title: Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative.
abstract: BACKGROUND
  Quality of care of patients with acute myocardial infarction (AMI) has received intense attention. However, it is unknown if a structured initiative for improving care of patients with AMI can be effectively implemented at a wide variety of hospitals.
  
  
  OBJECTIVE
  To measure the effects of a quality improvement project on adherence to evidence-based therapies for patients with AMI.
  
  
  METHODS
  The Guidelines Applied in Practice (GAP) quality improvement project, which consisted of baseline measurement, implementation of improvement strategies, and remeasurement, in 10 acute-care hospitals in southeast Michigan.
  
  
  METHODS
  A random sample of Medicare and non-Medicare patients at baseline (July 1998--June 1999; n = 735) and following intervention (September 1--December 15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed AMI. A random sample of Medicare patients at baseline (January--December 1998; n = 513) and at remeasurement (March--August 2001; n = 388) admitted to 11 hospitals that volunteered, but were not selected, served as a control group.
  
  
  METHODS
  The GAP project consisted of a kickoff presentation; creation of customized, guideline-oriented tools designed to facilitate adherence to key quality indicators; identification and assignment of local physician and nurse opinion leaders; grand rounds site visits; and premeasurement and postmeasurement of quality indicators.
  
  
  METHODS
  Differences in adherence to quality indicators (use of aspirin, beta-blockers, and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion; smoking cessation and diet counseling; and cholesterol assessment and treatment) in ideal patients, compared between baseline and postintervention samples and among Medicare patients in GAP hospitals and the control group.
  
  
  RESULTS
  Increases in adherence to key treatments were seen in the administration of aspirin (81% vs 87%; P =.02) and beta-blockers (65% vs 74%; P =.04) on admission and use of aspirin (84% vs 92%; P =.002) and smoking cessation counseling (53% vs 65%; P =.02) at discharge. For most of the other indicators, nonsignificant but favorable trends toward improvement in adherence to treatment goals were observed. Compared with the control group, Medicare patients in GAP hospitals showed a significant increase in the use of aspirin at discharge (5% vs 10%; P<.001). Use of aspirin on admission, ACE inhibitors at discharge, and documentation of smoking cessation also showed a trend for greater improvement among GAP hospitals compared with control hospitals, although none of these were statistically significant. Evidence of tool use noted during chart review was associated with a very high level of adherence to most quality indicators.
  
  
  CONCLUSIONS
  Implementation of guideline-based tools for AMI may facilitate quality improvement among a variety of institutions, patients, and caregivers. This initial project provides a foundation for future initiatives aimed at quality improvement.
authors.affiliation: Division of Cardiology, University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA.
authors.forename: Rajendra H
authors.initials: RH
authors.lastname: Mehta
authors.forename: Cecelia K
authors.initials: CK
authors.lastname: Montoye
authors.forename: Meg
authors.initials: M
authors.lastname: Gallogly
authors.forename: Patricia
authors.initials: P
authors.lastname: Baker
authors.forename: Angela
authors.initials: A
authors.lastname: Blount
authors.forename: Jessica
authors.initials: J
authors.lastname: Faul
authors.forename: Canopy
authors.initials: C
authors.lastname: Roychoudhury
authors.forename: Steven
authors.initials: S
authors.lastname: Borzak
authors.forename: Susan
authors.initials: S
authors.lastname: Fox
authors.forename: Mary
authors.initials: M
authors.lastname: Franklin
authors.forename: Marge
authors.initials: M
authors.lastname: Freundl
authors.forename: Eva
authors.initials: E
authors.lastname: Kline-Rogers
authors.forename: Thomas
authors.initials: T
authors.lastname: LaLonde
authors.forename: Michele
authors.initials: M
authors.lastname: Orza
authors.forename: Robert
authors.initials: R
authors.lastname: Parrish
authors.forename: Martha
authors.initials: M
authors.lastname: Satwicz
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Smith
authors.forename: Paul
authors.initials: P
authors.lastname: Sobotka
authors.forename: Stuart
authors.initials: S
authors.lastname: Winston
authors.forename: Arthur A
authors.initials: AA
authors.lastname: Riba
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
mesh_terms: D000368:Aged; D005260:Female; D019983:Guideline Adherence; D006761:Hospitals / Q000592:standards*; D006801:Humans; D008297:Male; D008484:Medicaid / Q000592:standards; D006278:Medicare / Q000592:standards; D008824:Michigan; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy*; D010043:Outcome and Process Assessment, Health Care; D010353:Patient Education as Topic; D017410:Practice Guidelines as Topic; D019984:Quality Indicators, Health Care; D017749:Total Quality Management