title: Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome.
abstract: BACKGROUND
  Performance metrics currently focus on the measurement of the application of guideline-indicated medications without considering the appropriate dosing of these drugs.
  
  
  RESULTS
  We studied 39 291 patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) registry with non-ST-segment elevation acute coronary syndromes. We evaluated hospital variability in the composite use of American College of Cardiology/American Heart Association guideline-recommended therapies (adherence) and the proportion of treated patients with the recommended dose of heparins or a glycoprotein IIb/IIIa antagonist (safety), and its association with risk-adjusted in-hospital mortality and bleeding. The rates of composite guideline adherence (median, 85%; 25th, 75th percentile, 82, 88) and antithrombotic dosing safety (median, 53%; 25th, 75th percentile, 45%, 60%) varied among hospitals. Correlation between hospital composite adherence and safety metrics was significant but low (r=0.16, P=0.008). Risk-adjusted in-hospital mortality was inversely related to both guideline adherence (odds ratio-10% increment, 0.80; 95% confidence interval, 0.67-0.94) and safety metrics (odds ratio-10% increment, 0.90; 95% confidence interval, 0.83-0.98). Safety was inversely related to major bleeding (adjusted odds ratio-10% increment, 0.93; 95% confidence interval, 0.87-0.98). In comparison with hospitals with low adherence and safety (≤median performance) metrics, those with mixed performance metrics (high adherence and low safety, low adherence and high safety) had intermediate risk-adjusted mortality rates, whereas hospitals with above-average performance on both metrics (>median performance) had a trend for lowest risk adjusted mortality rates (odds ratio 0.83; 95% confidence interval, 0.68-1.01). Hospitals with high safety had lower bleeding rates in comparison to those with low safety.
  
  
  CONCLUSIONS
  Guideline adherence and dosing safety appeared to provide independent and complementary information on hospital bleeding and mortality, supporting the need for broader metrics of quality that should include measures of both guideline-based care and safety.
authors: From Duke Clinical Research Institute and Duke University Medical Center, Durham, NC. raj.mehta@dm.duke.edu.
authors: Rajendra H
authors: RH
authors: Mehta
authors: From Duke Clinical Research Institute and Duke University Medical Center, Durham, NC.
authors: Anita Y
authors: AY
authors: Chen
authors: From Duke Clinical Research Institute and Duke University Medical Center, Durham, NC.
authors: Karen P
authors: KP
authors: Alexander
authors: From Duke Clinical Research Institute and Duke University Medical Center, Durham, NC.
authors: E Magnus
authors: EM
authors: Ohman
authors: From Duke Clinical Research Institute and Duke University Medical Center, Durham, NC.
authors: Matthew T
authors: MT
authors: Roe
authors: From Duke Clinical Research Institute and Duke University Medical Center, Durham, NC.
authors: Eric D
authors: ED
authors: Peterson
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy*; D000572:American Heart Association; D002317:Cardiovascular Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D019983:Guideline Adherence; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology / Q000517:prevention & control*; D006493:Heparin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D017052:Hospital Mortality; D006761:Hospitals / Q000145:classification / Q000706:statistics & numerical data; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D016017:Odds Ratio; D061214:Patient Safety / Q000706:statistics & numerical data; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D017410:Practice Guidelines as Topic; D016896:Treatment Outcome; D014481:United States
chemical_list: D002317:Cardiovascular Agents; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D006493:Heparin
keywords: acute coronary syndrome; myocardial infarction; outcome assessment (health care); quality control; safety