Hospitals Vary Widely in Applying Proven STEMI Treatments

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Hospitals Need to Step Up Their Quality Improvement Commitment

An important finding from the study reported by Dr. Jernberg and his coauthors is the large variation among Swedish hospitals in the implementation of evidence-based and guideline-recommended treatments. Significant evidence exists that U.S. hospitals also have a wide variation in the quality of care they deliver to ST-elevation MI patients, as well as to patients with other disorders. Participation by hospitals in registries that provide timely feedback on patient management may be the best way to deal with these variations and improve the quality of care patients receive globally.

Many explanations exist for why hospitals vary in the extent to which they deliver evidence-based care. The commitment of hospitals and their staffs to delivering optimal care depends on institutional resources, goals, administrative support, physician leadership, having quality measures in place, and having a system for providing feedback on care that’s been delivered.

Although several options are available to hospitals for monitoring the care they deliver and receiving feedback, one system that is especially well suited for the care of patients with STEMI is the National Cardiovascular Data Registry (NCDR) ACTION Registry–Get With the Guidelines program of the American College of Cardiology and the American Heart Association. Participating hospitals get weekly, virtually real-time feedback on their performance, so that they can track how well they treat patients compared with similar hospitals, and so that they receive information on cases where their care fell short quickly enough to perform a meaningful investigation into what happened. This program also provides to participating hospitals, without charge, standardized order software that eliminates the need for physicians to always remember to write prescriptions for each drug that a STEMI patient should receive.

Unfortunately, a large number of U.S. hospitals that care for acute MI patients do not participate in this registry or in any other similar program. According to information provided by the ACC, in April 2011, 557 U.S. hospitals participated in the ACTION Registry-GWTG, less than 25% of the roughly 4,000 U.S. hospitals that provide care to patients with acute MI. Although reasons for lack of participation can differ, in general I think it is due to a lack of leadership in the hospital and a lack of focus on providing the best quality of care to patients. The time may have come to change our systems so that participation in a quality-improvement program is not discretionary. Simply encouraging physicians and hospitals to do the right thing may no longer be enough as we continue to see wide discrepancies in the application of evidence-based interventions and in patient outcomes.

Societies and regulatory agencies that issue treatment guidelines should include in their recommendations that hospitals participate in some type of national or regional registry. Payers can also make such participation part of their pay-for-performance stipulations. Regulatory groups can establish criteria that say that if hospitals fail to comply with registry participation and other quality improvement steps they will face financial penalties, or that steps will be taken so that patients are diverted to other institutions. Participation can also be a criterion for hospital accreditation. In short, we need stricter enforcement to ensure that quality improvement becomes a key part of hospital systems.

If we fail to implement systems that will ensure that we deliver the best, proven care to our patients then we do them a disservice. Hospitals that do not have the leadership, the resources, and the commitment to do this should not be caring for patients. Other hospitals in an area that are willing to do what is necessary to deliver the best care should be the ones that care for patients.

Debabrata Mukherjee, M.D., is professor of medicine and chief of cardiovascular medicine at Texas Tech University in El Paso. His comments are based on an interview and on an accompanying editorial (JAMA 2011:305:1710-11). He said that he has no disclosures.



Implementation of evidence-based treatments for patients with acute myocardial infarction saves lives, but hospitals show substantial variation in the extent to which they apply these treatments, according to a study of more than 60,000 patients treated at 72 Swedish hospitals during 1996-2007.

During the period studied, Swedish hospitals increasingly used proven treatments for patients presenting with ST-elevation MIs, including increased use of reperfusion therapies, aspirin, clopidogrel, statins, beta-blockers, and ACE inhibitors or angiotensin receptor blockers. Concurrently with increased use of these interventions, the standardized, 1-year mortality of patients dropped from 19% in 1996 to 11% in 2007, Dr. Tomas Jernberg, a cardiologist at Karolinska University Hospital in Stockholm, and his associates reported in an article published online on April 27 (JAMA 2011;305:1677-84).

But in addition to documenting the efficacy of evidence-based therapies for treating acute STEMI, the findings also revealed a wide variation in the application of these therapies by all 72 Swedish hospitals that provide care for patients with acute cardiac diseases.

For example, in 2007, 61% of STEMI patients in Sweden underwent primary percutaneous coronary intervention (PCI), up from 12% in 1996. But in 2007, the 95% confidence interval for hospitals delivering primary PCI was 45%-77%, meaning that 2.5% of the participating Swedish hospitals delivered primary PCI to fewer than 45% of their patients, while the 2.5% of Swedish hospitals that used primary PCI most often delivered it to more than 77% of their STEMI patients.

For several treatments, hospital-to-hospital variation in implementation decreased substantially over the period studied, so that by 2007 most hospitals used the treatment to about the same extent. For example, no hospital prescribed clopidogrel to these patients in 1996 (the drug was approved in Europe in 1998), but its use rose to 82% by 2007. Initially, hospitals showed a wide variability in the introduction of clopidogrel, which peaked in 2002, when a 40% gap separated the top quarter of prescribing hospitals from the bottom quarter. But during 2003-2007, this gap shrank, and by 2007 the difference in prescribing rates between the top and bottom hospital quartiles stood at only 3.4%.

However, variations in the prescribing of ACE inhibitors or ARBs persisted through 2007, "indicating a continuous uncertainty around the indications for these treatments early after ST-elevation MI," the authors wrote. By 2007, about 70% of these patients began receiving an ACE inhibitor or ARB at their hospital discharge, but the percentage varied from as low as 50% at some hospitals to as high as 80% at others.

"Our study demonstrates a large variation in the implementation of new treatments between different hospitals. These large variations, especially regarding coronary angiography during the hospital stay and subsequent dual antiplatelet therapy, were greatest during the start-up of new treatment modalities, likely reflecting differential rates of adoption of new treatments and decreased gradually over time," the authors said. They highlighted this variability and its reduction over time as a key factor in improved patient outcomes.

"Variation in treatment and deviations from guideline recommendations have negative effects on mortality and morbidity. The gradual reduction in variability leading to a high level of guideline adherence might therefore be a key reason for the reduction in mortality" seen during 1996-2007. "Therefore, identification of undue variations in the processes of care and highlighting areas of need for quality improvement programs are important tasks for the quality registries in health care," they concluded.

Dr. Jernberg and his coauthors said that they had no disclosures.

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