

RESULTS

The findings of this review revealed five main ways in which health equity is in context of CPGs including if they target or exacerbate inequity among disadvantaged populations, equity and CPG development, implementation, and evaluation, and checklists and tools to assist developers and users of CPG to consider equity. Although critical appraisal tools exist to assist users of CPGs assess and to evaluate how well CPGs address issues of equity, the definition of equity and how CPG development panels should incorporate and articulate it remains unclear and haphazard. As such, recommendations intended to be implemented by HCPs to optimize health equity remains diverse and unclear.

CONCLUSION

The way equity is discussed within the reviewed health literature has implications for their uptake by and utility for HCPs. The ability of HCPs to implement CPGs may be hindered without an appreciation and integration of equity considerations across the various phases of CPG conceptualization, development, implementation, and evaluation, and their relevance and appropriateness to diverse geographic and socioeconomic contexts with variable access to health human resources and services. This situation could be improved if equity were more clearly articulated within all aspects of the CPG process.

CLINICAL RELEVANCE

Understanding how equity is discussed in the literature relative to CPGs has implications for their uptake by and utility for HCPs in their goal of providing equitable health care. Successful implementation of CPGs with consideration equity could be improved if equity were more clearly articulated within all aspects of the CPG process including conceptualization, development, implementation, and evaluation.

Performance of acute coronary syndrome approaches in Brazil: a report from the BRACE (Brazilian Registry in Acute Coronary SyndromEs)

AIMS

Diagnostic and therapeutic tools have a significant impact on morbidity and mortality associated with acute coronary syndromes (ACS). Data about ACS performance measures are scarce in Brazil, and improving its collection is an objective of the Brazilian Registry in Acute Coronary syndromEs (BRACE).

METHODS AND RESULTS

The BRACE is a cross-sectional, observational epidemiological registry of ACS patients. Stratified 'cluster sampling' methodology was adopted to obtain a representative picture of ACS. A performance score (PS) varying from 0 to 100 was developed to compare studied parameters. Performance measures alone and the PS were compared between institutions, and the relationship between the PS and outcomes was evaluated. A total of 1150 patients, median age 63 years, 64% male, from 72 hospitals were included in the registry. The mean PS for the overall population was 65.9% ± 20.1%. Teaching institutions had a significantly higher PS (71.4% ± 16.9%) compared with non-teaching hospitals (63.4% ± 21%; P < 0.001). Overall in-hospital mortality was 5.2%, and the variables that correlated independently with in-hospital mortality included: PS-per point increase (OR = 0.97, 95% CI 0.95-0.98, P < 0.001), age-per year (OR = 1.06, 95% CI 1.03-1.09, P < 0.001), chronic kidney disease (OR = 3.12, 95% CI 1.08-9.00, P = 0.036), and prior angioplasty (OR = 0.25, 95% CI 0.07-0.84, P = 0.025).

CONCLUSIONS

In BRACE, the adoption of evidence-based therapies for ACS, as measured by the performance score, was independently associated with lower in-hospital mortality. The use of diagnostic tools and therapeutic approaches for the management of ACS is less than ideal in Brazil, with high variability especially among different regions of the country.

The Impact of Unstable Angina Guidelines in the Triage of Emergency Department Patients with Possible Acute Coronary Syndrome

Objective. The primary aim of this study is to determine whether implementing the Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline improves emergency physician's decision making in patients with symptoms of possible acute coronary syndrome (ACS), including those for whom the diagnosis of unstable angina is uncertain. Methods. The authors conducted a prospective guideline implementation trial with pre-post design in the emergency departments of 1 university hospital and 1 university-affiliated community teaching hospital from January 2000 to May 2001. They enrolled 1140 adults who presented with chest pain or other symptoms of possible ACS. The intervention included the following: 1) physician training in use of the AHCPR risk groups, 2) algorithm for risk stratification, and 3) group feedback. To determine how accurately physicians interpreted the guideline algorithm, the authors compared their risk ratings with actual guideline risk groups. Results. No significant difference in physician triage decisions was observed between baseline and intervention periods. Analysis of physician's risk ratings during the intervention period revealed low overall concordance with actual guideline risk groups (kappa = 0.31); however, physician's risk ratings showed superior discrimination in identifying patients with confirmed ACS (receiver operating characteristic [ROC] area .81 v. .74, P = 0.008). Strict adherence to guideline recommendations would have resulted in hospitalizing 9% more non-ACS patients without lowering the rate of missed ACS. Conclusion. Implementation of the AHCPR guideline did not improve triage decisions in emergency department patients with possible ACS. Assessing physician triage solely based on concordance with the AHCPR guideline may not accurately reflect the quality of patient care.

Does Concordance with Guideline Triage Recommendations Affect Clinical Care of Patients with Possible Acute Coronary Syndrome?

Background. The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear. Methods. This analysis included 7466 adults who presented to the emergency department (ED) with symptoms of possible acute coronary syndrome (ACS) and who participated in 3 prospective clinical effectiveness trials during the period 1993 to 2001. The authors used logistic regression to assess the impact of concordance with guideline triage recommendations on subsequent diagnostic testing, follow-up care, and 30-day mortality and applied propensity score methods to adjust for selection bias. Results. Among low-risk patients (n = 1099), ED discharge was not associated with higher mortality and did not increase the need for emergency care or hospitalization during follow-up (adjusted odds ratio [OR] = 1.0, 95% confidence interval [CI] = 0.63—1.6 for ED revisits); however, 1.7% of discharged low-risk patients had confirmed ACS. Among intermediate- to high-risk patients (n = 6367), admission to a monitored bed was not associated with reduction in 30-day mortality but significantly reduced the need for follow-up ED care (adjusted OR = 0.81, 95% CI = 0.69—0.96). Conclusions. This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.

Barriers and facilitators of nurses' use of clinical practice guidelines: An integrative review

BACKGROUND

Preventable harm continues to be one of the leading causes of patient death. Each year about 400,000 patients die from sepsis, hospital acquired infections, venous thromboembolism, and pulmonary embolism. However, as shown in the recent reduction in hospital acquired infections, the number of deaths could be reduced if healthcare providers used evidence-based therapies, which are often included in clinical practice guidelines (CPGs).

PURPOSE

The purpose of this integrative review is to appraise and synthesize the current literature on barriers to and facilitators in the use of clinical practice guidelines (CPGs) by registered nurses.

DESIGN

Whittemore and Knafl integrative review methodology was used. Primary quantitative and qualitative studies about the nurses' use of CPGs and published in peer-reviewed journals between January 2000 and August 2015 were included.

METHODS

The Critical Skills Appraisal Program (CASP) was used to critically appraise the quality of sixteen selected quantitative and qualitative studies.

RESULTS

Internal factors were attitudes, perceptions, and knowledge whereas format and usability of CPGs, resources, leadership, and organizational culture were external factors influencing CPG use.

CONCLUSION

Given each barrier and facilitator, interventions and policies can be designed to increase nurses' use of CPGs to deliver more evidence based therapy. In order to improve the use of CPGs and to ensure high quality care for all patients, nurses must actively participate in development, implementation, and maintenance of CPGs.

Comparison of transradial and transfemoral coronary intervention in octogenarians with acute myocardial infarction

BACKGROUND

The transradial (TR) approach for percutaneous coronary intervention (PCI) is challenging and associated with failure in elderly patients. We compared the TR and transfemoral (TF) approaches in patients>80 years with acute myocardial infarction (MI) undergoing PCI.

METHODS

A total of 1945 (7.2%) octogenarians were enrolled from among 27,129 patients in the Korea Acute Myocardial Infarction Registry. The TR group (n=336, 17.3%) was compared with the TF group (n=1609, 82.7%) in the overall and propensity-matched cohorts with respect to procedural success, complications, in-hospital mortality, and one-year mortality and total major adverse cardiac event (MACE; death, MI, and revascularization) rate.

RESULTS

In the overall cohort, the TR group had lower incidence of Killip class III or IV compared to the TF group. The disease extent and lesion severity were similar between groups, as was the procedural success rate (97.7% vs. 98.3%); however, in-hospital complications were significantly lower in the TR group (8.1% vs. 20.3%). In-hospital mortality was significantly lower in the TR group than the TF group (3.4% vs. 11.4%), as were the one-year mortality and total MACE (9.8% vs. 18.4% and 13% vs. 21.9%, respectively). These outcomes were consistent in the propensity-matched cohort. The TR approach was found to be a significant predictor of low in-hospital mortality (OR 0.355, 95% CI 0.139-0.907), but not of one-year mortality (OR 0.644, 95% CI 0.334-1.240).

CONCLUSIONS

In octogenarians with acute MI undergoing PCI, the TR approach was more effective than the TF approach as it had lower complication rate and better clinical outcomes with comparable procedural success.

Achievement of guideline-concordant care and in-hospital outcomes in patients with coronary artery disease in teaching and nonteaching hospitals: results from the Get With The Guidelines-Coronary Artery Disease program

BACKGROUND

Secondary prevention therapies improve longitudinal outcomes in patients with coronary artery disease. Previous studies showed that teaching hospitals (THs) more consistently use evidence-based secondary prevention therapies than non-THs (NTHs). It is unclear whether these differences persist after initiation of a national quality improvement system.

METHODS AND RESULTS

We analyzed 270902 patients across 361 hospitals in the Get With The Guidelines-Coronary Artery Disease program from June 2000 to September 2009. The primary outcome was guideline-concordant care, defined as compliance with all Get With The Guidelines-Coronary Artery Disease quality measures: (1) aspirin within 24 hours, (2) aspirin at discharge, (3) angiotensin-converting enzyme inhibitor/angiotensin receptor blockers for systolic dysfunction, (4) β-blockers at discharge, (5) lipid therapy if low-density lipoprotein >100 mg/dL, and (6) smoking cessation. We used multivariate modeling to compare the relationship between TH and NTH status on quality measures, in-hospital mortality, and length of stay. Guideline-concordant care was higher at THs (78.4% versus 73.3%; P<0.01). The adjusted odds ratio between 2000 and 2009 for guideline-concordant care at THs compared with NTHs was 2.78 (confidence interval, 1.28-6.06; P=0.01). Guideline-concordant care increased from 2000 to 2009 at THs (n=176; 65.3%→88.3%; adjusted odds ratio for year increase, 1.24 [confidence interval, 1.16-1.30; P<0.01]) and NTHs (n=185; 61.0%→93.9%; adjusted odds ratio for year increase, 1.35 [confidence interval, 1.26-1.45]; P<0.01). THs had shorter length of stay (adjusted odds ratio, 0.74 for length of stay >4 days; confidence interval, 0.58-0.94) from 2000 to 2009. Lower in-hospital mortality was observed at THs (3.7% versus 4.4% at NTHs; P<0.01), but this was not significant after adjustment.

CONCLUSIONS

Adherence to guideline-recommended therapies increased over time with participation in the Get With The Guidelines-Coronary Artery Disease program, regardless of the teaching status. Guideline-concordant care over the full decade was higher in THs; however, NTHs demonstrated greater incremental improvement over time.

Prognostic value of reported chest pain for cardiovascular risk stratification in primary care

BACKGROUND

The prognostic significance of chest pain is well established in patients with coronary artery disease, but still ill defined in primary prevention. Therefore, the aim of our analysis was to assess the prognostic value of different forms of chest pain in a large cohort of primary care subjects under the conditions of contemporary modalities of care in primary prevention, including measurement of serum levels of the biomarker NT-pro-BNP.

DESIGN

We carried out a post-hoc analysis of the prospective DETECT cohort study.

METHODS

In a total of 5570 unselected subjects, free of coronary artery disease, within the 55,518 participants of the cross-sectional DETECT study, we assessed chest pain history by a comprehensive questionnaire and measured serum NT-pro-BNP levels. Three types of chest pain, which were any chest pain, exertional chest pain and classical angina, were defined. Major adverse cardiovascular events (MACEs = cardiovascular death, myocardial infarction, coronary revascularization procedures) were assessed during a 5-year follow-up period.

RESULTS

During follow-up, 109 subjects experienced a MACE. All types of reported chest pain were associated with an approximately three-fold increased risk for the occurrence of incident MACEs, even after adjusting for cardiovascular risk factors. Any form of reported chest pain had a similar predictive value for MACEs as a one-time measurement of NT-pro-BNP. However, adding a single measurement of NT-pro-BNP and the information on chest pain resulted in reclassification of approximately 40% of subjects, when compared with risk prediction based on established cardiovascular risk factors.

CONCLUSIONS

In primary prevention, self-reported chest pain and a single measurement of NT-pro-BNP substantially improve cardiovascular risk prediction and allow for risk reclassification of approximately 40% of the subjects compared with assessing classical cardiovascular risk factors alone.

PCI Outcomes in High-Risk Groups (Diabetes Mellitus, Smoker, Chronic Kidney Disease and the Elderly)

Ischemic heart disease remains the leading cause of morbidity and mortality in both genders in developed countries. Many women underestimate the effect of coronary artery disease on their health and as a result, the female population tends to be under-investigated for symptoms, with less-aggressive treatment approaches, leading to perceived worse outcomes in this group. Many assumptions about women are from studies where the female population is under-represented and in trials that do not account for gender differences. This article discusses percutaneous coronary intervention in high-risk groups and whether such a gender difference exists.

Performance measures have a major effect on cardiovascular outcomes: a review

Improved application of existing therapies, directed by evidence-based guidelines, may offer immediate savings of life and function to patients with cardiovascular disease. We sought to evaluate the evidence that use of performance measures derived from clinical practice guidelines is associated with better clinical outcomes in this context. We conducted a search of the MEDLINE database for published studies evaluating the relationship of evidence-based therapies and outcomes in patients with coronary artery disease or heart failure. Studies examined included single-center, regional, national, and international experiences, and varied considerably in design. Most studies linking guidelines-based care to outcomes focused on patients with coronary artery disease; relatively few addressed patients with heart failure. Few studies, all nonrandomized, examined the use of specific interventions to improve quality of care in the context of standardized care tools. Almost all studies showed a strong and "dose-response" association between adherence to guidelines and performance measures and outcomes. Higher quality of care, as documented by better performance based on measures derived from practice guidelines, is associated with improved outcomes in patients with cardiovascular disease.

Facility-level factors influencing chronic heart failure care process performance in a national integrated health delivery system

BACKGROUND

Gaps between evidence and practice in the care of patients with chronic heart failure (CHF) in the United States suggest major opportunities for improvement. However, the organizational factors and implementation approaches that influence adherence to national guidelines are poorly understood.

OBJECTIVES

The objectives of this study were to explore the degree to which providers in the Veterans Health Administration system adhere to CHF clinical practice guidelines, and to identify facility-level factors influencing adherence.

DESIGN

In a national cross-sectional study, facility quality managers were surveyed regarding quality improvement efforts, guideline implementation, and context. These data were linked to organizational structure data and provider adherence data from chart reviews. The unit of analysis was the facility. The data were adjusted for the average number of comorbidities per CHF patient. Multivariate logistic regression models were constructed to model factors affecting adherence to CHF guidelines.

SAMPLE

The sample consisted of 143 Veterans Administration Medical Centers with ambulatory care clinics.

RESULTS

The quality manager survey included data from 91% of facilities. Facility-level estimates of provider adherence measures were, on average, 85% or more for most measures. In multivariate analyses, facilities with higher levels of adherence were more likely to have: (1) providers who had been given a brief guideline summary, (2) providers receptive to the guidelines, (3) guideline-specific task forces to support implementation, and 4) a well-planned implementation process.

CONCLUSIONS

Healthcare organizations should adapt implementation to meet local conditions, including creating guideline-specific task forces, developing a well-planned implementation process, fostering provider buy-in, and providing guideline summaries to providers.

Context, automated decision support, and clinical practice guidelines: Does the literature apply to the United States practice environment?

BACKGROUND

Context - the combined effect of factors such as physician type, clinical setting, and guideline characteristics - influences the ability of automated decision support (ADS) to improve physician compliance with clinical practice guidelines (CPGs). Our goal was to determine whether research about the utility of ADS for promoting CPG compliance is contextually applicable to United States physicians.

METHODS

We extracted information about physicians, settings, and guidelines from all articles published in the last 10 years that describe original research about the use of ADS to promote CPG compliance. The extracted information was compared to the range of practice contexts seen in the United States.

RESULTS

Nearly two-thirds (65.3%) of papers described studies conducted in an academic setting, but only 11% of physicians report academic affiliations (p<0.0001). Physician reimbursement structure is often not reported. Salaried physicians were explicitly included as subjects in 14% of articles, but make up 45% of US physicians (p<0.0001). There are little data about the generalizability of ADS research to emergency care settings (6% of articles), and nursing home or skilled nursing facilities (10% of articles). Finally, ADS has not been studied at all in several epidemiologically important disease categories.

CONCLUSION

The literature does not adequately address some physician, setting, and guideline contexts. Before making policy or spending decisions based on the effectiveness of ADS, additional research is needed to determine whether ADS research can be generalized to under-represented contexts.

Improved adherence to Swedish national guidelines for acute myocardial infarction: the Quality Improvement in Coronary Care (QUICC) study

BACKGROUND

The adherence to evidence-based treatment guidelines for acute myocardial infarction (AMI) is still suboptimal. Therefore, we designed a study to evaluate the effects of a collaborative quality improvement (QI) intervention on the adherence to AMI guidelines. The intervention used a national web-based quality registry to generate local and regular real-time performance feedback.

METHODS

A 12-month baseline measurement of the adherence rates was retrospectively collected, comprising the period July 1, 2001, through June 30, 2002. During the intervention period of November 1, 2002, through April 30, 2003, multidisciplinary teams from 19 nonrandomized intervention hospitals were subjected to a multifaceted QI-oriented intervention. Another 19 hospitals, unaware of their status as controls, were matched to the intervention hospitals. During the postintervention measurement period of May 1, 2003, through April 30, 2004, a total of 6726 consecutive patients were included at the intervention (n = 3786) and control (n = 2940) hospitals. The outcome measures comprised 5 Swedish national guideline-derived quality indicators, compared between baseline and postintervention levels in the control and QUICC intervention hospitals.

RESULTS

In the control and QI intervention hospitals, the mean absolute increase of patients receiving angiotensin-converting enzyme inhibitors was 1.4% vs 12.6% (P = .002), lipid-lowering therapy 2.3% vs 7.2% (P = .065), clopidogrel 26.3% vs 41.2% (P = .010), heparin/low-molecular weight heparin 5.3% vs 16.3% (P = .010), and coronary angiography 6.2% vs 16.8% (P = .027), respectively. The number of QI intervention hospitals reaching a treatment level of at least 70% in 4 or 5 of the 5 indicators was 15 and 5, respectively. In the control group, no hospital reached 70% or more in just 4 of the 5 indicators.

CONCLUSIONS

By combining a systematic and multidisciplinary QI collaborative with a web-based national quality registry with functionality allowing real-time performance feedback, major improvements in the adherence to national AMI guidelines can be achieved.

Evolution in Cardiovascular Care for Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

OBJECTIVES

This study evaluated the impact of age on care and outcomes for non-ST-segment elevation acute coronary syndromes (NSTE ACS).

BACKGROUND

Recent clinical trials have expanded treatment options for NSTE ACS, now reflected in guidelines. Elderly patients are at highest risk, yet have previously been shown to receive less care than younger patients.

METHODS

In 56,963 patients with NSTE ACS at 443 U.S. hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) National Quality Improvement Initiative from January 2001 to June 2003, we compared use of guidelines-recommended care across four age groups: <65, 65 to 74, 75 to 84, and > or =85 years. A multivariate model tested for age-related differences in treatments and outcomes after adjusting for patient, provider, and hospital factors.

RESULTS

Of the study population, 35% were > or =75 years old, and 11% were > or =85 years old. Use of acute anti-platelet and anti-thrombin therapy within the first 24 h decreased with age. Elderly patients were also less likely to undergo early catheterization or revascularization. Whereas use of many discharge medications was similar in young and old patients, clopidogrel and lipid-lowering therapy remained less commonly prescribed in elderly patients. In-hospital mortality and complication rates increased with advancing age, but those receiving more recommended therapies had lower mortality even after adjustment than those who did not.

CONCLUSIONS

Age impacts use of guidelines-recommended care for newer agents and early in-hospital care. Further improvements in outcomes for elderly patients by optimizing the safe and early use of therapies are likely.

Influence of clinical trial enrollment on the quality of care and outcomes for patients with non-ST-segment elevation acute coronary syndromes

BACKGROUND

Clinical trials provide evidence that is formulated into recommendations for practice guidelines, but it remains uncertain whether patients enrolled in trials are similar to those treated in routine practice and whether trial enrollment influences inhospital treatments and outcomes.

METHODS

Using data from the CRUSADE quality improvement initiative, we evaluated predictors of trial enrollment, treatment patterns, and clinical outcomes among high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) who were and were not enrolled in a clinical trial during hospitalization.

RESULTS

Among 55,172 high-risk patients presenting with NSTE ACS at 443 US hospitals, 1397 (2.5%) patients were enrolled in a clinical trial during index hospitalization. Significant predictors of trial enrollment included male sex, lack of renal insufficiency, and absence of congestive heart failure on presentation. Acute (<24 hours) and discharge secondary prevention interventions recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS were used more commonly in patients enrolled in clinical trials. Cardiac catheterization (84.5% vs 65.8%, P < .0001), percutaneous coronary intervention (48.2% vs 36.3%, P < .0001), and bypass surgery (19.1% vs 11.3%, P < .0001) were also performed more frequently in trial patients. The adjusted risk of inhospital mortality was similar in trial versus nontrial patients (odds ratio 0.86, 95% CI 0.60-1.24).

CONCLUSIONS

Patients with NSTE ACS participating in clinical trials are more likely to receive beneficial therapies and interventions throughout hospitalization, but preferential recruitment of patients with lower-risk features may limit the external validity of trial results.

Improved adherence to practice guidelines yields better outcome in high-risk patients with acute coronary syndrome without ST elevation: findings from nationwide FINACS studies

OBJECTIVES

Treatment options for acute coronary syndrome (ACS) without ST elevation have evolved rapidly during the recent years, but the successful implementation of practice guidelines incorporating new treatments into practice has been challenging. In this study, we evaluate whether targeted educational intervention could improve adherence to treatment guidelines of ACS without ST elevation.

DESIGN, SETTING AND SUBJECTS

A previous study, FINACS I, evaluated the treatment and outcome of 501 consecutive non-ST elevation ACS patients that were referred in early 2001 to nine hospitals, covering nearly half of the Finnish population. That study revealed poor adherence to ESC guidelines, so targeted educational intervention on optimal practice was arranged before the second study (FINACS II), which was performed in the same hospitals using the same protocol as FINACS I. FINACS II, undertaken in early 2003, evaluated 540 consecutive patients. Interventions. Targeted educational programmes on optimal practice.

MAIN OUTCOME MEASURES

The use of evidence-based therapies in non-ST elevation ACS patients. In-hospital event-free (death, new myocardial infarction, refractory angina, readmission with unstable angina and transient cerebral ischaemia/stroke) survival, and event-free survival at 6 months.

RESULTS

Baseline characteristics and risk markers were similar in both studies, and no significant changes in resources were seen. In 2003, the in-hospital use of statins, ACE-inhibitors, clopidogrel and glycoprotein (GP) IIb/IIIa receptor antagonists increased significantly, and in-hospital angiography was performed more often, especially in high-risk patients (59% vs. 45%, P < 0.05); waiting time also shortened (4.2 +/- 5.5 vs. 5.8 +/- 4.7 days, P < 0.01). Overall no significant change was seen in the frequency of death either in-hospital (2% vs. 4%, P = NS) or at 6 months (7% vs. 10%, P = NS) in FINACS II. However, the survival of high-risk patients improved both in-hospital (95% vs. 90%, P = 0.05) and at 6 months (89% vs. 78%, P = 0.05).

CONCLUSION

In patients with non-ST elevation ACS-targeted educational interventions appeared to be associated with improved adherence to practical guidelines, which yielded a better outcome in high-risk ACS patients.

Care concordant with guidelines predicts decreased long-term mortality in patients with unstable angina pectoris and non-ST-elevation myocardial infarction

Data are sparse regarding the long-term benefit of care concordant with clinical practice guidelines in patients presenting with unstable angina pectoris and non-ST-segment elevation myocardial infarction (UAP/NSTEMI), particularly in the general care setting. We extended follow-up in a preexisting cohort of 275 patients hospitalized with primary UAP/NSTEMI. Using Cox models, we compared long-term mortality between patients who received care concordant with > or =80% of 8 important guideline recommendations during the index hospitalization and patients who did not. Among all study patients, 68% received guideline-concordant care. During follow-up (median 9.4 years) 49% of patients died. Patients with UAP/NSTEMI who received guideline-concordant care had significantly decreased long-term mortality compared with those who received guideline-discordant care (hazards ratio [HR] 0.45, 95% confidence interval [CI] 0.32 to 0.64). Guideline-concordant care remained associated with decreased mortality after adjusting for other predictors of long-term mortality (HR 0.57, 95% CI 0.39 to 0.84) and after adjustment for the propensity to receive guideline-concordant care (HR 0.61, 95% CI 0.43 to 0.88). The benefit of guideline-concordant care relative to discordant care was preserved in high-risk populations shown to be less likely to receive guideline-concordant care, including patients with advanced age, congestive heart failure, elevated serum creatinine, and prior myocardial infarction. Care concordant with UAP/NSTEMI clinical practice guidelines is associated with substantially improved long-term survival. Our findings endorse the approach adopted by authors of clinical practice guidelines in generalizing evidence-based medicine to usual clinical care. In firmly establishing the benefit of consensus guidelines, the foundation is set for efforts to improve practitioner compliance with these standards.

Clinical Practice Guidelines and Performance Indicators as Related—But Often Misunderstood—Tools

BACKGROUND

Widespread variation in medical practice indicates that existing scientific evidence is often not translated into appropriate clinical care. Two tools have evolved that try to address this variation: clinical practice guidelines (CPGs) and performance indicators (PIs).

TENSIONS BETWEEN CPGS AND PIS

CPGs present available evidence that is subsequently reviewed and frequently adopted by professional organizations, so that clinicians may judge whether specific management recommendations are appropriate for each patient. PIs are devised to measure and document performance to motivate organizations to improve through the use of common metrics.

IMPLICATIONS OF THESE TENSIONS

The increasingly widespread use of PIs with CPGs (and clinicians' confusion of them with CPGs) risks lowering the standards of clinical care. PIs are not intended to set optimal standards of care for any individual patient. Clinicians should not restrict their quality monitoring to a focus on PIs because they could miss important opportunities to learn and to improve the care they deliver to their individual patients.

CONCLUSION

Tensions between CPGs and PIs do not mean that these tools should be abandoned but rather that they need to be refined. Recognition of the imperfections of CPGs and PIs should not blind clinicians to the ultimate goals of these tools--to promote quality (through changes in practice and/or selection) and ensure that medical care is based on scientific evidence.

Predictors of long-term mortality after hospitalization for primary unstable angina pectoris and non-ST-elevation myocardial infarction

Data are sparse regarding long-term outcomes after hospitalization for unstable angina pectoris (UAP) and non-ST-elevation myocardial infarction (NSTEMI), as defined by contemporary criteria. We extended follow-up in a preexisting database of unselected patients with primary UAP and NSTEMI admitted by way of the emergency department from 1991 to 1992. Stepwise Cox models were used to identify multivariate predictors of long-term mortality. There were 275 patients (mean age 66 +/- 12 years, 33% women) who survived to hospital discharge; 134 patients (49%) died during follow-up (median 9.4 years). Significant multivariate predictors of long-term mortality were: age (hazard ratio [HR] per decade 1.7, 95% confidence interval [CI] 1.4 to 1.9); prior MI (HR 1.7, 95% CI 1.2 to 2.5); diabetes (HR 1.7, 95% CI 1.2 to 2.4); congestive heart failure (HR 2.2, 95% CI 1.5 to 3.4); elevated creatinine (HR 2.5, 95% CI 1.7 to 3.8); elevated leukocyte count (HR 1.7, 95% CI 1.1 to 2.5); systolic blood pressure <120 mm Hg at presentation (HR 2.0, 95% CI 1.1 to 3.6); lack of coronary revascularization during the index hospitalization (HR 2.0, 95% CI 1.3 to 3.0); and lack of discharge beta-blocker therapy (HR 1.5, 95% CI 1.1 to 2.2). A clinical prediction rule was generated by assigning weighted point scores for the presence of each significant covariate. Long-term mortality increased markedly with each quintile of score; for quintiles 1 to 5, mortality rates were 8.5%, 29.4%, 47.6%, 75.0%, and 91.5%, respectively (p value for trend <0.001). These data are among the first assessments of long-term mortality after hospitalization for primary UAP and NSTEMI, as defined by contemporary guideline criteria. Easily obtained clinical covariates provide excellent prediction of long-term mortality up to 10 years after hospitalization for primary UAP and NSTEMI.

Changing the model of care for patients with acute coronary syndromes

Acute coronary syndromes (ACS) represent a major cause of morbidity and mortality for patients with cardiovascular disease, but evidence-based therapies shown to improve outcomes for ACS are often underused in clinically eligible patients. Although clinical practice guidelines have been developed to provide standards for the diagnosis and treatment of patients with ACS and to provide physicians with a framework for clinical decision-making, multiple obstacles have hindered their implementation and questions remain about the applicability of guidelines for diverse clinical situations. Systematic reviews of quality-improvement studies have shown that multifaceted approaches using targeted educational interventions, creation of quality standards, and regular performance feedback are needed to ensure sustained improvements in care. Approaches to quality improvement thus are being redirected to focus on multidisciplinary collaborations designed to improve the entire process of care for patients with ACS. Multiple large observational registries and quality-improvement initiatives now are capturing data regarding adherence to practice guidelines and contemporary patterns of care for ACS. This comprehensive evaluation of ACS treatment will help guide efforts designed to promote evidence-based care and ultimately determine the effect of widespread implementation of practice guidelines on clinical outcomes. The shifting model of care for ACS therefore suggests that quality improvement and monitoring of adherence to practice guidelines should be considered components of optimal clinical practice.

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease in the elderly: the Multicenter Airway Research Collaboration

OBJECTIVES

To determine adherence of emergency department (ED) management of acute exacerbation of chronic obstructive pulmonary disease (COPD) to current treatment guidelines.

DESIGN

A prospective cohort study, as part of the Multicenter Airway Research Collaboration.

SETTING

The study was performed at 29 EDs in 15 U.S. states and three Canadian provinces.

PARTICIPANTS

ED patients, aged 55 and older, who presented with COPD exacerbation and underwent a structured interview in the ED and another by telephone 2 weeks later.

MEASUREMENTS

Adherence of ED management of COPD exacerbation to that recommended in current treatment guidelines.

RESULTS

The cohort consisted of 397 subjects, of whom 224 (56%) reported only COPD and 173 (44%) reported asthma and COPD. The average age was 70. Most (80%) patients had used rescue medications in the 6 hours before seeking emergency care. Only 31% were evaluated using spirometry and 48% using arterial blood gas measurement. ED treatment included inhaled short-acting beta-agonists for 91% of patients, inhaled anticholinergics for 77%, methylxanthines for 0.3%, systemic corticosteroids for 62%, and antibiotics for 28%. More than half the patients required hospitalization. At 2-week follow-up, 43% of patients reported a relapse event or ongoing exacerbation. Overall, adherence to national and international guidelines was low.

CONCLUSION

Important differences exist between guideline recommendations and actual ED management of COPD exacerbations in older adults. Outcomes after ED treatment are poor and may be related to these shortcomings in quality of care. Better adherence to guideline recommendations when caring for elderly patients with COPD exacerbations may lead to improved clinical outcomes and better resource usage.

What factors influence provider knowledge of a congestive heart failure guideline in a national health care system?

Provider knowledge is a potential barrier to adherence to clinical guidelines. The purpose of this study is to assess the impact of organizational, provider, and guideline factors on provider knowledge of a congestive heart failure (CHF) clinical practice guideline (CPG) in the Veterans Health Administration (VHA) health care system. We developed a survey to investigate institution-level factors influencing the effectiveness of guideline implementation, including characteristics of the guideline, providers, hospital culture and structure, and regional network. Survey participants were quality managers, primary care administrators, and other individuals involved in primary care CPG implementation at 143 VHA hospitals with ambulatory care clinics. Potential explanatory variables were grouped into 11 factors. Multivariate regression models assessed the association between these factors and reported levels of provider knowledge regarding the CHF guideline at the hospital level. Two hundred forty surveys from 126 of 143 (88%) VHA hospitals were returned. Provider knowledge of the CHF guideline was estimated as "great" or "very great" by 58% of respondents. Three predictor factors (dissemination approaches, use of technology in guideline implementation, and hospital culture) were independently associated (P < or = .05) with provider knowledge. Specific variables within these categories that were related to greater knowledge included physician belief that guidelines were applicable to their practice, distribution of guideline summaries, use of guideline storyboards in clinic areas, the use of technology (eg, electronic patient records) in CPG implementation, and establishment of implementation checkpoints and deadlines. Provider knowledge of guidelines is affected by factors at various organizational levels: dissemination approaches, use of technology, and hospital culture. Guideline implementation efforts that target multiple organizational levels may increase provider knowledge.

Guideline-discordant care in acute myocardial infarction: predictors and outcomes

OBJECTIVES

To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care.

DESIGN

Retrospective cohort study.

SETTING

Two community general hospitals.

PARTICIPANTS

607 consecutive patients admitted with AMI between July 1997 and December 2000.

MAIN OUTCOME MEASURES

Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay.

RESULTS

At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% CI, 1.7-3.6), silent infarction (OR, 2.7; 95% CI, 1.6-4.6), anterior infarction (OR, 2.5; 95% CI, 1.7-3.8), a history of heart failure (OR, 6.3; 95% CI, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% CI, 1.5-6.4); and heart rate >/= 100 beats/min (OR, 2.1; 95% CI, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% CI, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% CI, 0.90-7.1).

CONCLUSIONS

Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI. Such care appears to increase the risk of inhospital death.

Outcomes and secondary prevention strategies for male hip fractures

OBJECTIVE

To assess clinical outcomes and determine whether osteoporosis assessment and secondary prevention strategies were performed for male veterans hospitalized for hip fractures.

DESIGN

Retrospective chart review for male veterans hospitalized for hip fracture from January 1993 through July 1999.

SETTING

The Veterans Affairs Medical Center, Madison, WI.

RESULTS

Medical charts were available for 46 of 53 male patients admitted for hip fracture during the study period. Three subjects were excluded because hip fracture was associated with high-impact trauma. Mean age of the 43 study patients was 72 years (range 43-91 y), and mean length of hospitalization was 16 days (median 11 d, range 3-108 d). Thirty-two (82%) of 39 veterans whose disposition was documented were discharged to a nursing home. Eleven (26%) of 43 men died within 12 months after fracture. Twelve (28%) had fractured previously. Four (10%) subsequently had another fracture. Three of 9 patients with documented ambulation status were ambulatory at 1 year. Three patients received a bone mass measurement within a prespecified time interval of 6 months subsequent to fracture. No patient's records included a diagnosis of osteoporosis either before or within 6 months after fracture. One-third of the patients had documentation of calcium or multivitamin supplementation at discharge. One patient was receiving calcitonin at the time of fracture and continued to receive it afterward. No other patient was prescribed antiresorptive therapy by the time of hospital discharge.

CONCLUSIONS

Male veterans with hip fractures received inadequate evaluation and treatment for osteoporosis, although a substantial portion had documentation of recurrent fractures. Education of clinicians and creation of algorithms for management of established osteoporosis may improve outcomes for these individuals.