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Mehta RH, Montoye CK, Gallogly M, et al. Improving Quality of Care for Acute Myocardial Infarction: The Guidelines Applied in Practice (GAP) Initiative. JAMA. 2002;287(10):1269–1276. doi:10.1001/jama.287.10.1269
Author Affiliations: Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor (Drs Mehta and Eagle, and Ms Kline-Rogers); American College of Cardiology, Bethesda, Md (Mss Montoye and Gallogly, and Dr Orza); Michigan Peer Review Organization, Plymouth (Mss Baker, Blount, and Faul, Dr Roychoudhury, and Ms Satwicz); Division of Cardiology, Department of Internal Medicine, Henry Ford Health System, Detroit, Mich (Dr Borzak, Ms Fox); Division of Cardiology, Department of Internal Medicine, St John Hospital and Medical Center, Detroit, Mich (Dr LaLonde); Disease Management, St John Health System, Warren, Mich (Ms Freundl); Greater Detroit Area Health Council, Detroit, Mich (Mr Parrish); Division of Cardiology, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Mich (Ms Smith, Dr Winston); Department of Internal Medicine, Division of Cardiology, Detroit Medical Center, Detroit, Mich (Dr Sabotka); and Department of Internal Medicine, Division of Cardiology, Dearborn, Mich (Ms Franklin, Dr Riba).
Context Quality of care of patients with acute myocardial infarction (AMI) has
received intense attention. However, it is unknown if a structured initiative
for improving care of patients with AMI can be effectively implemented at
a wide variety of hospitals.
Objective To measure the effects of a quality improvement project on adherence
to evidence-based therapies for patients with AMI.
Design and Setting The Guidelines Applied in Practice (GAP) quality improvement project,
which consisted of baseline measurement, implementation of improvement strategies,
and remeasurement, in 10 acute-care hospitals in southeast Michigan.
Patients A random sample of Medicare and non-Medicare patients at baseline (July
1998–June 1999; n = 735) and following intervention (September 1–December
15, 2000; n = 914) admitted at the 10 study centers for treatment of confirmed
AMI. A random sample of Medicare patients at baseline (January–December
1998; n = 513) and at remeasurement (March–August 2001; n = 388) admitted
to 11 hospitals that volunteered, but were not selected, served as a control
Intervention The GAP project consisted of a kickoff presentation; creation of customized,
guideline-oriented tools designed to facilitate adherence to key quality indicators;
identification and assignment of local physician and nurse opinion leaders;
grand rounds site visits; and premeasurement and postmeasurement of quality
Main Outcome Measures Differences in adherence to quality indicators (use of aspirin, β-blockers,
and angiotensin-converting enzyme [ACE] inhibitors at discharge; time to reperfusion;
smoking cessation and diet counseling; and cholesterol assessment and treatment)
in ideal patients, compared between baseline and postintervention samples
and among Medicare patients in GAP hospitals and the control group.
Results Increases in adherence to key treatments were seen in the administration
of aspirin (81% vs 87%; P = .02) and β-blockers
(65% vs 74%; P = .04) on admission and use of aspirin
(84% vs 92%; P = .002) and smoking cessation counseling
(53% vs 65%; P = .02) at discharge. For most of the
other indicators, nonsignificant but favorable trends toward improvement in
adherence to treatment goals were observed. Compared with the control group,
Medicare patients in GAP hospitals showed a significant increase in the use
of aspirin at discharge (5% vs 10%; P<.001). Use
of aspirin on admission, ACE inhibitors at discharge, and documentation of
smoking cessation also showed a trend for greater improvement among GAP hospitals
compared with control hospitals, although none of these were statistically
significant. Evidence of tool use noted during chart review was associated
with a very high level of adherence to most quality indicators.
Conclusions Implementation of guideline-based tools for AMI may facilitate quality
improvement among a variety of institutions, patients, and caregivers. This
initial project provides a foundation for future initiatives aimed at quality
Despite considerable investment in the development and dissemination
of national guidelines for the management of acute myocardial infarction (AMI),1 the Center for Medicare and Medicaid Services' (CMS)
Cooperative Cardiovascular Project recently reported that quality of care
for Medicare beneficiaries with AMI was far from optimal.2
Many subsequent studies have shown similar disappointing adherence to the
therapies recommended in published guidelines.3-6
Furthermore, quality of care of patients with AMI varies with age, sex, race,
geographic location, physician specialty, and hospital teaching status.2,3,7-16
This variation in care is likely linked to outcomes.11,13,17
Although recent analyses of care patterns over time have suggested steady
improvement in the use of key therapies in patients with AMI,18,19
there remain important opportunities to improve adherence to evidence-based
In this report, we describe the initial impact of the Guidelines Applied
in Practice (GAP) initiative of the American College of Cardiology (ACC) in
southeast Michigan. Conceptually, the program sought to incorporate national
guidelines into care processes, focused on both caregivers (physicians and
nurses) and patients, in part by creating tools and systems that reinforce
adherence to key evidence-based therapies.
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