GAP: Guideline-based tools improve MI care
GAP: Guideline-based tools improve MI care
Tue, 12 Mar 2002 22:02:56
Chicago, IL - A new analysis of medical records suggests that significant improvement in the quality of care offered to MI patients was accomplished with the use of guideline-based tools and interventions, part of an American College of Cardiology initiative known as Guidelines Applied in Practice (GAP). The new report, which compared a random sample of medical records before and after institution of the GAP initiative in 10 Michigan hospitals, is published in the March 13, 2002 issue of JAMA.
Implementation of the project, which includes reminder materials such as discharge forms, resulted in significant improvement in adherence to several standards of care, including the use of aspirin and -blockers.
In an interview with heartwire, senior author Dr Kim A Eagle (University of Michigan Hospital, Ann Arbor, MI) said that in the current healthcare milieu, the possibility that treatments will either not be given or not be documented is "very real."
Eagle likened the GAP materials to the safety checks that even experienced pilots have to run through every time they take a plane off the ground: "That's a life-or-death checklist. We know now that there are certain things we can do that will improve outcomes in cardiovascular care, and we have to build those right into the care. We have to have reminders so that in the chaos of any given day, you don't forget."
Opinion leaders and tool kits
It is well known that the translation of clinical research into clinical practice is slow, and studies confirm that adherence to guidelines is "disappointing," the researchers write. The GAP initiative, like a similar program undertaken recently by the American Heart Association called "Get With the Guidelines," aim to improve the pace of this translation.
The project was begun in each of 10 hospitals with a kick-off presentation introducing the "tool kit" including materials such as AMI standard orders, a clinical pathway, a pocket guide, patient information, and discharge forms. All of the materials (which can be found on the ACC website) can be customized with the hospital's own logos and "culture," Eagle said.
In addition, local physician opinion leaders were identified from another healthcare system to promote the program and help institute it, and "grand rounds" visits were made to each hospital.
To evaluate its effectiveness, the authors measured adherence to 12 quality indicators for AMI care before and after the intervention at participating and control hospitals. Indicators included use of aspirin, -blockers, and ACE inhibitors within 24 hours of admission and at discharge; time to reperfusion; counseling on diet and quitting smoking; and cholesterol assessment and treatment.
The researchers analyzed data on a random sample of 1649 patients with documented MI admitted to the 10 study centers, 735 from a period before the intervention (July 1998 to June 1999) and 914 from the postintervention period (September 1 to December 15, 2000). A random sample of Medicare patients from 11 hospitals that volunteered to participate, but were not selected, served as a control group.
The time line for the program between introduction, implementation and evaluation was "aggressive," Eagle noted, all completed within a year. The follow-up evaluation showed positive trends in all the quality indicators, reaching statistical significance in the early administration of aspirin and -blockers, and the late use of aspirin and smoking cessation counseling.
GAP: Indicators showing statistically significant improvement after intervention
Evidence of the use of GAP tools noted during chart review was associated with an even higher level of adherence to key quality indicators, Eagle noted. "In some ways the amount of improvement in GAP I was modest, but the opportunity we can see before us is truly far more than we achieved in the first phase," he said.
Other GAP projects are now being launched in the treatment of heart failure and angina in Alabama and Oregon, and two other acute MI GAP initiatives are underway in Michigan, one in 19 hospitals.
"It's my understanding that the ACC and AHA leadership are in discussions about how to create a synergistic national effort to improve MI care around the country, calling on the strengths of both organizations and their current programs," Eagle added.
Improvement modest?
In an editorial accompanying the publication, Dr Michael W Rich (Washington University School of Medicine, St Louis, MO) applauds GAP and other such initiatives, but points out that the results reported by Eagle et al were still somewhat disappointing.
"To overcome perceived barriers to implementing the AMI guidelines, the GAP investigators seemingly did everything right," Rich writes, engaging the help of the ACC, the Center for Medicare and Medicaid Services (CMS) and the Michigan Peer Review Organization, forging cooperative relationships with local hospitals, and providing "high quality" materials to support the initiative.
"Yet, despite these intensive efforts, the beneficial effects of the GAP intervention were at best modest," Rich says. "In addition, since considerable resources were allocated to achieve small gains, the cost-effectiveness ratio is likely to be quite high." He speculates that the ambitious time line may have been too aggressive to show the intervention's full potential benefit, and points out that the performance indicators for participating hospitals were already comparatively good at baseline.
Rich adds, though, that even these modest gains may provide important benefits with continued vigilance. But before the program is widely implemented, more rigorous evaluation, including randomized trials, is necessary to determine more precisely the benefit, Rich concludes, "not only with respect to improving processes of care, but also with respect to improving patient outcomes."
Chicago, IL - A new analysis of medical records suggests that significant improvement in the quality of care offered to MI patients was accomplished with the use of guideline-based tools and interventions, part of an American College of Cardiology initiative known as Guidelines Applied in Practice (GAP). The new report, which compared a random sample of medical records before and after institution of the GAP initiative in 10 Michigan hospitals, is published in the March 13, 2002 issue of JAMA.
Implementation of the project, which includes reminder materials such as discharge forms, resulted in significant improvement in adherence to several standards of care, including the use of aspirin and -blockers.
In an interview with heartwire, senior author Dr Kim A Eagle (University of Michigan Hospital, Ann Arbor, MI) said that in the current healthcare milieu, the possibility that treatments will either not be given or not be documented is "very real."
Eagle likened the GAP materials to the safety checks that even experienced pilots have to run through every time they take a plane off the ground: "That's a life-or-death checklist. We know now that there are certain things we can do that will improve outcomes in cardiovascular care, and we have to build those right into the care. We have to have reminders so that in the chaos of any given day, you don't forget."
Opinion leaders and tool kits
It is well known that the translation of clinical research into clinical practice is slow, and studies confirm that adherence to guidelines is "disappointing," the researchers write. The GAP initiative, like a similar program undertaken recently by the American Heart Association called "Get With the Guidelines," aim to improve the pace of this translation.
The project was begun in each of 10 hospitals with a kick-off presentation introducing the "tool kit" including materials such as AMI standard orders, a clinical pathway, a pocket guide, patient information, and discharge forms. All of the materials (which can be found on the ACC website) can be customized with the hospital's own logos and "culture," Eagle said.
In addition, local physician opinion leaders were identified from another healthcare system to promote the program and help institute it, and "grand rounds" visits were made to each hospital.
To evaluate its effectiveness, the authors measured adherence to 12 quality indicators for AMI care before and after the intervention at participating and control hospitals. Indicators included use of aspirin, -blockers, and ACE inhibitors within 24 hours of admission and at discharge; time to reperfusion; counseling on diet and quitting smoking; and cholesterol assessment and treatment.
The researchers analyzed data on a random sample of 1649 patients with documented MI admitted to the 10 study centers, 735 from a period before the intervention (July 1998 to June 1999) and 914 from the postintervention period (September 1 to December 15, 2000). A random sample of Medicare patients from 11 hospitals that volunteered to participate, but were not selected, served as a control group.
The time line for the program between introduction, implementation and evaluation was "aggressive," Eagle noted, all completed within a year. The follow-up evaluation showed positive trends in all the quality indicators, reaching statistical significance in the early administration of aspirin and -blockers, and the late use of aspirin and smoking cessation counseling.
GAP: Indicators showing statistically significant improvement after intervention
Intervention |
Pre-GAP |
Post-GAP |
p value |
| 81% |
87% |
0.02 |
|
| 65% |
74% |
0.04 |
|
| 84% |
92% |
0.002 |
|
| 53% |
65% |
0.02 |
Evidence of the use of GAP tools noted during chart review was associated with an even higher level of adherence to key quality indicators, Eagle noted. "In some ways the amount of improvement in GAP I was modest, but the opportunity we can see before us is truly far more than we achieved in the first phase," he said.
Other GAP projects are now being launched in the treatment of heart failure and angina in Alabama and Oregon, and two other acute MI GAP initiatives are underway in Michigan, one in 19 hospitals.
"It's my understanding that the ACC and AHA leadership are in discussions about how to create a synergistic national effort to improve MI care around the country, calling on the strengths of both organizations and their current programs," Eagle added.
Improvement modest?
In an editorial accompanying the publication, Dr Michael W Rich (Washington University School of Medicine, St Louis, MO) applauds GAP and other such initiatives, but points out that the results reported by Eagle et al were still somewhat disappointing.
"To overcome perceived barriers to implementing the AMI guidelines, the GAP investigators seemingly did everything right," Rich writes, engaging the help of the ACC, the Center for Medicare and Medicaid Services (CMS) and the Michigan Peer Review Organization, forging cooperative relationships with local hospitals, and providing "high quality" materials to support the initiative.
"Yet, despite these intensive efforts, the beneficial effects of the GAP intervention were at best modest," Rich says. "In addition, since considerable resources were allocated to achieve small gains, the cost-effectiveness ratio is likely to be quite high." He speculates that the ambitious time line may have been too aggressive to show the intervention's full potential benefit, and points out that the performance indicators for participating hospitals were already comparatively good at baseline.
Rich adds, though, that even these modest gains may provide important benefits with continued vigilance. But before the program is widely implemented, more rigorous evaluation, including randomized trials, is necessary to determine more precisely the benefit, Rich concludes, "not only with respect to improving processes of care, but also with respect to improving patient outcomes."
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