Guideline-Based Standardized Care Is Associated With Substantially Lower Mortality in Medicare Patients With Acute Myocardial Infarction
Journal - Journal of the American College of Cardiology
OBJECTIVES: We sought to assess the impact of the American College of Cardiology’sGuidelines Applied in Practice (GAP) project for acute myocardialinfarction (AMI) care, encompassing 33 acute-care hospitalsin southeastern Michigan, on rates of mortality in Medicarepatients treated in Michigan.
BACKGROUND: The GAP project increases the use of evidence-based therapiesin patients with AMI. It is unknown whether GAP also can reducethe 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 studiedto assess the influence of the GAP program on mortality. Multivariatemodels tested the independent impact of GAP after controllingfor other conditions on in-hospital, 30-day, and one-year mortality.
RESULTS: Average patient age was 76 years, 48% were women, and 16% representednon-white minorities. The rate of mortality decreased afterGAP 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 correlatedwith a 21% to 26% reduction in mortality, particularly at 30days (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 patientsfor 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 improved30-day and one-year mortality. This benefit is most marked whenpatients are cared for using standardized, evidence-based clinicalcare tools.Abbreviations: 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