ORLANDO — Implementation of an acute MI guideline program in 33 Michigan hospitals resulted in significantly reduced 1-year mortality in both men and women, although the improvement was notably smaller among women, Kim A. Eagle, M.D., said at the annual meeting of the American College of Cardiology.
The gender gap in improved survival appeared to stem chiefly from the less frequent utilization of the ACC's Guidelines Applied in Practice (GAP) program's most effective tool—the discharge contract—in female MI patients, added Dr. Eagle, clinical director of the cardiovascular center at University of Michigan, Ann Arbor.
The GAP program is designed to increase rates of evidence-based, guideline-recommended treatments by creating clinical care tools and systems of care that promote their routine use. Among these tools are standard orders; critical pathways; chart stickers and other reminders; pocket guidelines; patient education handouts; the patient discharge contract; and provider performance feedback.
Dr. Eagle reported on 2,857 acute MI Medicare patients at 33 Michigan hospitals. Roughly half of the study patients were hospitalized in the first 4 months following GAP implementation at each participating hospital. The other half comprised a randomly drawn sample of MI patients in the year prior to GAP implementation.
Utilization rates of the high-priority early and late therapies increased following introduction of GAP, as did short- and long-term survival. But the improvements in survival were larger in men. (See graph.)
Of note, the GAP intervention that had the biggest influence on 30-day and 1-year mortality in a multivariate analysis was the use of the discharge contract, which was utilized in 34% of men but in only 28% of women. Use of the discharge tool was independently associated with a 54% relative risk reduction in 1-year mortality in women and a 38% reduction in men.
The discharge contract provides an opportunity for the patient and caregivers to go over the key evidence-based medications the patient ought to be on at discharge, barring contraindications—namely, aspirin, a β-blocker, ACE inhibitor, and lipid-lowering agent—as well as lifestyle goals and the follow-up plan.
The most likely explanation for the reduced utilization of discharge contracts among women is that something about their greater mean age—they averaged about 6 years older than men with MI—made it more difficult to implement the contract. This issue requires further study, according to Dr. Eagle.
The GAP demonstration project was funded chiefly by a grant from Blue Cross Blue Shield of Michigan.
John S. Rumsfeld, M.D., who chaired a session on quality improvement at the ACC meeting, said the impressive Michigan outcomes should provide the impetus for GAP or similar programs to be implemented nationwide.
“Everybody believes in guidelines, but we know they have not been applied in practice. It's more difficult than it sounds,” said Dr. Rumsfeld, of the division of cardiology at the University of Colorado, Denver. “We're all busy clinicians. We can't just be told to do more. We have to find ways to change systems of care to improve quality.”
KEVIN FOLEY, RESEARCH/DESIGN