Overcoming the Challenges Facing Quality-Improvement Strategies for Non–ST-Segment Elevation Acute Coronary Syndromes
Am Fam Physician. 2004 Nov 15;70(10):1868-1876.
The diagnostic and therapeutic approach to patients with non–ST-segmentelevationacute coronary syndromes (NSTE ACS — unstable angina and non-ST-segment elevation myocardial infarction) has evolved considerably over the past decade with publication of multiple landmark trials that have redefined the care of these patients and continual updating of the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of NSTE ACS.1–6 Despite these achievements, treatment patterns for these syndromes remain suboptimal.3,7 Quality-improvement efforts are therefore needed to promote increased adherence to the ACC/AHA guidelines and overcome challenges that limit the use of beneficial therapies for NSTE ACS.3
The first challenge involves accurately identifying patients with NSTE ACS from the much larger population of patients who present to emergency departments with suspected ischemic symptoms. Whereas patients with acute ST-segment elevation myocardial infarction usually present with clear chest pain symptoms and often are identified rapidly from the initial electrocardiogram (ECG), patients with NSTE ACS often do not have definitive symptoms or clear ischemic ECG changes on presentation.8,9 Thus, determination of risk status for patients with NSTE myocardial infarction relies heavily on documentation of elevated cardiac biomarkers such as troponins, but interpretation of troponin results often is uncertain in clinical practice given limitations of the available troponin assays and disagreements on what level of troponin elevation should be used to guide therapeutic decision making.10–12
The second challenge involves promoting practice guideline recommendations among all specialties that typically care for patients with NSTE ACS. A recent analysis demonstrated that almost one half of high-risk patients with NSTE ACS in U.S. hospitals are cared for by non-cardiologists who use guideline-recommended therapies and interventions less frequently than cardiologists.13 Similar disparities in care by specialty have been demonstrated in patients with acute myocardial infarction or congestive heart failure.14,15 Explanations for differential care patterns by specialty have not been defined clearly, but may relate to the availability of cardiology services and invasive procedures (especially at community hospitals), poor cooperation among specialties, and inadequate dissemination of guideline recommendations to non-cardiology specialties. Therefore, improved collaboration among specialties is needed to increase adherence to guidelines.
The third challenge involves defining and demonstrating success with quality-improvement efforts. Achievable benchmarks of care such as thresholds for ideal use of aspirin and heparin (designated by treatment patterns at hospitals that have the highest adherence to practice guidelines) have been used as performance indicators to successfully motivate changes in practice. However, benchmarks for the use of medications and procedures are difficult to delineate given uncertainties about contraindications to specific therapies and disagreement among physicians about the benefits of certain medications.16 Results from quality-improvement studies often are questioned because of methodologic limitations that restrict the applicability of the findings to diverse practice environments.17 Nonetheless, key components to successful quality-improvement efforts appear to include developing a consensus about the goals of interventions, administrative support, leadership from physician champions, and regular performance feedback.18 There is no “right” formula for quality improvement, but sustained enthusiasm and flexibility regarding performance improvement approaches may be the best starting points.
Despite the challenges of improving the quality of care for patients with NSTE ACS, there should be a strong impetus for changing current practice patterns because improved performance is associated with a lower risk of mortality.19–22 Specifically, in the ongoing Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) national quality-improvement initiative involving more than 400 hospitals in the United States, in-hospital mortality rates were almost 50 percent lower in hospitals with the best overall adherence to the ACC/AHA guidelines for NSTE ACS compared with hospitals that had the worst adherence to guidelines.22 Therefore, multidisciplinary quality-improvement strategies are needed to promote use of these guidelines, ensuring sustained improvements in care.
1. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on the management of patients with unstable angina) [published correction appears in Circulation 2000;102:1739] Circulation. 2000;102:1193–209.
2. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—summary article: report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on Management of Patients with Unstable Angina) J Am Coll Cardiol. 2002;40:1366–74.
3. Roe MT, Ohman EM, Pollack CV Jr, Peterson ED, Brindis RG, Harrington RA, et al. Changing the model of care for patients with acute coronary syndromes. Am Heart J. 2003;146:605–12.
4. Inhibition of platelet glycoprotein IIb/IIIa with eptifiba-tide in patients with acute coronary syndromes. N Engl J Med. 1998;339:436–43.
5. Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879–87.
6. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation [published correction appears in N Engl J Med 2001;345:1716] N Engl J Med. 2001;345:494–502.
7. Fox KA, Goodman SG, Klein W, Breiger D, Steg PG, Dabbous O, et al. Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2002;23:1177–89.
8. Ohman EM, Granger CB, Harrington RA, Lee KL. Risk stratification and therapeutic decision making in acute coronary syndromes. JAMA. 2000;284:876–8.
9. Kontos MC, Jesse RL. Evaluation of the emergency department chest pain patient. Am J Cardiol. 2000;85:32B–39B.
10. Hamm CW. Cardiac biomarkers for rapid evaluation of chest pain. Circulation. 2001;104:1454–6.
11. Jaffe AS, Ravkilde J, Roberts R, Naslund U, Apple FS, Galvani M, et al. It’s time for a change to a troponin standard. Circulation. 2000;102:1216–20.
12. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined—a consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction [published correction appears in J Am Coll Cardiol 2001;37:973] J Am Coll Cardiol. 2000;36:959–69.
13. Peterson ED, Roe MT, Li Y, Harrington RA, Brindis RG, Smith SC Jr, et al. Influence of physician specialty on care and outcomes of acute coronary syndrome patients: results from CRUSADE. Abstract presented at American College of Cardiology Scientific Sessions 2003. J Am Coll Cardiol. 2003;41:534A.
14. Jollis JG, DeLong ER, Peterson ED, Muhlbaier LH, Fortin DF, Califf RM, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med. 1996;335:1880–7.
15. Havranek EP, Wolfe P, Masoudi FA, Rathore SS, Krumholz HM, Ordin DL. Provider and hospital characteristics associated with geographic variation in the evaluation and management of elderly patients with heart failure. Arch Intern Med. 2004;164:1186–91.
16. Kiefe CI, Allison JJ, Williams OD, Person SD, Weaver MT, Weissman NW. Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial. JAMA. 2001;285:2871–9.
17. Krumholz HM, Herrin J. Quality improvement studies: the need is there but so are the challenges. Am J Med. 2000;109:501–3.
18. Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. A qualitative study of increasing beta-blocker use after myocardial infarction: why do some hospitals succeed?. JAMA. 2001;285:2604–11.
19. Giugliano RP, Lloyd-Jones DM, Camargo CA Jr, Makary MA, O’Donnell CJ. Association of unstable angina guideline care with improved survival. Arch Intern Med. 2000;160:1775–80.
20. Allen LA, O’Donnell CJ, Guigliano RP, Camargo CA Jr, Lloyd-Jones DM. Care concordant with guidelines predicts decreased long-term mortality in patients with unstable angina pectoris and non-ST-elevation myocardial infarction. Am J Cardiol. 2004;93:1218–22.
21. Mukherjee D, Fang J, Chetcuti S, Moscucci M, Kline-Rogers E, Eagle KA. Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes. Circulation. 2004;109:745–9.
22. Peterson ED, Roe MT, Lytle BL, Newby LK, Fraulo ES, Gibler WB, et al. The association between care and outcomes in patients with acute coronary syndromes: national results from CRUSADE. Abstract presented at American College of Cardiology Scientific Sessions 2004 J Am Coll Cardiol. 2004;43:406A.
Copyright © 2004 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions