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.
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.
Rogers
Adam M
AM
Department of Medicine, University of California, San Francisco, CA, USA.
Ramanath
Vijay S
VS
Grzybowski
Mary
M
Riba
Arthur L
AL
Jani
Sandeep M
SM
Mehta
Rajendra
R
De Franco
Anthony C
AC
Parrish
Robert
R
Skorcz
Stephen
S
Baker
Patricia L
PL
Faul
Jessica
J
Chen
Benrong
B
Roychoudhury
Canopy
C
Elma
Mary Anne C
MA
Mitchell
Kristi R
KR
Froehlich
James B
JB
Montoye
Cecelia
C
Eagle
Kim A
KA
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