title: Reinforcement as a means for quality improvement in management of coronary syndromes: adherence to evidence-based medicine.
abstract: OBJECTIVE
  To study the effect of reinforcement as a quality improvement intervention in the evidence-based management of the coronary syndromes.
  
  
  METHODS
  In the pre-intervention phase, the charts of 140 consecutive patients with ICD-9 codes 410-414 for coronary syndromes were reviewed for measurement of total cholesterol on admission and fasting low density lipoprotein (LDL) cholesterol, implementation of aspirin therapy on admission, beta-blockers' use during hospitalization, and treatment with angiotensin converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction. Reinforcement was used as an intervention for quality improvement. All personnel of Division of Cardiology including nursing staff, medical residents, cardiology fellows, and attending physicians were reinforced to adhere to the evidence-based management. In the post-intervention phase, charts of 140 consecutive patients with ICD-9 codes 410-414 for coronary syndromes were reviewed to assess the improvement in the same quality of care parameters.
  
  
  RESULTS
  By reinforcement, a significant improvement was noted in all quality of care parameters studied. Proportion of patients who had total cholesterol measured on admission increased from 78% to 92% (P<0.005), and those who had fasting LDL cholesterol measured increased from 22% to 70% (P<0.0001). Use of aspirin at admission (in 74% of patients pre- vs. 80% of patients post-intervention, P<0.05), beta-blockers during hospitalization (in 62% of patients pre- vs. 78% of patients post-intervention, P<0.001), and ACE inhibitors in patients with left ventricular systolic dysfunction (in 58% of patients pre- vs. 89% of patients post-intervention, P<0.001) improved significantly after reinforcement to the medical personal.
  
  
  CONCLUSIONS
  Reinforcement to adhere to the evidence-based management results in a significant improvement in the quality of care provided to the patients with coronary syndromes.
authors.affiliation: Division of Cardiology, Creighton University Cardiac Center, Creighton University School of Medicine, 3006 Webster Street, Omaha, NE 68131-2044, USA. ikhan@cardiac.creighton.edu
authors.forename: Ijaz A
authors.initials: IA
authors.lastname: Khan
authors.forename: Nirav J
authors.initials: NJ
authors.lastname: Mehta
authors.forename: Ramesh M
authors.initials: RM
authors.lastname: Gowda
authors.forename: Terrence J
authors.initials: TJ
authors.lastname: Sacchi
authors.forename: Balendu C
authors.initials: BC
authors.lastname: Vasavada
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003327:Coronary Disease / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012054:Reinforcement, Psychology; D017749:Total Quality Management / Q000379:methods*; D014481:United States