Successful implementation of guidelines for encouraging the use of beta blockers in patients after acute myocardial infarction.
OBJECTIVE
To assess whether implementation of guidelines increases the prescription of drugs, particularly beta blockers, recommended for secondary prevention after acute myocardial infarction.


METHODS
Prescription patterns among 355 patients discharged from a public teaching hospital after recovery from myocardial infarction were prospectively monitored in a before-after trial. The implementation strategies included educational interventions (large group meetings), placement of guidelines in patients' records, and bimonthly general reminders sent to physicians.


RESULTS
Beta blockers were prescribed in 93 (38%) of 243 survivors of acute myocardial infarction before guideline implementation (12-month control period), as compared with 71 (63%) of 112 patients (P <0.001) after their implementation (6-month period). During the entire study period, the prescription of beta blockers at a neighboring public teaching hospital, used as a comparison, was unchanged. After adjusting for potential confounders, implementation of the guidelines remained significantly associated with prescription of beta blockers at discharge [odds ratio (OR) = 10; 95% confidence interval (CI), 3.2 to 33; P <0.001]. Other independent predictors of prescription of beta blockers were previous coronary artery bypass grafting (OR = 8.7; 95% CI, 2.5 to 31; P = 0.001), hypertension (OR = 2.5; 95% CI, 1.4 to 4.5; P = 0.003), age per 10-year increase (OR = 0.82; 95% CI, 0.67 to 0.99; P = 0.04), secular trend in prescription patterns expressed in months (OR = 0.9; 95% CI, 0.8 to 1.0; P = 0.02), a left ventricular ejection fraction < or = 40% (OR = 0.2; 95% CI, 0.1 to 0.4; P <0.001), the presence of atrioventricular block (OR = 0.1; 95% CI, 0.02 to 0.7; P = 0.02), and concomitant prescription of digoxin (OR = 0.2; 95% CI, 0.05 to 0.8; P = 0.02) or calcium antagonists (OR = 0.06; 95% CI, 0.01 to 0.3; P = 0.001).


CONCLUSIONS
When appropriately developed and implemented by local experts, literature-based guidelines may be effective in modifying use of recommended drugs for secondary prevention of coronary artery disease, such as prescription of beta blockers.
Sarasin
F P
FP
Medical Clinic 1, Department of Internal Medicine, Hôpital Cantonal, University of Geneva Medical School, Switzerland.
Maschiangelo
M L
ML
Schaller
M D
MD
Héliot
C
C
Mischler
S
S
Gaspoz
J M
JM
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D002316:Cardiotonic Agents / Q000627:therapeutic use; D001026:Coronary Artery Bypass; D004077:Digoxin / Q000627:therapeutic use; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D006327:Heart Block / Q000150:complications; D006801:Humans; D006973:Hypertension / Q000150:complications; D008297:Male; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy* / Q000517:prevention & control* / Q000601:surgery; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D012720:Severity of Illness Index; D013318:Stroke Volume; D013557:Switzerland; D018487:Ventricular Dysfunction, Left / Q000209:etiology
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D002121:Calcium Channel Blockers; D002316:Cardiotonic Agents; D004077:Digoxin