title: The association between guideline-based treatment instructions at the point of discharge and lower 1-year mortality in Medicare patients after acute myocardial infarction: the American College of Cardiology's Guidelines Applied in Practice (GAP) initiative in Michigan.
abstract: BACKGROUND
  The American College of Cardiology's Guidelines Applied in Practice (GAP) initiative for acute myocardial infarction (AMI) has been shown to increase the use of guideline-based therapies and improve outcomes in patients with AMI. It is unknown whether hospitals that are more successful in using the standard discharge contract--a key component of GAP that emphasizes guideline-based medications, lifestyle modification, and follow-up planning--experience a proportionally greater improvement in patient outcomes.
  
  
  METHODS
  Medicare patients treated for AMI in all 33 participating GAP hospitals in Michigan were enrolled. We aggregated the hospitals into 3 tertiles based on the rates of discharge contract use: 0% to 8.4% (tertile 1), >8.4% to 38.0% (tertile 2), and >38.0% to 61.1% (tertile 3). We analyzed 1-year follow-up mortality both pre- and post-GAP and compared the mortality decline post-GAP with discharge contract use according to tertile.
  
  
  RESULTS
  There were 1368 patients in the baseline (pre-GAP) cohort and 1489 patients in the post-GAP cohort. After GAP implementation, mortality at 1 year decreased by 1.2% (P = .71), 1.2% (P = .68), and 6.0% (P = .03) for tertiles 1, 2, and 3, respectively. After multivariate adjustment, discharge contract use was significantly associated with decreased 1-year mortality in tertile 2 (odds ratio 0.43, 95% CI 0.22-0.84) and tertile 3 (odds ratio 0.45, 95% CI 0.27-0.75).
  
  
  CONCLUSIONS
  Increased hospital utilization of the standard discharge contract as part of the GAP program is associated with decreased 1-year mortality in Medicare patient populations with AMI. Hospital efforts to promote adherence to guideline-based care tools such as the discharge contract used in GAP may result in mortality reductions for their patient populations at 1 year.
authors: Department of Medicine, University of California, San Francisco, CA, USA.
authors: Adam M
authors: AM
authors: Rogers
authors: Vijay S
authors: VS
authors: Ramanath
authors: Mary
authors: M
authors: Grzybowski
authors: Arthur L
authors: AL
authors: Riba
authors: Sandeep M
authors: SM
authors: Jani
authors: Rajendra
authors: R
authors: Mehta
authors: Anthony C
authors: AC
authors: De Franco
authors: Robert
authors: R
authors: Parrish
authors: Stephen
authors: S
authors: Skorcz
authors: Patricia L
authors: PL
authors: Baker
authors: Jessica
authors: J
authors: Faul
authors: Benrong
authors: B
authors: Chen
authors: Canopy
authors: C
authors: Roychoudhury
authors: Mary Anne C
authors: MA
authors: Elma
authors: Kristi R
authors: KR
authors: Mitchell
authors: James B
authors: JB
authors: Froehlich
authors: Cecelia
authors: C
authors: Montoye
authors: Kim A
authors: KA
authors: Eagle
mesh_terms: D000368:Aged; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D006278:Medicare; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy*; D010351:Patient Discharge; D011996:Records; D013997:Time Factors