Guideline-Based Standardized Care Is Associated With Substantially Lower Mortality in Medicare Patients With Acute Myocardial Infarction: The American College of Cardiology’s Guidelines Applied in Practice (GAP) Projects in Michigan

doi:10.1016/j.jacc.2004.12.083

Journal of the American College of Cardiology

Volume 46, Issue 7, 4 October 2005, Pages 1242-1248

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Objectives

We sought to assess the impact of the American College of Cardiology’s Guidelines Applied in Practice (GAP) project for acute myocardial infarction (AMI) care, encompassing 33 acute-care hospitals in southeastern Michigan, on rates of mortality in Medicare patients treated in Michigan.

Background

The GAP project increases the use of evidence-based therapies in patients with AMI. It is unknown whether GAP also can reduce the rate of mortality in patients with AMI.

Methods

Using a before (n = 1,368) and after GAP implementation (n = 1,489) cohort study, 2,857 Medicare patients with AMI were studied to assess the influence of the GAP program on mortality. Multivariate models tested the independent impact of GAP after controlling for other conditions on in-hospital, 30-day, and one-year mortality.

Results

Average patient age was 76 years, 48% were women, and 16% represented non-white minorities. The rate of mortality decreased after GAP for each interval studied: hospital, 10.4% versus 13.6%; 30-day, 16.7% versus 21.6%; and one-year, 33.2% versus 38.3%; all p < 0.02. After multivariate adjustment, GAP correlated with a 21% to 26% reduction in mortality, particularly at 30 days (odds ratio of GAP to baseline 0.74; 95% confidence interval [CI] 0.59 to 0.94; p = 0.012) and one year (odds ratio 0.78; 95% CI 0.64 to 0.95; p = 0.013), particularly in the patients for whom a standard discharge tool was used (1-year mortality, odds ratio 0.53; 95% CI 0.36 to 0.76; p = 0.0006).

Conclusions

Embedding AMI guidelines into practice was associated with improved 30-day and one-year mortality. This benefit is most marked when patients are cared for using standardized, evidence-based clinical care tools.

Abbreviations and Acronyms

ACC

American College of Cardiology

AMI

acute myocardial infarction

BCBSM

Blue Cross Blue Shield of Michigan

CMS

Centers for Medicare and Medicaid Services

GAP

Guidelines Applied in Practice

Cited by (0)

: On behalf of the American College of Cardiology Foundation (Bethesda, Maryland) Guidelines Applied in Practice Steering committee: Raymond J. Gibbons, MD, FACC, (Chair), Christopher P. Cannon, MD, FACC, Richard A. Chazal, MD, FACC, James T. Dove, MD, FACC, Kim A. Eagle, MD, FACC, Arthur Garson, Jr., MD, MPH, MACC, Rick A. Nishimura, MD, FACC. The Guidelines Applied in Practice projects for AMI care were supported by unrestricted grants from the national American College of Cardiology Foundation, the Michigan Chapter of the American College of Cardiology, the Centers for Medicare & Medicaid Services, Michigan Peer Review Organization, Pfizer, Inc., AstraZeneca, the Greater Detroit Area Health Council, the Greater Flint Health Coalition, the Mardigian Foundation, and the University of Michigan. The analyses on which this publication is based were performed under contract number 500-02-MI-02, “Utilization and Quality Control Quality Improvement Organization for the state of Michigan” and sponsored by the Centers for Medicare & Medicaid Services, Department of Health and Human Services. The content of this article does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. The article is a result of the Health Care Quality Improvement Program initiated by the Centers for Medicare & Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the authors concerning experience in engaging with the issues presented here are welcomed.