Elsevier

American Heart Journal

Volume 154, Issue 3, September 2007, Pages 461-469
American Heart Journal

Clinical Investigation
Acute Ischemic Heart Disease
The association between guideline-based treatment instructions at the point of discharge and lower 1-year mortality in Medicare patients after acute myocardial infarction: The American College of Cardiology's Guidelines Applied in Practice (GAP) initiative in Michigan

https://doi.org/10.1016/j.ahj.2007.05.003Get rights and content

Background

The American College of Cardiology's Guidelines Applied in Practice (GAP) initiative for acute myocardial infarction (AMI) has been shown to increase the use of guideline-based therapies and improve outcomes in patients with AMI. It is unknown whether hospitals that are more successful in using the standard discharge contract—a key component of GAP that emphasizes guideline-based medications, lifestyle modification, and follow-up planning—experience a proportionally greater improvement in patient outcomes.

Methods

Medicare patients treated for AMI in all 33 participating GAP hospitals in Michigan were enrolled. We aggregated the hospitals into 3 tertiles based on the rates of discharge contract use: 0% to 8.4% (tertile 1), >8.4% to 38.0% (tertile 2), and >38.0% to 61.1% (tertile 3). We analyzed 1-year follow-up mortality both pre- and post-GAP and compared the mortality decline post-GAP with discharge contract use according to tertile.

Results

There were 1368 patients in the baseline (pre-GAP) cohort and 1489 patients in the post-GAP cohort. After GAP implementation, mortality at 1 year decreased by 1.2% (P = .71), 1.2% (P = .68), and 6.0% (P = .03) for tertiles 1, 2, and 3, respectively. After multivariate adjustment, discharge contract use was significantly associated with decreased 1-year mortality in tertile 2 (odds ratio 0.43, 95% CI 0.22-0.84) and tertile 3 (odds ratio 0.45, 95% CI 0.27-0.75).

Conclusions

Increased hospital utilization of the standard discharge contract as part of the GAP program is associated with decreased 1-year mortality in Medicare patient populations with AMI. Hospital efforts to promote adherence to guideline-based care tools such as the discharge contract used in GAP may result in mortality reductions for their patient populations at 1 year.

Section snippets

The GAP projects

After initial development at the University of Michigan Health System,7 the ACC AMI GAP projects included a 10-hospital pilot study9 in Southeast Michigan in 1999, a 5-hospital project in Flint and Saginaw10 in 2001, and an 18-hospital expansion project8 in Southeast Michigan in 2002. The AMI GAP projects were conducted in partnership with the MPRO, local health coalitions, the ACC, and local nonprofit or government hospitals, of which most were teaching hospitals. The GAP fosters systems-based

Results

Of the 2857 patients studied, 47.9% (n = 1368) were in the baseline or pre-GAP cohort, whereas 52.1% (n = 1489) were in the post-GAP cohort. Tertile 1 included 418 pre-GAP patients and 445 post-GAP patients; tertile 2 included 454 pre-GAP patients and 525 post-GAP patients; tertile 3 included 496 pre-GAP patients and 519 post-GAP patients. Table I reports patient characteristics in each cohort by tertile. The average patient age was 76.3 years. Patients in all 3 tertiles were similar with

Discussion

The results of this study suggest an association between utilization of the standard discharge contract in the context of GAP and mortality at 1 year in Medicare beneficiaries hospitalized for AMI (Figure 3, Table III). Mortality at 1 year was estimated to be 6.0% lower among patient populations treated at hospitals where the discharge contract was most often used. None of the 33 participating hospitals achieved >61.1% utilization of the discharge contract; and therefore, the potential

References (24)

  • I.S. Udvarhelyi et al.

    Acute myocardial infarction in the Medicare population: process of care and clinical outcomes

    JAMA

    (1992)
  • J.M. Lappe et al.

    Improvements in 1-year cardiovascular clinical outcomes associated with a hospital-based discharge medication program

    Ann Intern Med

    (2004)
  • Cited by (0)

    The Guidelines Applied in Practice projects for acute myocardial infarction care were supported by unrestricted grants from the national American College of Cardiology Foundation, the Michigan chapter of the American College of Cardiology, the Centers for Medicare and Medicaid Services, the Michigan Peer Review Organization, the Medicare Quality Improvement Organization for the State of Michigan, Pfizer Inc, AstraZeneca, the Greater Detroit Area Health Council, the Greater Flint Health Coalition, the Mardigian Foundation, and the University of Michigan.

    The analyses upon which this publication is based were performed under Contract Number 500-02-MI-02, “Utilization and Quality Control Peer Review Organization for the State of Michigan,” and sponsored by the Centers for Medicare and Medicaid Services, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services; nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Centers for Medicare and Medicaid Services, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this contractor. Feedback to the authors concerning the issues presented is welcomed.

    m

    Current address: St Joseph Mercy Hospital, Ann Arbor, MI.

    n

    Guidelines Applied in Practice steering committee: Raymond J. Gibbons, MD; Christopher P. Cannon, MD; Richard A. Chazal, MD; James T. Dove, MD; Kim A. Eagle, MD; Arthur Garson, Jr, MD, MPH; Rick A. Nishimura, MD.

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