Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative.
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.
Mehta
Rajendra H
RH
Division of Cardiology, University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA.
Montoye
Cecelia K
CK
Gallogly
Meg
M
Baker
Patricia
P
Blount
Angela
A
Faul
Jessica
J
Roychoudhury
Canopy
C
Borzak
Steven
S
Fox
Susan
S
Franklin
Mary
M
Freundl
Marge
M
Kline-Rogers
Eva
E
LaLonde
Thomas
T
Orza
Michele
M
Parrish
Robert
R
Satwicz
Martha
M
Smith
Mary Jo
MJ
Sobotka
Paul
P
Winston
Stuart
S
Riba
Arthur A
AA
Eagle
Kim A
KA
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