Durham, NC - New research shows that hospitals that adhere to national guidelines for the treatment of acute coronary syndrome (ACS) had better outcomes than those that did not [1].

This is one of the first studies to link variability in hospital performance with patient outcomes, lead author Dr Eric D Peterson (Duke University Medical Center, Durham, NC) told heartwire. The work is published in the April 26, 2006 issue of the Journal of the American Medical Association.

Peterson adds that doctors often dismiss guidelines as "cookbook medicine" but this study "counters that argument." Performance indicators "are important," he notes, "and this association with outcome is the missing link that we haven't had before."

Dr Eric D Peterson (Source: Duke University Medical Center)

Peterson and colleagues examined how well hospitals followed ACC/AHA recommendations for treating patients with non-ST-segment-elevation (NSTE) myocardial infarction ACS using data from the CRUSADE National Quality Improvement Initiative between 2001 and 2003. The study included information on 350 US medical centers and 64 775 patients.

They found that, overall, the nine ACC/AHA recommended treatments for patients with NSTE ACS were followed 74% of the time. The nine therapies included aspirin, beta blockers, heparin, and IV GP IIb/IIIa inhibitors used within the first 24 hours as well as five discharge regimens (aspirin, beta blockers, clopidogrel, ACE inhibitors, and lipid-lowering drugs).

This indicates that even among the CRUSADE hospitals—which have chosen to participate in this quality-improvement initiative—current ACS care is "not perfect," say the researchers, because in one in four cases, patients are not receiving medicines that are proven to save lives.

Peterson told heartwire that it is likely that care is even worse in hospitals not participating in initiatives such as CRUSADE.

This association with outcome is the missing link that we haven't had before.

The researchers also calculated patient composite adherence scores; results were summated at the hospital level and were divided into quartiles, showing significant variation in hospitals' performance on individual care characteristics.

Hospitals in the highest adherence group (quartile 4) had a median adherence score of 82% compared with 63% for those in the lowest group (quartile 1). These guideline-adherence rates were in turn significantly associated with in-hospital deaths; mortality rates ranged from 6.31% in the lowest adherence group to 4.15% in the highest adherence group (p<0.001).

After adjusting for risk, the researchers found that every 10% increase in composite adherence was associated with a 10% decrease in its patients' likelihood of in-hospital death (odds ratio 0.9; p<0.001). 

"While we found modest correlation between use of the individual treatments and improved mortality, when we looked at all nine treatments together, we found a significant association between adherence and improved mortality," Peterson says.

"Importantly, adherence to proven guidelines may serve as a marker for the overall culture of the hospital and its commitment to providing the best possible care," he adds. "The performance of these hospitals on the measurements we used may indirectly reflect the hospital's overall culture, business practices, and clinical skills."

Peterson told heartwire that the study "illustrates another characteristic that is important—innovation." Adoption of newer guideline recommendations, such as GP IIb/IIIa inhibitors, clopidogrel, and lipid-lowering therapy, were all more closely associated with hospital outcome than many of the well-established treatments.

"Keeping up with the latest [guidelines] is another indicator of a hospital's overall culture of providing the best possible care," he adds.