Quality Improvement Project Boosts Hospital Care for Older Heart Patients

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Quality improvement project boosts hospital care for older heart patients By LESLIE H. LANGUNC-CH School of Medicine

CHAPEL HILL - Hospitals can significantly improve the care of people 65 years old and older who are admitted for a heart attack, according to a report from the University of North Carolina at Chapel Hill.

The study conducted in collaboration with the Medical Review of North Carolina - the state quality improvement organization - clearly demonstrated that hospitals can improve the quality of care given these patients when they adopt specific treatment guidelines shown by research to be highly effective.A report of the study was published last month in the North Carolina Medical Journal.

"This study is an excellent example of how evidence-based medicine can be applied," said cardiologist Carla A. Sueta, MD, associate professor of medicine at UNC-Chapel Hill School of Medicine. "We already have data that tells us what to do for these patients and that's outlined in guidelines developed by the American College of Cardiology and the American Heart Association. We know what to do but we're not doing it as good as we could."

According to Sueta, clinical coordinator for MRNC, heart attack is associated with a high inpatient death rate (12% in North Carolina) and is a condition commonly leading to readmission within 30 days of hospital discharge.

In 1995, the federal Health Care Financing Administration (HCFA) launched the Cooperative Cardiovascular Project (CCP). This project examined hospitals across the nation on seven quality indicators of care based on the ACC/AHA treatment guidelines.

The indicators included: use of clot-busting drugs or balloon angioplasty to open blocked coronary arteries; use of aspirin during hospitalization and at discharge; use of beta-blocker heart drugs at discharge; counseling about smoking cessation; for patients with heart dysfunctions, use of ACE inhibitor medications; and avoidance of calcium channel-blocking medications.

"We know from other data that patient outcomes will be approved if these interventions are followed," Sueta said. "Good studies show that older patients who get beta blockers, for instance, live longer and have fewer heart attacks."

In response to a request by MRNC, sixty hospitals in the state agreed to participate in the study. At the outset, all received 'baseline' data from the CCP on their own hospital. The data were collected on patients discharged between February 1, 1994 and July 31 1995. They also received the unabridged ACC/AHA guidelines and were asked to develop a plan about how they were going to improve the situation. The plan was reviewed and approved by the Sueta and MRNC staff. The 'evaluation' data were collected from medical records on patients discharged between September 1, 1996 and December 31, 1997.

"Five of the seven quality indicators showed significant improvement," Sueta said. "We found a significant increase in the percentage of patients who received aspirin both when they came in during heart attack and when they got discharged. The hospitals also dramatically increased the people who went home on beta blockers from 55% to 76%, and they dramatically increased the medicine patients should get for a heart dysfunction. Use of an ACE inhibitor went from 61% to 71%."

Indicators showing no improvement involved smoking cessation counseling and reperfusion therapy (either giving medications that dissolve clots or opening blocked coronary arteries through angioplasty procedures).

Reasons for the lack of across the board improvement are unclear, the study authors said. As to smoking cessation counseling, "I think we need to get more aggressive about doing it," said Sueta.

"Still, the results are impressive," she adds. "They really speak to the ability of hospitals to use various interventions that result in improvement in the care for these patients."

The study did not identify any hospital-specific approaches to improvement that accounted for greater success.

"This leads me to conclude that you really need a multifaceted approach," said Sueta. "This would include staff education, developing systems, or standard pathways to treat these patients, and self-monitoring to make sure you're following your plan.

"In terms of improvement we saw in the study, each hospital has to customize their strategies to their institution. The fact that quality of care can be enhanced through simple, hospital-based interventions should encourage all hospitals to develop such strategies."

Co-authors of the report along with Sueta are Anna Schenck, PhD of UNC-CH, Randa Hall, MBA, MSHA, and Ross Simpson, Jr, MD, PhD of Medical Review of North Carolina.

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media note: To access the report online, go to www.ncmedicaljounal.com.Contact Dr. Sueta at 919-843-5215, email: [email protected]School of Medicine contact, Les Lang, 919-843-9687, [email protected]